Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 18 Effective Delegation and Supervision

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Effective Delegation and Supervision Delegation and Supervision in the Health Care System

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.  Reduced reimbursement from Medicare, Medicaid, and private insurance companies  Prospective payment system  Growing uninsured population  Rapid advances in medical technology  Nursing shortage Issues Affecting Staffing Patterns

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Changes in Staffing Patterns  Decline in the number and utilization of registered nurses (RNs) and an increase in the employment of nursing assistive personnel (NAP)  Increased utilization of NAP forces the RN to delegate more nursing tasks.  Roles and responsibilities of care providers (RNs, licensed practical nurses/licensed vocational nurses [LPNs/LVNs], NAP) are significantly overlapping

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.  Need competent, appropriately supervised NAP and LPNs/LVNs in patient care  RNs’ confidence with delegation and supervision skills is essential  RNs must understand legal responsibility related to delegation and supervision Economic Necessity

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Effective Delegation and Supervision What Is Delegation?

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Definition  Transfer of responsibility for the performance of an activity from one individual to another while accountability for the outcome is retained  RN transfers responsibility and authority for the performance of an activity but remains accountable for overall nursing care  Management strategy used to ensure the accomplishment of cost-effective patient care

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Two-Way Process  RN delegator is responsible for the following: The act of delegation The act of delegation Supervising the performance of the delegated task Supervising the performance of the delegated task Assessment and follow-up evaluation Assessment and follow-up evaluation Any intervention or corrective action that may be required to ensure safe and effective care Any intervention or corrective action that may be required to ensure safe and effective care

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Two-Way Process  The delegatee (LPN/LVN, NAP) is accountable for the following: His or her own actions His or her own actions Accepting delegation within the parameters of his or her training and education Accepting delegation within the parameters of his or her training and education Communicating the appropriate information to the delegator Communicating the appropriate information to the delegator Completing the task Completing the task

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Effective Delegation and Supervision What Should and Should Not Be Delegated?

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.  No definitive list of what can and cannot be delegated  Varies among states, organizations, and specific situations  Assessment, evaluation, and nursing judgment cannot be delegated. No Definitive List

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. No Definitive List  RNs will have to seek guidance and integrate information from State Nursing Practice Acts State Nursing Practice Acts Patient needs Patient needs Job descriptions Job descriptions Employee competency Employee competency Policies and procedures Policies and procedures Clinical situation Clinical situation Professional standards of nursing practice Professional standards of nursing practice

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.  State Nursing Practice Acts  Will provide guidance for legal delegation  Delegation criteria may not be clearly spelled out or may be presented in various parts of the Act  State board of nursing also may offer guidance  RN should understand the legal scope of practice for an LPN/LVN  Practice by NAP is generally governed by the health care organization’s standards State Nursing Practice Acts

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.  RN is required to perform a patient assessment and to know the level of care required  Generally, the more stable the patient, the more likely delegation is to be safe  Many tasks that can be delegated may be intertwined with a nursing responsibility Patient Needs

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.  Delineates the tasks, duties, and responsibilities required as a condition of employment  Generally comply with state laws and the health care organization’s standards of care  RN should be aware of the job training required to function as described in the job description  In all cases, legal requirements related to delegation supersede any organizational policy or job description Job Descriptions

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.  Staff member must have the skills and knowledge necessary to perform a task before it is delegated  Competencies confirm that the individual has demonstrated specific knowledge and skills  Regulatory and accrediting agencies, such as The Joint Commission, require written documentation of staff competencies  RNs should be knowledgeable about the documented competencies of staff members whom they supervise Competencies

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.  Examples of competencies for an ambulatory care clinic: Medication management Medication management Telephone triage Telephone triage Infection control Infection control Glucose testing Glucose testing Reporting abuse and neglect Reporting abuse and neglect Competencies

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.  The specific skill and supervision requirements for various tasks are designated in written policies and procedures  Ensure that the delegatee is trained in and understands the organization’s general standards of care (e.g., infection control) Organizational Policies and Procedures

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.  Does the NAP/LPN/LVN realistically have time to perform the task?  Is the staff member familiar with characteristics of the patient population?  How complex is the task?  Does the individual have the resources (supplies, equipment) to perform the task?  Is the RN able to provide an adequate level of supervision? Clinical Situation

