Sally Sutherland-Fraser - Health Education & Learning Partnerships - Delegation and Supervision in the Operating Suite: Implications for the Perioperative Team

[email protected] 0438408267 [email protected] 0417480662

Delegation and supervision:

Implications for managers Sally Sutherland-Fraser

Operating Theatre Management Conference Sydney August 28-29th 2014

mailto:[email protected]


Copyright © 2014 Health Education & Learning Partnerships. All Rights Reserved.


Graduation Group PEPEN Pilot, 2003


Decision Making Tool

for the delegation of

the novice EEN to the

instrument nurse role


The full spectrum of roles, functions, responsibilities, activities

and decision-making capacity which individuals within a

profession are educated, competent and authorised to perform

Scope of Practice

Cannot be defined as a simple list of tasks or procedures

Some functions within the scope of practice of any profession

may be shared with other professions / individuals / groups

Activities delegated to another person by a registered nurse or midwife

cannot be delegated by that person to any other individual, unless they

have since obtained the autonomous authority to perform the activity


The full spectrum of roles, functions, responsibilities, activities

and decision-making capacity which individuals within a

profession are educated, competent and authorised to perform

Cannot be defined as a simple list of tasks or procedures

Some functions within the scope of practice of any profession

may be shared with other professions / individuals / groups

Activities delegated to another person by a registered nurse or midwife

cannot be delegated by that person to any other individual, unless they

have since obtained the autonomous authority to perform the activity

Scope of Practice p.19 ANMC, 2007 (NMBA, 2010),

A national framework for the development of decision-making tools for nursing and midwifery practice


Session Content

1. Show you why you need to be good at this

2. Examine our regulatory framework

3. Review definitions

4. Explore legal case reports

5. Identify resources to support front-line managers


Why do we need to delegate care?


Delegate because…

Demanding clinical environment

Separation of the team

Match skills to patient needs

Develop your staff


Why should we supervise delegated care?


Supervise delegated care because…

Diverse teams – roles and designations

Different scopes of practice and mixed skill levels

Ensure delegations remain lawful

Monitor performance and patient outcomes


What level of supervision…

I guess you’d

call this Direct”

Supervision…


Additional burden of management role

Not only managing

diverse teams…

Also managing

individuals who may have

a poor grasp of

Scopes of practice

Delegation & supervision

Decision-making tools

Accountability


Garling Report 2008

13.19 A complaint was referred to …the HCCC

[which] found that the intern had failed to assess

the severity of the patient’s renal and cardiac failure

and therefore did not undertake appropriate

investigations.

13.20 …The HCCC’s expert reviewer said that as an intern, the doctor

would not be expected to make a sufficient assessment of the

patient or a management plan without direct senior involvement…


Garling Report 2008

13.102 Another common complaint …which

impacts on the supervision of junior nurses,

was that the ‘skill mix’ in nursing has become

too junior…

with inadequate support for junior nurses,

either in terms of education or supervision by more

experienced nurses.


Garling Report 2008

19.35 Why clinical staff do not respond to

deteriorating patients:

• unclear as to the criteria;

• overdependence on automatic monitoring;

• lack of clarity in respect of their role and responsibilities;

• lack of adequate/clear documentation;

• inadequacies in handover practices; and

• issues arising from the organisation of the staff of a ward;

• inadequate staffing levels;

• doctors who would not accept the subjective judgments advanced by

more junior medical officers or nursing staff.


Health plans for 2015 = More workers to supervise?

• Increase in midwifery staffing, aligned to Birthrate Plus

• 2475 more nursing staff

• Increased capacity for EN and AIN training

• Commonwealth funding, RTOs and NSW Health to support

delivery of training places

• 60 Re-entry to Nursing Scholarships targeting

individuals who don’t meet the NMBA recency of

practice standard

• Expand the access to the Hospital Skills Program to a

broader range of health workforce professionals


1. Regulatory framework

Statutory body established in July 2010 under the Health

Practitioner Regulation National Law (NSW)

Manages notifications (complaints) about the conduct,

performance or health of nursing and midwifery

practitioners and students

http://www.legislation.nsw.gov.au/maintop/view/inforce/act+86a+2009+cd+0+N




What roles exist within this framework?

From A to Z:

Assistant in Nursing

Enrolled Nurse

Midwife

Midwife Practitioner

Nurse Practitioner

Registered Nurse

Student Midwife

Student Nurse


Midwife

Student Midwife

Nurse Practitioner

Registered Nurse

Enrolled Nurse

Student Nurse


Who is regulated under this system?


What roles exist within this framework?

From A to Z:


Enrolled Nurse

Midwife


Nurse Practitioner

Registered Nurse

Student Midwife

Student Nurse


Midwife

Student Midwife

Nurse Practitioner

Registered Nurse

Enrolled Nurse

Student Nurse

Who is regulated under this system?

Un licensed health care worker


Non nurse, non midwife, support worker

• May have care-worker qualification or no formal education

• Not professionally regulated, so not bound by standards set by

licensing authority

• Support workers are individually accountable for their own actions and

accountable to the registered nurse or midwife and their employer for

delegated actions.

• Routine client-specific activities requiring a narrow range of skill and

knowledge may be delegated to support workers.

• An activity is routine if the need for the activity, the consumer’s

response and the outcome of the activity have been established over

time, and are therefore predictable.

