Delegation and Decision Making

1. RN Delegation and Decision Making UAP LVN

2. Decision Making and Delegation • Key to delegation is ability to make correct decisions and think critically! • What is decision-making in nursing? • What are some examples of nursing decisions? • What are the ethical principles involved?

3. Decision Making and Delegation • What is decision making in nursing? • It’s a systematic cognitive process in which you: • identify and evaluate alternatives, come to a conclusion, and select an action • As an RN you must make judgments and decisions based upon education and experience • What is Critical thinking? • Systematic way to form and shape one’s thinking • *Critical Thinking Def.- the ability to focus your thinking so that you get the results you need.

4. What is critical thinking anyway?? NOT!!!

5. Why is it so important? • Critical thinking skills are needed for • Early detection of problems • Interventions to prevent adverse occurrences • Interventions to decrease mortality and morbidity and failure to rescue rates • Improving patient outcome rates

6. Characteristics of Critical Thinkers • Open minded • Systematic • Analytical • Inquisitive • Judicious • Truth seeking • Confident in reasoning

7. What is a critical thinking disposition? A. Authoritarian B. Systematic C. Laissez-faire D. Ambitious B. Systematic Rationale: critical thinking dispositions include a systematic & flexible approach.

8. Critical Thinking Exercise • As new assistant charge nurse, you have responsibility for scheduling employees assigned to your unit. In the past, this has been done by one individual without consultation from others. You would like to try a group decision making process. • What factors need to be considered in moving to this process? • What will be the benefits? Drawbacks? • If you decide to go ahead with the plan how will you structure it?

9. Steps in the Decision Making Process • Data gathering • Analysis • Establishing Goals/Outcomes/Strategies • Implement chosen alternatives • Evaluate Outcomes • Resources

10. Decision Making Tools • Listing Pros and cons • Algorithms • Clinical pathways • Thinking hats

12. Critical or Clinical Pathways

13. Group Decision Making Questions • Does the group have sufficient knowledge? • Is there enough time? • Is the group mature enough? • Conflict • Individual differences • Will management support the group?

14. Methods of Participative Group Decision Making • Consensus • general agreement that members will support a strategy even if not their chosen one • Majority Rule • vote is taken and the most votes win

15. Other Approaches used for Participative Decision Making Brainstorming- time and expensive Task force- group formed to discuss a certain problem. Quality circles- people working in same area with common concerns meet on a regular basis Nominal group technique-manager selects members and presents a problem. Each writes a solution and then all solutions are discussed and ranked Delphi- person selects members and polls them for alternatives. Membership is anonymous so can’t influence decisions

16. Sources of Ethical Guidance • Beneficence: do or bring about good (similar to nonmaleficence – do no harm) • Autonomy: each individual makes personal decisions • Justice: obligation to be fair to all people, non-discrimatory. Pt. should be informed of wrongs. • Fidelity: carry out the agreement and responsibilities one has undertaken: faithful to the clients- opposite of patient abandonment • Veracity: to tell the truth…

17. Supporting Ethical Decision Making • Knowing- using assessment skills and knowledge base as well as self-assessment • Facilitating- acquiring pertinent information and facilitating communication • Guiding- have you thought about? It sounds to me… Supporting ethical decision making by patient and families

18. Decision Making to Delegation • Delegation: When you authorize a competent person to act for or in your stead while still retaining accountabilityand using a UAP • What is a UAP? • The Registered Nurse is empowered to make that decision

19. Problems with delegating and UAPS • There are 65 job titles for UAP • There is no universal training • There is no universal hiring • Lack of consistent job descriptions between different settings in same facility

20. National Council of State Boards of Nursing • 1987 - NCSBN became concerned about ability of nurse’s to delegate • 1990-1995 – conceptual papers written. • Defined delegation: Transferring to a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains accountability for this delegation.

21. Delegation • You must delegate if you want to deliver quality care to all of your patients in a timely manner • What is it? • It is giving someone authority and responsibility to do something that is normally part of someone else’s job. • It is not “dumping problems on someone else. • It is not abandonment. The “manager” retains accountability and needs to supervise . • It is giving the employee appropriate authority to act alone.

