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Effective Delegation and Supervision

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  1. Effective Delegation and Supervision Insert Chapter 18 opening illustration

  2. Key Concepts • Staffing patterns in the current health care system • Principles of delegation and supervision • Safe delegation practices • Delegation vs. assignment

  3. Effective Delegation and Supervision • Accomplish patient care safely • Effectively use a variety of skilled and nonskilled workers • Provide essential skills for the RN in any practice role or setting

  4. Issues Affecting Staffing Patterns • Balanced Budget Act of 1997 • Managed care • Prospective payment system • Nursing shortage

  5. Changes in Staffing Patterns • Decline in the number and utilization of RNs • Increased utilization of unlicensed assistive personnel (UAP) • Overlapping of care providers’ roles

  6. Economic Necessity • Place for competent, appropriately supervised UAPs and licensed practical nurses/licensed vocational nurses (LPNs/LVNs ) in patient care • RNs’ confidence with delegation and supervision skills is essential

  7. Delegation • Management strategy to accomplish cost-effective health care • Transfer of responsibility and authority for the performance of an activity • RN remains accountable for outcomes • Two-way process between RN and delegatee

  8. RN Delegator Responsibilities • The act of delegation • Supervising the performance of the delegated task • Assessment and follow-up evaluation • Any intervention or corrective actions required to ensure safe and effective care

  9. Delegatee Responsibilities • Monitoring his or her own actions • Accepting delegation within the parameters of training and education • Communicating appropriate information to delegator • Completing the task

  10. What Can Be Delegated? • No definitive list • Varies: • From state to state • From organization to organization • From situation to situation • Assessment, evaluation, and nursing judgment cannot be delegated

  11. Delegation Guidance • State nursing practice acts • Patient needs • Job descriptions • Competencies of employees • Policies and procedures • Clinical situation • Professional standards of nursing practice

  12. State Nursing Practice Acts • Provide guidance for legal delegation • Criteria may be presented in various parts of the act • State Board of Nursing can offer guidance • Know legal scope of practice for LPN/LVN • UAP practice generally governed by the health care organization

  13. Patient Needs • RN must perform patient assessment • Stable patients generally mean a safer delegation opportunity • Tasks that can be delegated may be intertwined with a nursing responsibility

  14. Job Descriptions • Detail tasks and responsibilities required as a condition of employment • Comply with state laws and organization’s standards of care • Training should be related to the job description • Legal requirements supersede organizational policies

  15. Competencies • Confirm the staff member’s specific knowledge and skills • Written competency documentation required by regulatory and accrediting agencies • RN should be knowledgeable of staff members’ competencies

  16. Organizational Policies and Procedures • Designate specific skill level and supervision requirements for tasks • Designate general standards of care such as infection control

  17. Clinical Situation • Time to perform the task • Familiarity with characteristics of the population • Complexity of the task • Resources to perform the task • Adequate supervision available

  18. Professional Standards of Nursing Practice • Agreed-upon levels of nursing practice competence determined by American Nurses Association (ANA) and specialty nursing organizations

  19. ANA’s Delegation Standard • When delegating, the RN will consider: • Assessment of the patient condition • Capabilities of the nursing and assistive staff • Complexity of the task to be delegated • Amount of clinical supervision needed • Staff workload

  20. ANA’s Delegation Standard—cont’d • What can be delegated: • Feeding, drinking, positioning, ambulating, grooming, toileting, dressing, and socializing • Collecting, reporting, and documenting data related to these activities • Maintaining a clean, safe, and efficient environment • Housekeeping, transporting, and record keeping • Stocking and maintaining supplies

  21. ANA’s Delegation Standard—cont’d • What cannot be delegated: • Initial nursing assessment • Determination of nursing diagnoses • Establishment of nursing care goals • Development of nursing plan of care • Evaluation of patient’s progress • Health counseling or teaching • Activities that require specialized nursing knowledge, skill, or judgment

  22. Safe Delegation Practices • Establish a foundation of knowledge • Assess patient before delegation • Know delegatee’s knowledge and skill level • Know the task to be delegated • Comply with skill requirements in written policies and procedures

  23. Safe Delegation Practices—cont’d • Explain task and outcomes • Expect responsible action • Assess and supervise job performance • Provide for positive outcomes • Evaluate and follow-up

  24. Safe Delegation Practices—cont’d • Know specific standards of nursing practice • Be involved in LPN/LVN and UAP training programs • Help develop LPN/LVN and UAP job descriptions • Always evaluate the delegated action • Never ignore poor performance

  25. High-Risk Delegation • Task should be performed only by an RN • Task could involve substantial risk for the patient • Delegatee has not had the necessary training • RN fails to provide adequate supervision • RN fails to evaluate the delegated action

  26. Delegation and the Nursing Process • Assess the patient and plan the care • Identify tasks that someone else can perform • Implement the plan of care • Assign and supervise task performance • Evaluate performance and client response

  27. Five Rights of Delegation • Right task • Right circumstances • Right person • Right direction and communication • Right supervision and evaluation

  28. Supervision • Active process of directing, guiding, and influencing a worker’s performance • On-site supervision • Physically present or immediately available • Off-site supervision • Available through written and verbal communication • Increased use of telecommunications technology is raising supervision questions

  29. Components of Supervision • Initial direction • Periodic inspection • Levels of supervision • Unsupervised • Initial direction and periodic inspection • Continuous

  30. Supervising • Make frequent rounds, observe, and communicate • Provide the appropriate level of supervision • Be available for questions/unexpected problems • Supervise in a positive, supportive manner

  31. Supervising—cont’d • Intervene immediately if the task is not being performed safely and appropriately • Never ignore poor performance—document and report • Use mistakes as learning opportunities

  32. Assigning vs. Delegating • Assignment • Transfer of responsibility and accountability is downward or lateral • Activities designated are consistent with job position and qualifications • Staff member assumes responsibility and is accountable

  33. Assignment Considerations • UAP assignments are functions and tasks, not patients or groups of patients • LPN/LVN may be assigned specific clients for whom to perform care • RN remains responsible for nursing practice activities

  34. Assignment Considerations—cont’d • Patient’s psychologic status • Patient’s physiologic status • Complexity of care • Infection control or cross-contamination • Level of supervision required • Staff development opportunities

  35. The Transdisciplinary Team • Teams valuable in meeting patient care needs • Team members should know scope of practice and training of other team members • Team members may report to the RN • Team members may report to supervisors in their individual disciplines and work collaboratively with the RN

  36. Barriers to Effective Delegation • Fear of being disliked • Fear of losing control • Fear of taking risks • Fear of making mistakes • Lack of confidence • Lack of knowledge

  37. Effective Delegation and Supervision Skills • Communicate effectively • Create an environment of trust and cooperation • Create an environment of teaching and learning • Promote patient satisfaction • Provide feedback and follow-up

  38. Appropriate Feedback • Provide honest feedback about performance • Praise good performance • Address poor performance • Immediately stop inappropriate, unsafe, or incompetent performance • Document and report • Request additional training or other action