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RN. Delegation and Decision Making. UAP. LVN. 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? .

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delegation and decision making

RN

Delegation and Decision Making

UAP

LVN

decision making and delegation
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?
decision making and delegation1
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.
why is it so important
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
characteristics of critical thinkers
Characteristics of Critical Thinkers
  • Open minded
  • Systematic
  • Analytical
  • Inquisitive
  • Judicious
  • Truth seeking
  • Confident in reasoning
what is a critical thinking disposition
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.

critical thinking exercise
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?
steps in the decision making process
Steps in the Decision Making Process
  • Data gathering
  • Analysis
  • Establishing Goals/Outcomes/Strategies
  • Implement chosen alternatives
  • Evaluate Outcomes
  • Resources
decision making tools
Decision Making Tools
  • Listing Pros and cons
  • Algorithms
  • Clinical pathways
  • Thinking hats
group decision making questions
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?
methods of participative group decision making
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
other approaches used for participative decision making
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

sources of ethical guidance
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…
supporting ethical decision making
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

decision making to delegation
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

problems with delegating and uaps
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

national council of state boards of nursing
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.

delegation
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.
slide23

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

assignment versus delegation
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
5 rights of delegation ncsbn
5 Rights of Delegation (NCSBN)

Right Task

Right Direction/Communication

Right Circumstances

Right Supervision/ Evaluation

Right Person

5 rights of delegation ncsbn1
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
evaluation and feedback
Evaluation and Feedback
  • Evaluation
  • Feedback
  • There is no blanket delegation of tasks
stay focused
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?
questions to ask before delegating
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?
nursing practice act

Nursing Practice Act

Delegation Resource

RULES AND REGULATIONS related to PROFESSIONAL NURSE EDUCATION, LICENSURE AND PRACTICE

bon delegation rules
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
slide33
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
which of the following situations are exclusions to the nurse practice act according to 224 2
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
224 6 general criteria for delegation
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.
224 6 general criteria for delegation1
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
224 7 supervision
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
slide38

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.
224 8 delegation of tasks green light tasks
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
224 8 delegation of tasks green light tasks1
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
224 8 delegation of tasks
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
224 8 delegation of tasks1
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
224 8 delegation of tasks2
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
224 8 delegation of tasks3
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
224 9 the medication aide permit holder
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
224 9 the medication aide permit holder1
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)
224 9 the medication aide permit holder2
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
answer these questions about the medication aide permit holder in a long term care facility
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
test your understanding of delegation general criteria
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
224 10 supervising uap performing task delegated by other practitioners
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
the power to delegate
The Power to Delegate?
  • MD’s from the BME
    • MD employs MA; Can RN supervise the MA in office situation?
    • No. 224.10 “depends if RN has ‘supervisory responsibility over the MA…and verify training of the UAP, can verify task and can supervise the UAP…”
  • LVNs may not delegate
  • RN’s do not delegate to LVNs
  • RN’s make assignments to LVN’s
  • BON of Texas
  • RN’s cannot “give-away” accountability or quality of care
answer a couple of challenging questions
Answer a couple of challenging questions!
  • 1. A nurse delegates a glucose finger stick to UAP who records a result of 40, but fails to notify the RN of the finding. Legal accountability for the delayed intervention would be with the
      • a. RN
      • b. unit manager
      • c. UAP
      • d. hospital
  • 2. Which statement to a UAP is MOST likely to accomplish the desired result of getting a blood gas to the lab immediately?
      • a. “This is stat!”
      • b. “Take this specimen to the lab immediately. We need the results now.”
      • c. “Please do this as soon as possible!”
      • d. “I need this in the lab now as the patient’s p02 is 84.”
test your understanding
Test your Understanding
  • As a RN you have an eager nursing student working as a CA on your team. A NG tube needs to be inserted. The CA /nursing student wants the opportunity to perform the skill. What is your best response?
    • A. Sure, go ahead.
    • B. Have you ever done it before?
    • C. In your role as CA you cannot insert an NG tube
    • Your best answer…as a CA your job description would not include this role, though you had training in nursing program…might be permitted to do this IF directly assisting the RN in performing the procedure. 224.2
  • In an emergency situation, Mary the RN requests Ed, the UAP, to assist in inserting a Foley catheter into an uncooperative patient. Ed had previous training in the skill; Mary directly supervises the procedure.
    • Is this delegation?
    • No this is not delegation: Mary is directly assisting Ed in the procedure. See 224.2
rule 225 independent living environment
Rule 225 Independent Living Environment

Three levels of tasks

Activities of daily living (ADLs)

