Delegating in a Dynamic Healthcare Environment

1. Delegating in a Dynamic Healthcare Environment Carolyn Morse Jacobs, RN, MSN, ONC

2. 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

3. Dynamic Environment • Influencing Factors • Demographic trends • population getting older • nurses maturing! • Cost of healthcare • reimbursement about 35 cent on the dollar (routine tasks by others, staff mix) • consumer involvement • Changing nature of work • healthcare delivery trends • more unlicensed personnel • team building • Advocacy Groups • Individuals with disabilities

4. History of Delegation • First 1980 • Revised in 1992 • BNE legislatively mandated to review rules • every 4 years • Re-organized in 2001 • New guidelines in 2003 for Texas 224.1-225 • Now combined RN Board Nurse Examiners with LVN Board Nurse Examiners. See BNE

5. BNE of Texas RN’s cannot “give-away” accountability or quality of care 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 The Power to Delegate?

6. Board of Nurse Examiners • Primary purpose • protect the public from unsafe practice of nursing • Powers and duties • approving schools of nursing • granting or revoking licenses • regulating practice of the profession

7. 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

8. Key Points • Delegable tasks • do not require application of the nursing process • are safest when results are predictable and low risk • policies developed “should be” consistent with practices rules • No “blanket delegation”

9. Key Points • RN Assessment • Reasonable and Prudent RN • Ask can the Task be Delegated • No Nursing Judgment • Identify UAP • Verify Competency • Supervision • RN Accountable • Clear Communication • Careful Follow-up/evaluation • Right Circumstance

10. Key Points • Unstable and unpredictable • Requires RN’s regularly scheduled presence • RN must be readily available to supervise

11. Nursing Practice Acthttp://www.bne.state.tx.us/ RULES AND REGULATIONS related to PROFESSIONAL NURSE EDUCATION, LICENSURE AND PRACTICE

12. Delegation of Nursing Tasks by Registered Professional Nurses to UAP for Clients with Acute Conditions or in Acute Care Environments 224.1-224.11 224.1 Applications of chapter (1) …client has an acute health condition that is unstable or unpredictable (2) …client in acute care environment where nursing services are continuously provided…hospitals, etc 224.2 Exclusions from Chapter (1) tasks provided related to Gov. Code 531.051 or

13. 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 an 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

14. Determine in the following situations if and how 224.2 of the Nurse Practice Act applies. • As an RN you assign the LVN on your team to provide care for a group of 6 patients • As an RN you work with a nursing student in an externship and supervise the student while he/she gives IV push medications • As an RN you assign the CA to check intake and outputs for patients in room 1-10 • As an RN you provide complicated wound care for a neighbor; you refuse compensation

15. Determine in the following situations if and how 224.2 of the Nurse Practice Act applies. • 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 No, does not apply, exclusion in 224.2 • As an RN you assign the CA to check intake and outputs for patients in room 1-10 Yes, see 224.1 should be in an acute care setting environment where nursing services are continuously available; can delegate to UAP • As an RN you provide complicated wound care for a neighbor; you refuse compensation No, does not apply, exclusion in 224.2

16. 224.3 Purpose • RN unique position to develop and implement a nursing plan of care that incorporates a professional relationship between the RN and the client • Assessment, planning, implementation, evaluation scope of delegation and level of supervision determined by the RN… • Scope of delegation and the level of supervision by RN depend upon multiple factors…

17. 224.4 Definitions • (1) ADL • (2) Client • (3) Delegation: Authorizing an unlicensed person to provide nursing services while retaining accountability for how unlicensed person performs the task: Does NOT apply to situations in which a UAP directly assists RN by carrying our nursing tasks in presence of RN • (4) Unlicensed person…. • (A) monetarily compensated; assistive role • (B) includes but not limited to nurses aides, home health aides, medication aides, technicians… • ( C) professional nursing student; providing care for monetary compensation; not part of formal educationalprogram

18. 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? 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 (AKA…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 Test your Understanding

19. 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 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 (AKA…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 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) Test your Understanding

20. 224.5 RN Accountability for Delegated Tasks • (a) The RN’s accountability to the BNE with respect to its taking disciplinary action against the RN’s license is met when delegating RN has complied with can verify compliance with this chapter and specifically 224.6 and 224.8 • (b) does not change or apply to a RN’s civil liability. • The RN’s best protection is to adhere the nurse practice act!

21. 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.

22. 224.6 General Criteria for Delegation • (6) RN shall either instructed the UAP the delegated task or verified UAP’s competency • (7) RN must adequately supervise • (8) if the delegation continues over time, the RN must periodically evaluate the delegation of tasks • And for help with decisions in delegation: the decision-making tree

23. 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 she wants breakfast! • c. Ms. F a 40 yr old male stating that he 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

24. 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 No; requires RN assessment Ok b. Mr. Z. an 80 year old demanding that she wants breakfast! c. Ms. F a 40 yr old male stating that he has “heart burn” and wants breakfast to relieve the discomfort. No; needs RN assessment, “heartburn may indicate more serious problem, needs assessment Ok d. Mr. A a 70 yr old confused, incontinent male An Ok, but , so long as only personal needs only to be met, get patient clean and dry , no assessment expected. e. Ms. G. a first day post op hernia repair who needs to ambulate. No, still requires assessment, is first day post-op f. Ms. R. who has discharge orders and demands to go home No, requires teaching; UAP can only reinforce teaching

