“IF” “AND” OR “BUT” OF DELEGATION TO UNLICENSED HOME CARE STAFF

1. “IF” “AND” OR “BUT” OF DELEGATION TO UNLICENSED HOME CARE STAFF Jeanette Mefford, R.N., M.P.H. Mefford, Knutson & Associates, Inc. Minneapolis, MN

2. OBJECTIVES • Define Delegation and its relationship to nursing practice • Identify appropriate candidates for delegation within the home care setting • Identify barriers to effective and appropriate delegation • Identify the role of supervision in effective delegation Mefford, Knutson & Associates, Inc.

3. DELEGATION • Transferring to a competent individual the authority to perform a selected nursing task in a selected situation. • Nurse retains the accountability for the delegation • Primary legal obligation is to ensure the competency of the individual who will perform the delegated task Mefford, Knutson & Associates, Inc.

4. NURSE PRACTICE ACT • Law directs practice and is the legal foundation for what I do as a professional nurse • Understanding of laws and the rules help evaluate the safety and legality of actions I am requested to take. Mefford, Knutson & Associates, Inc.

5. DELEGATION Minnesota’s Nurse Practice Act: • Permits RNs to delegate. LPNs may not delegate. • RN may not delegate RN ONLY functions of assessment, evaluation and nursing judgment. • Delegation is at the professional judgment and discretion of the RN Mefford, Knutson & Associates, Inc.

6. DELEGATION CAN BE A POSITIVE EXPERIENCE IF Mefford, Knutson & Associates, Inc.

7. FIVE RIGHTS OF DELEGATION • Right Task • Right Circumstances • Right Person • Right Direction/Communication • Right Supervision/Evaluation Mefford, Knutson & Associates, Inc.

8. DELEGATION & THE NURSING PROCESS • Assess the patient and plan the care • Identify tasks that someone else can perform • Implement the plan of care • Assign and supervise task performance • Evaluate performance and client response Mefford, Knutson & Associates, Inc.

9. ANA’S DELEGATION STANDARD • When delegating, the RN will consider: • Assessment of the patient condition • Capabilities of the nursing and assistive staff • Complexity of the task to be delegated • Amount of clinical supervision needed • Staff workload Mefford, Knutson & Associates, Inc.

10. ANA’s Delegation Standard • What cannot be delegated: • Initial nursing assessment • Determination of nursing diagnoses • Establishment of nursing care goals • Development of nursing plan of care • Evaluation of patient’s progress • Health counseling or teaching • Activities that require specialized nursing knowledge, skill, or judgment Mefford, Knutson & Associates, Inc.

11. AND Mefford, Knutson & Associates, Inc.

12. THE KEY TO DELEGATION • Assessment • know your world • know your organization • know yourself • know your delegate • Plan- know what needs to be done • Intervene • Prioritize, communicate, resolve conflict • Evaluate • Feedback and problem solving Mefford, Knutson & Associates, Inc.

13. KNOW YOUR WORLD • Nursing Shortage • Demographics: age and poverty • Consumer Involvement • Payers—Cost containment • Changing Nature of Work Mefford, Knutson & Associates, Inc.

14. KNOW YOUR ORGANIZATION • Mission Statement, Principles and Values • Organizational Structure • Union/Non-Union Environments • Quality/compliance Program—Agency policy • Educational Resources Mefford, Knutson & Associates, Inc.

15. KNOW YOURSELF • Transition From Facility Based Care to Community Based Care System • The Move From Acute Care to Home Care • Stressors • Adaptations • Other Barriers Mefford, Knutson & Associates, Inc.

16. KNOW YOUR PRACTICE • “Is my nursing license on the line?” • Board of Nursing/ Professional Organizations • Lawsuits vs. Discipline • Nurse Practice Act • Medicare Guidelines—COPs/State License • LPN Role Mefford, Knutson & Associates, Inc.

17. Grounds for Disciplinary Actions • Failure to or inability to perform professional or practical nursing as defined n section 148.171, subdivision 14 or 15, with reasonable skill and safety, including failure of a registered nurse to supervise or a licensed practical nurse to monitor adequately the performance of acts by any person working at the nurse’s direction. Mefford, Knutson & Associates, Inc.