Health maintenance tasks

Nursing tasks

  • Gate Keeping Criteria
    • Independent Living Environment
    • Client or client’s responsible adult (CRA) is willing and able to participate in decisions
    • Tasks are related to stable and predictable health care conditions
225 6 b rn assessment of client
225.6(b) RN assessment of client
  • Six criteria
    • Ability of client
    • Support systems
    • Tasks
    • Client’s knowledge base
    • Traditional and non-traditional methods for communication
    • Frequency of Assessment
rn exemption from delegation
RN exemption from Delegation
  • If RN determines criteria under 225.6 are adequate in relation to
    • Activities of daily living (ADLs)
    • Health Maintenance Activities (HMAs)
  • RN may decide these tasks do not require involvement of RN
225 9 delegation criteria
225.9 : Delegation Criteria
  • Task does not require nursing judgment
  • UAP experience/competency
  • Employer has policy re: Delegation is decision of RN
  • Level of RN supervision
  • Five rights of delegation
more delegation criteria supervision
More delegation criteria: Supervision
  • Amount of supervision based on:
    • Client condition
    • UAP competency
    • Nature of task
    • Availability of RN’s to UAP
    • Client’s/CRA’s level of participation
tasks that may not be delegated
Tasks that may not be delegated
  • Rule 225.10- includes
    • ADL’s and HMA’s
    • Maintenance of indwelling tubes (foley, trach)
    • Maintenance O2, scheduled inhalation treatments
medication administarion
Medication administarion
  • Oral or via g-tube
  • Sublingual
  • Topical
  • Eye, ear, nose drops and sprays
  • Vaginal or rectal suppositories
  • Only injectable insulin (No other injectables)
  • No IV meds or fluids
prohibited medication tasks
Prohibited medication tasks
  • Does calculation
  • Injectable medications (except insulin)
  • Medications via a non-permanent tube
  • Verbal and telephone orders
  • Initial dose
slide63

What is my liability and how does delegation affect my license?RN’s are not automatically held liable for all acts of negligence on the part of those they supervise, but they can be if they were negligent in their supervisionUAP’s carry some accountability of their own and always have

http://www.lopez1.com/lopez/clinical.cases/092699.htm

slide64

Discuss situations in which the RN might incorrectly delegate.

You are the charge nurse on a pediatric unit. You have 16 patients. Staffing is yourself, one UAP and one LVN who routinely work on this unit, and an ER nurse who has been pulled to your unit for the shift. This is the first time he has worked on your unit. What criteria would you use to make assignments?

tips for effective delegation
Tips for Effective Delegation
  • Start with a positive attitude.
  • Clarify availability- especially if UAP with many RN’s
  • Give clear directions in a respectful manner. Include reportable parameters.
  • Be fair about undesirable activities.
  • Indicate priorities
  • Give and receive feedback
where do the lvn s fit into this
Where do the LVN’s fit into this?
  • Most, but not all, limit LPN scope of practice to:
    • collects, validates, organizes, and reports data,
    • contributes to assessment (not initial assessment)
    • selects standardized plan of care based on nursing diagnoses
    • contributes to identification of priorities, goals, and nursing activities
    • implements teaching plans
    • evaluates client responses & revises plan of care.
    • See link to compare LVN-RN Scope of Practice (print)
activities usually outside lvn scope of practice
Activities Usually Outside LVN Scope of Practice
  • Administering infusions of:
    • blood/blood products
    • total parenteral nutrition
    • chemotherapeutic or antineoplastic agents;
  • Administration of IV therapy to neonates.
  • Administration of some IV push medications.
  • Mixing IV medications.
questions
Questions
  • You are caring for a patient with esophageal cancer. Which task could be delegated to the nursing assistant?
  • Assist the patient with oral hygiene
  • Observe the patient’s response to feedings
  • Facilitate expressions of grief
  • Initiate daily weights
questions1
Questions
  • In caring for a patient with neutropenia, what tasks can be delegated to the nursing assistant? (Choose all that apply)
  • 1. Take vital signs every 4 hours.
  • 2. Report temperature elevation >100.4 F
  • 3. Assess for sore throat, cough or burning with urination.
  • 4. Gather the supplies to prepare the room for protective isolation.
  • 5. Report superinfections, such as candidiasis.
  • 6. Practice good handwashing technique.
question
Question
  • Which actions should you delegate to the nursing assistant for the client with diabetic ketoacidosis?
  • 1.Check finger stick glucose every hour.
  • 2. Record intake and output every hour
  • 3. Check vital signs every 15 minutes
  • 4. Assess for indicators of fluid imbalance
  • Taking accuchecks require additional training and is not automatically delegated without asking questions
delegation1
Delegation!

The End!

Review your Nurse Practice Act; and Apply the 5 rights of Delegation (task, circumstance, person, direction/communication, supervision/evaluation)

Delegation Gone Wild