1. Delegation & Supervision FOR CLINICAL DECISION MAKING RNSG 1247 DR. SADDLER, PHD ASSOCIATE DEGREE NURSING PROGRAM HOUSTON COMMUNITY COLLEGE – COLEMAN HEALTH SCIENCES

2. Objectives Using Fink’s (2013) taxonomy of learning in the cognitive realm, the students will successfully accomplish these objectives at the end of the lecture: 1. Identify specific strategies that increase the likelihood of effective delegation (Foundational Knowledge). 2. Critique a short video scenario regarding nursing delegation (Application). 3. Differentiate between tasks that should and should not be delegated (Integration). 4. Value the importance of delegation in their future role as a registered nurse (Human Dimension). 5. Respect their own abilities in becoming an effective delegator (Caring). 6. Identify important sources of information on proper delegation policies (Learning How to Learn).

3. Short Video

4. Introduction  Delegation  Getting work done through others or as directing the performance of one or more people to accomplish organizational goals  An essential element of directing the phase of management process  Occurs for many reasons

5. Introduction (cont.)  Good reasons for delegating  Too much work to accomplish alone  Time needed to accomplish other things that others may not have the expertise to do  Someone else is better qualified.  Opportunity to learn new things and experience success  Successful delegation enhances the power and impact of the delegator.

6. The Delegation Process 1. Define the task. 2. Decide on the delegate. 3. Determine the task. 4. Reach agreement. 5. Monitor performance and provide feedback.

7. Delegating Effectively  Requires trust to delegate  Requires communication  Requires training  Requires monitoring  Absolutely critical to managerial productivity and efficiency

8. Strategies for Successful Delegation  Plan ahead  Carefully assess situation  Attempt to delegate before becoming overwhelmed  Clearly delineate the desired outcome  Identify necessary skills and education levels  May be determined by legal and licensing statutes  Must identify skill or educational level necessary to complete the job

9. Strategies for Successful Delegation (cont.)  Identify necessary skills and education levels (cont.)  Be aware of state NPA essential elements regarding delegation  The definition of delegation  Items that cannot be delegated  Items that cannot be routinely delegated  Guidelines about tasks that can be delegated  A description of professional nursing practice

10. Strategies for Successful Delegation (cont.)  Identify necessary skills and education levels (cont.)  Be aware of state NPA essential elements regarding delegation (cont.)  A description of LPN/LVN nursing practice and unlicensed nursing roles  The degree of supervision required to complete the task  Guidelines for lowering delegation risks  Warnings about inappropriate delegation  If there is a restricted use of the word “nurse” to licensed staff

11. Strategies for Successful Delegation (cont.)  Select capable personnel  Identify who can complete the job  Delegated task should be considered important  Communicate goals clearly  Empower the delegate  Give them the resources and power to carry out the task  Set deadlines and monitor progress  Periodic reviews

12. Strategies for Successful Delegation (cont.)  Model the role and provide guidance  Convey feeling of confidence and encouragement  Encourage employees to solve problems  Be available to answer questions, provide guidance  Find balance between providing guidance and allowing others to determine how to accomplish a task  Reassuming should be the last resort.

13. Strategies for Successful Delegation (cont.)  Evaluate performance  Include positive and negative aspects  Shared reflection  Reward accomplishment  Appropriately reward a successfully completed task  Leaders measured by successes of the team

14. Question 1  Which of the following is not a good reason to delegate (Knowledge)? A. Need to accomplish other things that others may not have the expertise to do B. Someone else is better qualified. C. The person who achieves the delegated task has the opportunity to learn new things. D. You ran out of time to finish a project.

15. Answer  D. You ran out of time to finish a project  Rationale: Part of delegating a task is to ensure the individual has the proper amount of time to complete the task.