23. Shortage of RN’s • Cost containment • Sicker patients • Shorter length of stay • Increased number of UAP’s • Time management • Encourages team building • The Do's and Dont's of Delegation • Fear • Lack of knowledge • Lack of communication skills • Loss of control • They can do it better • Lack of confidence in their staff • Unclear job descriptions • Might lose license • Don’t have time Why delegate? Why RN’s don’t delegate

25. Assignment versus Delegation • Assignment – dividing workload to be done: describes entire set of tasks and responsibilities given to an individual Also refers to workload given to licensed staff • Delegation – giving authority to unlicensed person for specific task in a specific situation

26. 5 Rights of Delegation (NCSBN) Right Task Right Direction/Communication Right Circumstances Right Supervision/ Evaluation Right Person

27. 5 Rights of Delegation (NCSBN) • Right task – Nurse Practice Act, Job Descriptions • Right circumstances – What are the circumstances of patient at this time? • Right Person- Who is competent to perform task? • Right Directions/Communication • Right Supervision/Evaluation

28. Evaluation and Feedback • Evaluation • Feedback • There is no blanket delegation of tasks

29. Stay Focused • Delegation will never occur in isolation • There will be: • Internal Forces • External Forces • Most “Peer Review” incidents occurred as a result of distractions. • Rushed • Poor systems or infrastructures • Taking short cuts with policies and procedures • What went wrong?

30. Questions to ask before delegating • What is the task or job to be delegated? • Are the expected results predictable? • Does the task require on-going nursing assessment? • To whom shall the task be delegated?- skill level and time • Does the task involve critical thinking or nursing judgment? • If the delegatee needs help, am I available to help?

31. Nursing Practice Act Delegation Resource RULES AND REGULATIONS related to PROFESSIONAL NURSE EDUCATION, LICENSURE AND PRACTICE

32. BON Delegation Rules • Rule 224-Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personal for Clients with Acute Conditions or in Acute Care Environments • Rule 225 – RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions

33. 224.2 Exclusions from Chapter • (A) Supervise or instruct others in the gratuitous nursing care of the sick • (B) Qualified nursing faculty or preceptors directly supervising or instructing nursing students… • (C) Instruct/Supervise a UAP in the performance of nursing tasks as a part of an educational… • (D) Assign tasks to or to supervise LVNs or other licensed practitioners practicing within the scope of their licenses

34. Which of the following situations are exclusions to the Nurse Practice Act according to 224.2? • As an RN you assign the LVN on your team to provide care for a group of 6 patients • No, does not apply, do not delegate to LVN; have own practice act; only make assignments to them • As an RN you work with a nursing student in an externship and supervise the student while he/she gives IV push medications • Yes, does apply, exclusion in 224.2 • 3.As an RN you assign the CA to check intake and outputs for patients in room 1-10 • No, this is delegation according to 224 should be in an acute care setting environment where nursing services are continuously available; can delegate to UAP • 4. As an RN you provide complicated wound care for a neighbor; you refuse compensation • Yes, exclusion in 224.2

35. 224.6 General Criteria for Delegation • (1) RN must make an assessment of the clients nursing care needs prior to delegating • (2) nursing task must be one that a reasonable and prudent RN would find is within the scope of sound nursing judgment 5 rights • (3) can be properly and safely performed by the UAP, not jeopardizing client’s welfare • (4) requires no professional judgment • (5) adequate identification by individual training, education and/certification, experience/ permit etc.

36. 224.6 General Criteria for Delegation • (6) RN shall either instruct the UAP in the delegated task or verify UAP’s competency • (7) RN must adequately supervise • (8) if the delegation continues over time, the RN must periodically evaluate the delegation of tasks

37. 224.7 Supervision • (2) RN or equally qualified RN shall be available in person or by telecommunication • (A) acute care, long term care- • RN’s presence required to provide nursing services of client whose health status is changing and/or to evaluate the client’s health status • the RN must be readily available to supervise the UAP in the performance of delegated tasks • (B)nursing care provided in the client’s residence • When the client’s status is unstable and unpredictable, RN required to assess, plan intervene, and evaluate the client’s unstable and unpredictable status and need for skilled nursing service • RN makes supervisory visits at least every 14 calendar days. group homes, foster homes

38. Sue, RN, has provided careful instructions to Ted a UAP that she has worked with on many occasions and has had instructions on the task assigned. He is to feed a patient with some history of swallowing difficulties. • a. Allow Ted to do his assigned task • No.224.7 states that an RN’s presence and supervision is required • b. Work side by side with Ted • No.The task can be delegated; Ted has the experience and training; this is unnecessary. • c. Do not assign task to Ted as the patient is unstable • No.The task can be delegated; patient is not unstable at this time; Ted has experience and training in feeding • d. Check with Ted throughout the day • Yes. 224.7 requires that an RN’s presence and supervision is required; Ted has training and experience; your best answer.