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.  Professional standards of nursing practice  Agreed-upon levels of nursing practice as determined by the American Nurses Association (ANA) and specialty nursing organizations  ANA’s standard states that in delegation, the RN will consider the following: Assessment of the patient condition Assessment of the patient condition Capabilities of the nursing and assistive staff Capabilities of the nursing and assistive staff Complexity of the task to be delegated Complexity of the task to be delegated Amount of clinical oversight (supervision) the RN will be able to provide Amount of clinical oversight (supervision) the RN will be able to provide Staff workload Staff workload Professional Standards of Nursing Practice

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.  ANA has delineated activities that can be delegated by the nurse Functions that are technical and assistive in nature and can be taught (e.g., feeding, ambulating a stable patient) Functions that are technical and assistive in nature and can be taught (e.g., feeding, ambulating a stable patient) Activities that provide amenities to the patient (e.g., making beds, cleaning the environment) Activities that provide amenities to the patient (e.g., making beds, cleaning the environment) Professional Standards of Nursing Practice

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.  ANA has delineated activities that the RN cannot delegate: Initial nursing assessment and any subsequent assessment that requires nursing knowledge, judgment, and skill Initial nursing assessment and any subsequent assessment that requires nursing knowledge, judgment, and skill Determination of nursing diagnoses Determination of nursing diagnoses Establishment of nursing care goals Establishment of nursing care goals Development of nursing plan of care Development of nursing plan of care Evaluation of patient’s progress Evaluation of patient’s progress Health counseling or teaching Health counseling or teaching Activities that require specialized nursing knowledge, skill, or judgment Activities that require specialized nursing knowledge, skill, or judgment Professional Standards of Nursing Practice

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Effective Delegation and Supervision Developing Safe Delegation Practices

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.  Establish a foundation of knowledge  Know delegation criteria delineated in the state’s Nursing Practice Act  Know specific skill requirements designated in written policies, procedures, and standards of care  Know delegatee’s scope of practice, competencies, and job description  Know professional standards for nursing practice and specific recommendations on delegation Establish a Foundation of Knowledge

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Know the Patient  Assess the patient before delegation  What is the potential for change in the patient’s condition as a result of the delegated task?  Can the patient’s safety be maintained with delegated care?

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Know the Staff Member  Does the staff member have the skills and knowledge necessary to perform the task?  Does the staff member perform the task on a routine basis?  Be involved in training programs and the development of job descriptions for NAP and LPNs/LVNs

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Know the Task to Be Delegated  RN delegator must be competent and skilled in performing the task  Task must be in the RN’s scope of practice  Routine, standardized tasks are the safest to delegate  Complex tasks or activities that convey high risk for patient complications or unpredictable outcomes must be carefully considered

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Explain Task and Outcomes  Failure to effectively communicate may result in unsatisfactory performance, errors, or patient harm  Clearly explain the task, what must be done, and the expected outcomes  Demonstration and return demonstration may be required

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Expect Responsible Action  Delegatee becomes responsible for his or her own actions  RN should supervise appropriately  RN should not intervene unless assistance is requested, or an unsafe situation is recognized

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Assess and Supervise Job Performance  Assess and supervise job performance:  Make frequent rounds, observe, and communicate  Provide the appropriate level of supervision  Be available for questions or unexpected problems  Supervise in a positive and 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

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Provide for Positive Outcomes  Ongoing communication and support are vital  Necessary resources to perform the tasks should be available

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Evaluate and Follow Up  Evaluate and follow up:  Always evaluate the delegated action by reassessing the patient  Evaluate the staff member’s performance  Follow up with any interventions that may be required  Review and document the skills that were learned

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Characteristics of High-Risk Delegation  Delegated task can be performed only by the RN according to law, organizational policies, or professional standards of nursing practice  Delegated task could involve substantial risk or harm to a patient  RN knowingly delegates a task to an individual who does not have appropriate training  RN fails to provide adequate supervision  RN does not evaluate the delegated action by reassessing the patient

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Delegation and the Nursing Process  Components of the delegation process become familiar when compared with the nursing process  Assess the patient and plan the care, then identify tasks that someone else can perform  Implement the plan of care, and assign and supervise task performance  Evaluate the delegatee’s performance, planned outcomes, and client response

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. “Five Rights of Delegation”  Right task: Delegated tasks must conform to established guidelines  Right circumstances: Delegated tasks do not require independent nursing judgment  Right person: One who is qualified and competent  Right direction and communication: Clear explanation about the task and outcomes and when the delegatee should report back to the RN  Right supervision and evaluation: Feedback to assess and improve the process; evaluate patient outcomes

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Effective Delegation and Supervision Supervision

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Definition  The active process of directing, guiding, and influencing the outcome of a worker’s performance  On-site supervision—The nurse is physically present or is immediately available while the activity is being performed  Off-site supervision—The nurse has the ability to provide direction through various means of written and verbal communication

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Definition  Distinction between on-site and off-site supervision has become unclear with the use of telecommunications technologies  ANA has established operational guidelines for supervision related to telecommunication technologies Who is in control of the activity? Who is in control of the activity? How should controls be instituted? How should controls be instituted?