16. Question 2  Responsibility and accountability are both transferred to the delegate when a task is delegated (Comprehension). A. True B. False

17. Answer  B. False  Responsibility is transferred to the delegate when a task is delegated, but accountability is shared.  Responsibility – obligation to accomplish the task  Accountability – accepting ownership for the results or lack thereof

18. Common Delegation Errors  Delegation is a critical leadership skill that must be learned.  Common delegating errors  Underdelegating  Overdelegating  Improper delegating

19. Common Delegation Errors (cont.)  Underdelegating  Common causes  Fear that the manager will be perceived as incapable of completing a task  Need to do it all yourself  Lack of trust in others  Enjoy doing the task  Lack of skill in delegation or leadership  Waiting too long to delegate a task

20. Common Delegation Errors (cont.)  Overdelegating  Managers poor managers of time  Spending most of the time just trying to get organized  Feel insecure in ability to perform a task  Staff should have the right to refuse a delegated task.  Managers should ask first.  Avoid overworking competent employees

21. Common Delegation Errors (cont.)  Improper delegating  Occurs when managers lack basic management skills  Delegating at the wrong time, to the wrong person, or for the wrong reason  The person may not be capable.  Delegating decision making without providing adequate information

22. Question 3  Ellen, GN, is in her 6 th week of orientation in the trauma ICU. Her mentor, Amy, RN, notes that Mr. Anderson is scheduled for an MRI off the unit. Amy delegates the task of escorting Mr. Anderson to the MRI unit to Ellen who is not ACLS certified. During the MRI, Mr. Anderson is accidentally extubated and suffers respiratory and cardiac arrest. A code is called in the MRI suite and ER nurses must respond since an ACLS certified nurse in not with the patient.  This is an example of what delegation error (Application)? A. Underdelegation B. Overdelegation C. Reverse delegation D. None of the above.

23. Answer  B. Overdelegation  Amy (delegator) lost control of the situation by providing Ellen (delegate) too much authority/responsibility (transferring with no ACLS certification). The delegator is put in risk for liability.

24. The Five Rights of Delegation 1. Right Task: right task for a specific need 2. Right Circumstances: appropriate setting, available resources, and other relevant factors considered 3. Right Person: right person is delegating the right task to the right person to be performed on the right person. 4. Right Direction/Communication: clear, concise description of the task, including its objective, limits, and expectations 5. Right Supervision: appropriate monitoring, evaluation, intervention, as needed, and feedback

25. Delegation as a Function of Professional Nursing  To increase likelihood that increased delegation does not result in unsafe work environment, organizations:  Have a clearly defined structure where RNs are recognized as leaders of health care team  Job descriptions clearly define roles and responsibilities.  Educational programs help personnel learn roles and responsibilities of others.  Adequate programs are developed to foster leadership and delegation.

26. Delegating to Unlicensed Assistive Personnel  In 1990s, licensed professional nurses were replaced with unlicensed assistive personnel (UAP) or nursing assistive personnel (NAP).  This was in an effort to contain spiraling health care costs.  NAP free RNs to perform more complex duties.  Assuming the role of a delegator and supervisor to NAP increases scope of liability for RNs.  Should assess risk of failure before they decide to delegate a task

27. Delegating to Unlicensed Assistive Personnel (cont.)  RNs are not automatically held liable, but they may be held liable if they were negligent in the supervision of those employees at the time they committed the negligent act.  An RN needs to know the skill level of the person to whom work is delegated.  No required education standards or guidelines for NAP in acute-care hospitals  NAP educational levels vary from state to state.  May not be a distinct job description that describes the NAP scope of practice

28. Delegating to Unlicensed Assistive Personnel (cont.)  Some state boards of nursing trying to define scope of practice of NAP  Decision tree for delegation  Step-by-step analysis RNs can use  RNs must never lose sight of their ultimate responsibility for caring for the patient.  Only RNs have the formal authority to practice nursing.  RNs must continue to seek current information regarding national efforts to standardize scope of practice for NAP.