39. 224.8 Delegation of Tasks Green Light Tasks • (a) Tasks) Most Commonly Delegated…. • (1) non-invasive and non-sterile treatments • (2) the collecting, reporting, and documentation of data (but not interpreting it) including… • Vital signs, height, weight, I&O, Glucose monitoring; Environmental situations; Client or family comments ….relating to client’s care • (3) ambulation, positioning, and turning • (4) transportation of patient in the facility

40. 224.8 Delegation of TasksGreen Light Tasks Tasks Which are Most Commonly Delegated… . • (5) personal hygiene and elimination, including vaginal irrigations, sitz baths and cleansing enemas • (6) feeding- cutting up of food or placing of meal trays • (7) socialization activities • (8) ADLs • (9) reinforcement of health teaching planned and/or provided by the RN

41. 224.8 Delegation of Tasks Yellow Light Tasks Discretionary Delegation Tasks • (2) nursing tasks not usually within the scope of sound professional to delegate… • (A) sterile procedure …a wound or an anatomical site which potentially can become infected • (B) non-sterile procedure , such as dressing or cleansing penetrating wounds and deep burns • (C) care of broken skin other than minor abrasions or cuts generally classified as requiring only first aid treatment

42. 224.8 Delegation of Tasks Yellow Light Tasks Discretionary Delegation Tasks • (1) may be delegated to UAP if • (A) RN delegating task is directly responsible for nursing care given • (B) Agency employing UAP follows current protocol for training of UAP with input by RN • (C) Protocol recognizes that what can be safely delegated in ANY situation is within the specific scope of the RN’s professional judgment. Most critical

43. 224.8 Delegation of Tasks Red Light Tasks Nursing Tasks Prohibited from Delegation • (1) physical, psychological and social assessment which require professional nursing judgment, intervention, referral, or follow-up • (2) formulation of the NCP and evaluation of the client’s response to the care rendered • (3) specific tasks involved in the implementation of the NCP which require professionals nursing judgment or intervention

44. 224.8 Delegation of Tasks Red Light Tasks Nursing Tasks Prohibited from Delegation • ( • (4) the responsibility and accountability for client health teaching and health counseling which promotes client education and involves the client’s significant others… • Remember the UAP can only reinforce health teaching! • (5) administration of medication, except by medication aides as permitted under 224.9

45. 224.9 The Medication Aide Permit Holder (a) RN may delegate to medication aides the administration of medication to clients in long term care facilities and home health agencies if: • (1) medication aide holds valid permit • (2) RN assures that the medication aide functions in compliance with laws and regulations of the agency issuing the permit • (3) route of administration is oral, via permanently placed feeding tube, sublingual or topical including eye, ear or nose drops and vagina or rectal suppositories

46. 224.9 The Medication Aide Permit Holder • (b) The following tasks may NOT be delegated to medication aides (unless in compliance with Chapter 225 (Independent Living Environments….) • (1)calculation of any medication except for measuring a prescribed amount of liquid medication and breaking tablet that the RN has calculated • (2)Administration of the initial dose of a medication • (3)Administration of medications by an injectable route (except administration of insulin under 225.11 of this title)

47. 224.9 The Medication Aide Permit Holder (b) The following tasks may NOT be delegated to medication aides (unless in compliance with Chapter 225) • (4) administration of medications used for intermittent positive pressure breathing …(225.10) • (5) medications by way of a tube inserted in a cavity of the body except as stated in 225.11 • (6) receiving verbal or telephone orders from a physician, dentist • (7) ordering a client’s medication from the pharmacy

48. Answer These Questions about the Medication Aide Permit Holder in a Long Term Care Facility 2. The home care patient that the UAP is caring for has run out of her medication and needs to have her medications re-ordered. What action is appropriate? • A. Contact the RN to order the medication • B. Have the UAP re-order the medications • C. Have the patient re-order the medications 1. The Medication Aide can do all the following except: • A. administer eye drops • B. administer an enema • C. administer insulin • D. administer first dose of new medication

49. Test your Understanding of DelegationGeneral Criteria • As a new RN you have this patient assignment with a UAP. It is 8 am. Determine, based upon the Nurse Practice Act, which assignment should be given to the UAP and why. • a. Mr. C a 20 year post op ORIF • b. Mr. Z. an 80 year old demanding that he wants breakfast! • c. Ms. F a 40 yr old male stating that she has “heart burn” and wants breakfast to relieve the discomfort. • d. Mr. A a 70 yr old confused, incontinent male • e. Ms. G. a first day post-op hernia repair who needs to ambulate. • f. Ms. R. who has discharge orders and demands to go home

50. 224.10 Supervising UAP Performing Task Delegated by Other Practitioners (a) Applies to …professional nurse who practices…with a licensed practitioner who has delegated tasks to an UAP over whom the RN has supervisory responsibilities. The RN’s accountability to the BON, with respect to its taking disciplinary action against the RN’S license is met if the RN: • Verifies the training of the UAP • Verifies that the UAP can properly perform the task and not jeopardize the clients welfare… • Adequately supervises the UAP • (b) If the above not met…must communicate this fact to the licensee who delegated the task