18. DISCIPLINARY ACTION “Delegating or accepting the delegation of a nursing function, or a prescribed health care function when the delegation or acceptance could reasonably be expected to result in unsafe or ineffective patient care Mefford, Knutson & Associates, Inc.

19. DISCIPLINARY ACTION Knowingly aiding, assisting, advising, or allowing an unlicensed person to engage in the unlawful practice of professional, advanced practice registered, or practical nursing. Mefford, Knutson & Associates, Inc.

20. KNOW YOUR DELEGATE • The Question of Competency • Setting the Standards • Job Description • Validating/Documenting Competency • Unofficial Expectations of each Role • Assessing Strengths and Weaknesses Mefford, Knutson & Associates, Inc.

21. ASSIGNMENT CONSIDERATIONS • Unlicensed personnel assignments are functions and tasks, not clients or groups of clients • LPN/LVN may be assigned specific clients for whom to perform care • RN remains responsible for nursing practice activities Mefford, Knutson & Associates, Inc.

22. BUT DON’T BE SURPRISED--SUPERVISE Mefford, Knutson & Associates, Inc.

23. SUPERVISION • Active process of directing, guiding, and influencing a worker’s performance • On-site supervision • Physically present/ immediately available • Off-site supervision • Through written/verbal communication • Increased use of telecommunications technology is raising supervision questions Mefford, Knutson & Associates, Inc.

24. SUPERVISION defined by NPA guidance by an RN for the accomplishment of a function or activity. The guidance covers the activities included in monitoring as well as: • establishing the initial direction, • delegating, setting expectations, • directing activities and courses of action, • critical watching and overseeing, • evaluating and changing a course of action.Minn. Rules 6321.0100, subpt. 3. Mefford, Knutson & Associates, Inc.

25. Monitoring as defined by NPA • Periodic inspection by RN or LPN of a directed function or activity and includes • Watching performance • Checking and tracking performance • Updating a supervisor on progress or accomplishment • Contacting a supervisor, as needed, for direction and consultation Mefford, Knutson & Associates, Inc.

26. Degree of Supervision • RN makes determination about required nursing supervision which depends on: • Client needs • Stability of the client • Competency of the LPN or assistant • Nature of the tasks • Availability of supervision • If delegating nursing tasks to unlicensed persons licensure law requires supervision every 14 days Mefford, Knutson & Associates, Inc.

27. SUPERVISING ACTIVITIES • Scheduled visits to observe/communicate • Be available for questions/unexpected problems • Supervise in a positive, supportive manner • Intervene immediately if the task is not being performed safely and appropriately • Never ignore poor performance—document and report • Use mistakes as learning opportunities Mefford, Knutson & Associates, Inc.

28. ASSIGNING VS. DELEGATING • ASSIGNMENT • Transfer of responsibility and accountability is downward or lateral • Activities designated are consistent with job position and qualifications • Staff member assumes responsibility and is accountable Mefford, Knutson & Associates, Inc.

29. Premises of Delegation • Each person involved in delegation is accountable for own actions. RN may be disciplined for inappropriate delegation, LPN may be disciplined for accepting inappropriate delegation. • Supervision is inherent. If RN delegates a task, RN is responsible for supervising the delegatee, whether RN is present or not. • RN may assign LPN to monitor for the RN, but RN must be available for consultation and direction. Mefford, Knutson & Associates, Inc.

30. KEY TO SUCCESSFUL DELEGATION Delegation is an investment of time and energy that doesn’t always have immediate returns. Delegation is a skill: - It Has Distinct Steps - It Requires Practice To Improve - Repeated Practice Facilitates Improvement Mefford, Knutson & Associates, Inc.

31. Questions from the Board of Nursing • Discuss your methods of supervising the unlicensed assistive personnel and nurses involved in client care. • Discuss your methods of monitoring the care of clients. • Discuss your methods of making your expectations known to the staff. Mefford, Knutson & Associates, Inc.

32. WHY DELEGATE? • Delegating tasks is not in response to a shortage of nurses, but a shortage of professional nursing care. • Nurses are too busy performing tasks that do not require their knowledge and skill base. Mefford, Knutson & Associates, Inc.

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