25. 224.7 Supervision • The registered professional nurse shall provide supervision …acute conditions or in acute care environments… • (1) Degree of supervision required shall be determined by the RN by the RN after evaluation of the following… • (A) Stability of clients status in relation to task(s) to be delegated • (B) Training, experience, capability of UAP to whom nursing task is delegated • (C) Nature of nursing task being delegated • (D) Proximity and availability of the RN to the UAP

26. 224.7 Supervision • (2) RN or equally qualified RN shall be available in person or by telecommunications…and make decisions about levels of supervision using the following examples as guidelines… • (A) RN’s…presence required to provide nursing services, include assessment, planning, intervention and evaluation 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…settings include…..acute care…long term care…. • (B)…situations where nursing care provided in the client’s residence… the client’s status…unstable and unpredictable and RN required to assess, plan intervene, and evaluate the client’s unstable and unpredictable status and need for skilled nursing service, the RN makes supervisory visits at least every 14 calendar days. group homes, foster homes

27. Supervision What is the best action for the nurse to take in the following situation? 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 b. Work side by side with Ted c. Do not assign task to Ted as the patient is unstable d. Check with Ted throughout the day

28. Supervision • What is the best action for the nurse to take in the following situation? 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. • No a. Allow Ted to do his assigned task224.7 states that an RN’s presence and supervision is required • No b. Work side by side with Ted The task can be delegated; Ted has the experience and training; this is unnecessary. • Noc. Do not assign task to Ted as the patient is unstableThe task can be delegated; patient is not unstable at this time; Ted has experience and training in feeding • Yes d. Check with Ted throughout the day 224.7 requires that an RN’s presence and supervision is required; Ted has training and experience; your best answer.

29. 224.8 Delegation of Tasks • (a) Tasks) Most Commonly Delegated…. • (1) non-invasive and non-sterile treatments • (2) the collecting, reporting, and documentation of data 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 family a facility • (5) personal hygiene and elimination, including vaginal irrigations and cleansing enemas

30. 224.8 Delegation of Tasks • (a) Tasks) Which are Most Commonly Delegated…. • (6) feeding, cutting up of feed or placing of meal trays • (7) socialization activities • (8) ADLs • (9) reinforcement of health teaching planned and/or provided by the RN

31. 224.8 Delegation of Tasks • (b) Discretionary Delegation Tasks… • (1) may be delegate to UAP if • (A) RN delegating task is directly responsible for nursing care given to the client • (B) Agency employing UAP follows current protocol for training of UAP with input by RN currently employed in the facility that includes… • Complexity of the task • UAP demonstrates competency of the delegated task • Mechanism for re-evaluation of competency • Mechanism to identify the individuals to whom to delegate task • (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 !

32. 224.8 Delegation of Tasks • (b) 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 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

33. Use your knowledge to complete the following check list

34. Use your knowledge to complete the following check list

35. 224.8 Delegation of Tasks • (c) Nursing TasksProhibited from Delegation…not within scope of sound nursing judgment to delegate • (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

36. 224.8 Delegation of Tasks cont • (c) Nursing TasksProhibited from Delegation…not within scope of sound nursing judgment to delegate • (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, including IV’s except by medication aides as permitted under 224.9

37. 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, sl or topical including eye, ear or nose drops and vagina or rectal suppositories

38. 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 amount of 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 as permitted for administration of insulin under 225.11 of this title..

39. 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 medication 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) responsibility for receiving verbal or telephone orders from a physician, dentist… • (7) responsibility for ordering a client’s medication from the pharmacy

40. 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 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 Answer These Questions about the Medication Aide Permit Holder in a Long Term Care Facility

41. 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 (224.9) 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 (224.9) B. Have the UAP re-order the medications C. Have the patient re-order the medications Answer These Questions about the Medication Aide Permit Holder in a Long Term Care Facility

42. 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 RNS, 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 supervise the UAP • (b) If the above not met…must communicate this fact to the licensee who delegated the task

43. Answer a couple of challenging questions! • 1. A nurse delegates a glucose fingerstick 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 lab now as the patient’s p02 is 84.”

44. Answer some challenging questions! • 3. A patient reports that he feels “faint”. The RN is very busy and asks the UAP to check on the patient and obtain vital signs. What, if anything was incorrect, with the nurse’s action.”

45. Answer a couple of challenging questions! • 1. A nurse delegates a glucose fingerstick to UAP who records a result, but fails to notify the RN of the finding. Legal accountability for the delayed intervention would be with the • a. RN Yes the RN retains accountability; basic principle of delegation! • 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.” Must communicate clearly! • c. “Please do this as soon as possible!” • d. “I need this in lab now as the patient’s p02 is 84.”

46. Answer some challenging questions! • 3. A patient reports that he feels “faint”. The RN is very busy and asks the UAP to check on the patient and obtain vital signs. What, if anything was incorrect, with the nurse’.” • The nurse cannot delegate “Assessment”; it would, however, be appropriate for the RN to request that vital signs be taken, provided that specific parameters are given for the vital sign results that are to be reported. • 224.8 prohibits the RN delegating nursing tasks which require physical, psychological, and social assessments that demand professional nursing judgment, intervention referral or follow-up…

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