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Components of Supervision  Initial direction: instructions provided when the task is first delegated  Periodic inspection: the decision the RN makes regarding frequency of monitoring the delegatee’s performance

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Levels of Supervision  Unsupervised One RN works with another RN in a collegial relationship One RN works with another RN in a collegial relationship Neither RN is in the position of supervising the other Neither RN is in the position of supervising the other

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Levels of Supervision  Initial direction/periodic inspection RN is supervising a licensed or unlicensed caregiver RN is supervising a licensed or unlicensed caregiver Knows the individual’s training and competencies Knows the individual’s training and competencies Has developed a working relationship with the individual Has developed a working relationship with the individual

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Levels of Supervision  Continuous supervision RN has determined that the delegatee will need very frequent to continual support and assistance RN has determined that the delegatee will need very frequent to continual support and assistance Continuous supervision is required when Continuous supervision is required when  The working relationship is new  The task is very complex  The delegatee is inexperienced or has not demonstrated an acceptable level of competence

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Effective Delegation and Supervision Assigning versus Delegating

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Definition of Assignment  Distribution of work that each staff member is responsible for during a given work period  Designates activities consistent with job position and description, legal scope of practice, and educational background  The staff member assumes responsibility and is accountable for completing the assignment.

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Assignment Considerations  Assigning groups of clients to various care providers, including NAP and LPNs/LVNs is not appropriate  NAP assignments would include functions and tasks  LPNs/LVNs may be assigned specific clients for which to perform care, but RNs remain responsible for all nursing practice activities

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Assignment Considerations  The RN is responsible for assignments made to nursing personnel and should consider the following: Patient’s physiologic status and complexity of care Patient’s physiologic status and complexity of care Infection control or cross-contamination issues Infection control or cross-contamination issues Level of supervision required Level of supervision required Staff development opportunities such as assigning a less experienced nurse to a more complex patient with an increased level of supervision Staff development opportunities such as assigning a less experienced nurse to a more complex patient with an increased level of supervision

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Utilizing the Interdisciplinary Health Care Team  Interdisciplinary team members will be valuable in meeting patient care needs  RNs should know scope of practice and training background of team members

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Utilizing the Interdisciplinary Health Care Team  RN should know how the work is delegated or assigned to interdisciplinary team members Interdisciplinary team members may report to the RN, who is responsible for assigning and delegating patient care tasks Interdisciplinary team members may report to the RN, who is responsible for assigning and delegating patient care tasks Interdisciplinary team members may report to supervisors in their individual disciplines and may work in a collaborative manner with the RN to provide patient care Interdisciplinary team members may report to supervisors in their individual disciplines and may work in a collaborative manner with the RN to provide patient care

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Effective Delegation and Supervision Building Delegation and Supervision Skills

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.  Fear of being disliked, losing control, taking risks, making mistakes  Lack of confidence  Lack of knowledge Novice Nurses’ Barriers to Effective Delegation

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Communicate Effectively  Know exactly what needs to be done and what outcomes are expected  Maintain self-control and confidence  Listen carefully to the delegatee’s response  Ask for feedback by using open-ended, nonthreatening statements if the delegation action elicits a negative response

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Create an Environment of Trust and Cooperation  Maintain a nonthreatening and nonjudgmental attitude—Problems will be reported more quickly  Avoid blaming and criticizing when mistakes occur—Look for root causes such as inadequate training or too heavy workload  Encourage staff members to report and discuss problems

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Create an Environment of Teaching and Learning  Remember that inadequate training is a common cause for poor performance in the work setting  Identify staff learning needs and provide educational programs aimed at building skills and competencies  Be willing to teach and demonstrate how to perform a task rather than merely telling how it should be done

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Promote Patient Satisfaction  Clients need and want to know their caregivers’ qualifications  The RN is responsible for describing the health care team to the client

Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Provide Feedback and Follow Up  Delegation process is not complete until the RN reassesses the patient and adjusts the plan of care as indicated  Provide honest feedback to the delegatee about his or her performance  Praise good performance  Address poor job performance  Stop inappropriate, unsafe, or incompetent performance immediately; document and report to the nurse manager or supervisor  Request additional training or other appropriate action to ensure that patient safety is protected