Today’s Decision-Making and Delegation RN By Nancy Jenkins, RN, MSN/Carolyn Morse Jacobs Rn, MSN, ONC UAP LVN
Introduction to delegation (song) Pushin' the Papers
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? (p.180-182)
Decision-Making and Delegation • Key to delegation is ability to make correct decisions and think critically! • What is decision-making in nursing? • It’s a systematic cognitive process in which you: • identify alternatives, evaluate those alternatives, come to a conclusion, and select an action • As RN you must exercise judgments make decisions based upon education and experience • Critical thinking and decision-making: 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.
Critical Thinking and Decision Making • Characteristics that support critical thinking • Nurse’s own philosophy, beliefs, and knowledge about nursing, human beings, and health care • Ability of the nurse to communicate and reason • Maintaining a current knowledge base
Characteristics of Critical Thinkers • Open minded • Systematic • Analytical • Inquisitive • Judicious • Truthseeking • Confident in reasoning
Why is it so important? • Critical thinking skills are needed to • Decrease patient mortality and morbidity rates • Decrease failure to rescue rate
Nurses are the surveillance system • Nurses use critical thinking skills 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
Perspectives for Critical Thinking • Reflective thinking • Thinking ahead • Thinking in action • Thinking back • Parallel thinking • Using critical thinking from multiple perspectives • Six thinking hats
Question • What is a critical thinking disposition? A. Authoritarian B. Systematic C. Laissez-faire D. Ambitious
Answer B. Systematic Rationale: critical thinking dispositions include systematic.
Problem Solving and Decision Making • Data gathering • Use others as resources • Use standardized assessment tools • Use institutional policies, procedures, and protocols • Moving forward with limited data • Analysis
Problem Solving and Decision Making (cont’d) • Establishing goals, outcomes, and strategies • Recognizing the discrepancy • Establishing a goal or outcome • Strategies for action • Implementing the chosen action • Manager is accountable
Problem Solving and Decision Making (cont’d) • Evaluating outcomes and your problem-solving process • Final step in the problem-solving process • Compare the actual outcomes to the goals or outcome criteria • What do we do if we find that the outcomes are not what we wanted or anticipated?
Steps in the Decision-Making Process • Resources • Textbooks, professional journals • Policy and procedure manual and protocols (risk management) • Pre-arrest protocols • Heparin protocols • Algorithms • Experienced colleagues-”novice to expert” • Clinical Pathways or critical paths
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 Group Decision Making • Consensus • Def-general agreement that members will support a strategy even if not their chosen one • Involves compromise and revisions of original • Disadvantage- time and need to be present for all discussion • ** Good for professionals with same goals and work well together
Methods of Group Decision Making • Majority Rule • Def-vote is taken and the most votes will- elections • Advantage- quick • Disadvantage- may have large number refuse to follow the plan
Approaches used for Participative Decision Making • Brainstorming- time and is expensive, ex: retreat • Task force- group formed to discuss a certain problem. Ex- HESI • Quality circles- people working in same area with common concerns meet on a regular basis- level or faculty meetings • Nominal group technique- manager selects 7-10 members and presents a problem. Each ind. 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
Evaluating Your Critical Thinking • Clarity – Have I clearly stated problem? Is data clear? • Accuracy – Are my facts accurate? Reliable? Source? Is there bias? • Precision – Am I generalizing? Am I being precise enough? • Relevance – What data is relevant? Do I need more data?
Evaluating Critical Thinking • Depth – Have I explored the issue in the appropriate depth? Is my data or analysis too superficial • Breadth – Do I have the breadth of info needed? Is there a related topic that might shed light on issue? • Logic – Are my conclusions based on facts that I have? Could someone else follow my reasoning from data to conclusion? • Page 168
Question • Is the following statement true or false? One of the advantages to participative decision making in the task force model is that the people with dominant personalities can influence others in the group.
Answer False. Rationale: a disadvantage of a task force is that members with dominant personalities may influence the group.
Critical Thinking Exercise, p 179 • As new assistant charge nurse, you have responsibility for scheduling employees assigned to your unit. This has in past 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?
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… Ethical Decision Making Identifying and supporting ethical decision-making by patient and families
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…
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 • 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 • 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 • You must delegate if you want to deliver quality care to all of your patients in a timely manner!!
Delegation: 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.
Why the need to delegate? • Shortage of RN’s • Cost containment • Sicker patients • Shorter length of stay • Increased number of UAP’s • Time management • Encourages team building
Why RN’s don’t delegate • 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
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) Right Task Right Direction/Communication Right Circumstances Right Supervision/ Evaluation Right Person
5 Rights of Delegation (NCSBN) • Right task – Nurse Practice Act, Job Descriptions, Is assessment involved? Should be routine in nature • Right circumstances – What are the circumstances of patient at this time? • Has assessment been done? • Is patient stable, or unstable? • What is potential for harm? • Does task require problem solving/decision-making? • Level of technology? • Is teaching required? • Exactly what is needed at this time?
5 Rights of Delegation (NCSBN) 3. Right Person – • Who is competent to perform task? • Job description? Training? Scope of practice? • Ind. Strengths and weaknesses 4. Right Directions/Communication • Clear, Concise, Complete • Who, what, when, where, why, how? • Include parameters and timeframes • Help them prioritize • Right Supervision/Evaluation • Supervision is the active process of directing, guiding and influencing the outcome • Initial direction • Periodic inspection • Follow-up/feedback and appropriate action • Evaluation of patient outcomes and the person
Evaluation and Feedback • Evaluation – What do I see? • Was task completed correctly, on time? • Was info reported correctly? • Documented? • What was patient response? • Feedback – What do I do about it? • Start with positive first • Give constructive feedback- increases motivation • Ask for delegatee’s input • Be specific with feedback • Make a plan, with time frame for checking progress
Delegation There is no blanket delegation of tasks
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
To delegate or not. That is the Question. • Patient’s condition , including complications and stability. • Complexity of the assessment • Intricacy of the task • Capabilities of the UAP • Amount of technology required • Infection control and safety precautions • Potential for harm • Level of supervision required • Predictability of outcome • Extent of patient interaction • Environment
Question • The charge nurse on a step-down unit has just delegated some responsibilities to the LPN on her shift. The charge nurse knows that by delegating these responsibilities appropriately she has done what? A. Provided an essential foundation for patient safety B. Decreased her work load so she could get paper work done C. Made sure the LPN stays busy the entire shift D. Showed good management principles to the new unit manager
Answer A. Provided an essential foundation for patient safety Rationale: delegating appropriately provides an essential foundation for patient safety.
Common Errors in Delegation • Overloading yourself • Adapting to old patterns of behavior • Unclear communications • Failing to release control • Yielding to pressure to delegate inappropriately