30. Get Familiar! Know your roles and the roles of others.  Texas Board of Nursing: Scope of Practice for a Registered Nurse  https://www.bon.state.tx.us/practice_scope_of_practice_rn.asp https://www.bon.state.tx.us/practice_scope_of_practice_rn.asp  Texas Board of Nursing: Scope of Practice for a License Vocational Nurse  https://www.bon.state.tx.us/practice_scope_of_practice_lvn.asp https://www.bon.state.tx.us/practice_scope_of_practice_lvn.asp

31. Commonly Delegated Tasks according to TBON  Rule 224.8  Tasks Which are Most Commonly Delegated. By way of example, and not in limitation, the following nursing tasks are ones that are most commonly the type of tasks within the scope of sound professional nursing practice to be considered for delegation, regardless of the setting, provided the delegation is in compliance with §224.6 of this title (relating to General Criteria for Delegation) and the level of supervision required is determined by the RN in accordance with §224.7 of this title (relating to Supervision):

32. Commonly Delegated Tasks according to TBON (cont.)  (1) non-invasive and non-sterile treatments;  (2) the collecting, reporting, and documentation of data including, but not limited to:  (A) vital signs, height, weight, intake and output, capillary blood and urine test;  (B) environmental situations;  (C) client or family comments relating to the client's care; and  (D) behaviors related to the plan of care;  (3) ambulation, positioning, and turning;  (4) transportation of the client within a facility;  (5) personal hygiene and elimination, including vaginal irrigations and cleansing enemas;  (6) feeding, cutting up of food, or placing of meal trays;  (7) socialization activities;  (8) activities of daily living; and  (9) reinforcement of health teaching planned and/or provided by the registered nurse.

33. Subordinate Resistance to Delegation  Resistance common response  The delegator needs to see the delegated task from the subordinate’s perspective.  NAP must frequently adapt rapidly to changing priorities, often imposed by more than one delegator.  Subordinates believe they are incapable of completing a task; lack self- confidence.  Inherent resistance to authority  The task is overdelegated in terms of specificity, no room for creativity and independent thinking.

34. Case Study Scenario You are a senior nursing student caring for a patient with multiple fractures and a closed head injury in a neurotrauma unit as part of your clinical rotation. You feel challenged in caring for this patient (Mr. Smith) as there is much to learn about the many treatments, medications, and technologies being used as part of his care. As you are in the room providing care to Mr. Smith, his physician arrives and being asking you a few questions. You are a little nervous that the staff nurse assigned to Mr. Smith is not present, but are pleased with yourself that you are able to answer all the questions he has asked. The physician then turn to you as he is leaving the room, and issues two orders; one related to the ventilator settings for the patient and one related to his IV fluids. You quickly respond that you are a nursing student and cannot take the medical orders, but he simple says, “You are a smart guy/girl and you heard I said—Just pass it on to the nurse so she can write the order. I’m already late for surgery.” With that, he leaves.

35. Question 4  How did differences in power and status affect this delegation (Analysis)? A. The doctor delegated the right task to the nursing student. B. The nursing student should have been less nervous and accepted the verbal order. C. As a nursing student, you do not have an active license to take or carry out verbal orders from doctors. D. As a nursing student, you should do what the doctor says.

36. Answer  C. As a nursing student, you do not have an active license to take or carry out verbal orders from doctors.  Rationale: Interacting with doctors can be intimidating, but you do not have a license to carry out the order as a nursing student. Be knowledgeable of your role and do the right thing regardless if someone insists on it.

37. Question 5  Predict what you will do next (Synthesis)?

38. Answer  Open discussion.

39. Question 6  How would you have handled this situation to minimize the likelihood of this occurring (Evaluation)? Choose all that apply. A. Clearly state your role as a student nurse. B. Get your preceptor. C. Leave the room before he asks questions. D. None of the above.

40. Answer  A&B  Rationale: It’s important that you and the doctor understand your scope of practice as a student nurse. Getting the right person for the delegated task needs to be present. Leaving the room before being asking questions is not communicating effectively.  Any other suggestions?

42. References  Fink, L.D. (2013). Creating significant learning experiences: An integrated approach to designing college courses. San Francisco: CA: Jossey-Bass.  Knowles, M.S., Holton, E.F. & Swanson, R.A. (2012). The adult learner: The definitive classic in adult education and human resource development. London & New York: Routledge.  Marquis, B.L., Huston, C.J. (2012). Leadership and management tools for the new nurse. Philadelphia: Lippincott Williams and Wilkins.  Sullivan, E. J. (2012). Effective leadership and management in nursing (8th ed.). Boston: Pearson.