ANMC, 2007 (NMBA, 2010), A national framework for the development of decision-making tools for nursing and midwifery practice


How do we identify these roles?


“Finally, in this chapter I wish to make

recommendations about the wearing of

uniforms and name badges by health professionals.”

Commissioner Peter Garling SC, 2008





Before site incision - Confirm all team members have

introduced themselves by name …and role




NMBA Decision-making framework

• Supports nurses and midwives in

dynamic environments to make informed

decisions about the provision of safe and

high quality care

• Enables and facilitates the evolution of

new practice roles

• Provides a consistent approach to

informed decision-making

• Improves critical thinking of staff,

enhances understanding of accountability

and empowers staff


http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx













Need • Is there a need for the care activity?

Practice

• Is it within scope of practice and accepted professional standards?

Approval

• Is it supported / approved by the organisation?

Skill

• Is there a competent person available to perform the care activity?


How does this play out in your unit?

1. Allocation of roles at the start of the shift

Who delegates care activities and what guides those

decisions?

2. Relieving roles during the shift

Does this change the balance / authority?

3. Requests by medical officers

What would your nurses do if the surgeon asked them to

close the wound?

Delegation

• Transferring authority to a

competent person

• Can only be made by a person

who themselves is competent

to perform the activity they are

delegating

Conditions:

• Right person available at right

time to provide right service

• Delegator retains

accountability for the

decision to delegate and for

monitoring outcomes.

Allocation / Task

Assignment

• Asking another person to care

for one or more clients

• Activities are normally within

that person’s responsibility

and scope of practice.

Comparison


Accountability p.16 ANMC, 2007 (NMBA, 2010), A national framework

for the development of decision-making tools for nursing and midwifery practice

Don’t just sit there - monitor the outcomes

of your delegations!


Supervision p.19 ANMC, 2007 (NMBA, 2010), A national framework for the

development of decision-making tools for nursing and midwifery practice


Clinically focussed supervision ANMC, 2007 (NMBA, 2010),

A national framework for the development of decision-making tools for nursing and midwifery practice


Coroner’s Case

• Re-deployment of EN to surgical ward with postop

patients

• Regulatory requirements not observed

• Geographic isolation from RNs – “Reasonable”?

• Management lines not clear = inadequate supervision

• Poor communication and handover with failure to

detect and escalate care of deteriorating patient


Manager’s responsibilities

1. HCCC v Bousfield [2014] NSWCATOD 57 (2 June 2014)


2. HCCC v Piper [2014] NSWCATOD 62 (12 June 2014)

Individual’s responsibilities


‘Culture’ sometimes provides the means


Individual’s responsibilities


Further resources: HPCA Legal News

http://www.hpca.nsw.gov.au

/Legal-Information/Legal-

News/default.aspx

http://www.hpca.nsw.gov.au/Legal-Information/Legal-News/default.aspx








http://www.heti.nsw.gov.au/nursing-and-midwifery/superguide/

Further resources: HETI NSW Superguide







Further resources: References & websites

ANMC, 2007 (NMBA, 2010) A national framework for the development of decision-making tools for nursing and midwifery practice

file:///C:/Users/Sally%20SF/Downloads/Nursing-and-Midwifery-Board---Codes-and-Guidelines---National-framework-for-decision-

making---September-2007%20(2).PDF

HETI, 2013, The superguide: A supervision continuum for nurses and midwives http://www.heti.nsw.gov.au/nursing-and-

midwifery/superguide/

State of NSW, 2008, Final Report of the Special Commission of Inquiry: Acute Care in NSW Public Hospitals, Commissioner Peter

Garling, SC http://www.lawlink.nsw.gov.au/Lawlink/Corporate/ll_corporate.nsf/pages/attorney_generals_department_acsinquiry

Health Professional Councils Authority HPCA http://www.hpca.nsw.gov.au/Legal-Information/Legal-News/default.aspx

NSW Nursing & Midwifery Council NMC http://www.hpca.nsw.gov.au/Nursing-and-Midwifery-Council/Home/Home/default.aspx

Nursing & Midwifery Board of Australia NMBA http://www.nursingmidwiferyboard.gov.au/ http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx

C:/Users/Sally SF/Downloads/Nursing-and-Midwifery-Board---Codes-and-Guidelines---National-framework-for-decision-making---September-2007 (2).PDF


































http://www.lawlink.nsw.gov.au/Lawlink/Corporate/ll_corporate.nsf/pages/attorney_generals_department_acsinquiry






http://www.hpca.nsw.gov.au/Nursing-and-Midwifery-Council/Home/Home/default.aspx







http://www.nursingmidwiferyboard.gov.au/









Pieces in a chess set – a helpful analogy?

Know the moves

Work within the rules

Be strategic

Maximise potential

Scopes of practice

Regulatory framework

Workforce redesign

Grow your team

[email protected] 0438408267 [email protected] 0417480662

Thank you –

ANY QUESTIONS? Copyright © 2014 Health Education & Learning Partnerships. All Rights Reserved.

PO Box 77 Leichhardt | NSW | 2040

[email protected]




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Sally Sutherland-Fraser - Health Education & Learning Partnerships - Delegation and Supervision in the Operating Suite: Implications for the Perioperative Team