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Today’s Decision-Making and Delegation

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!

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Today’s Decision-Making and Delegation

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  1. Today’s Decision-Making and Delegation RN By Nancy Jenkins, RN, MSN/Carolyn Morse Jacobs Rn, MSN, ONC UAP LVN

  2. Introduction to delegation (song) Pushin' the Papers

  3. 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)

  4. 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.

  5. What is critical thinking anyway?? NOT!!!

  6. Why is it so important? • Critical thinking skills are needed to • Early detection of problems • Interventions to prevent adverse occurrences • Interventions to decrease mortality and morbidity and failure to rescue rates • Improving patient outcome rates

  7. Characteristics of Critical Thinkers • Open minded • Systematic • Analytical • Inquisitive • Judicious • Truthseeking • Confident in reasoning

  8. Question • What is a critical thinking disposition? A. Authoritarian B. Systematic C. Laissez-faire D. Ambitious

  9. Answer B. Systematic Rationale: critical thinking dispositions include systematic.

  10. Steps in the Decision-Making Process • Data gathering • Analysis • Establishing Goals/Outcomes/Strategies • Short term • Long-term • Plan Actions- prioritize these! • Implement chosen alternatives- policies and procedures and protocols • Evaluate Outcomes- ask was this the best way? • Resources • Textbooks, professional journals • Policy and procedure manual and protocols (risk management) • Pre-arrest protocols • Heparin protocols • Experienced colleagues-”novice to expert” • Clinical Pathways or critical paths

  11. Decision-Making Tools • Listing Pros and cons- helpful for jobs • Algorithms- critical care,CPR and ACLS • Clinical pathways • Thinking hats-different perspectives

  12. 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?

  13. Methods of Participative 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

  14. Methods of Participative Group Decision Making • Majority Rule • Def-vote is taken and the most votes win- elections • Advantage- quick • Disadvantage- may have large number refuse to follow the plan

  15. Other 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

  16. 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… Sources of Ethical Guidance Supporting ethical decision-making by patient and families

  17. 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…

  18. 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?

  19. 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

  20. 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

  21. 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.

  22. Delegation • You must delegate if you want to deliver quality care to all of your patients in a timely manner!!

  23. 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.

  24. 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

  25. 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

  26. 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

  27. 5 Rights of Delegation (NCSBN) Right Task Right Direction/Communication Right Circumstances Right Supervision/ Evaluation Right Person

  28. 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?

  29. 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

  30. 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

  31. Delegation There is no blanket delegation of tasks

  32. 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

  33. Questions to ask before delegating • What is the task or job to be delegated? • Are the expected results predictable? • Does the task require on-going nursing assessment? • To whom shall the task be delegated?- skill level and time • Does the task involve critical thinking or nursing judgment? • If the delegatee needs help, am I available to help?

  34. Nursing Practice Act Delegation Resource RULES AND REGULATIONS related to PROFESSIONAL NURSE EDUCATION, LICENSURE AND PRACTICE

  35. Rule 224 Rule 224

  36. BON Delegation Rules • Rule 224 – Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personal for Clients with Acute Conditions or in Acute Care Environments • Rule 225 – RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions

  37. 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

  38. Which of the following situations are exclusions to the Nurse Practice Act according to 224.2. • 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

  39. 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 Yes,does apply, exclusion in 224.2 • As an RN you assign the CA to check intake and outputs for patients in room 1-10 No, No, this is delegation according to 224 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 Yes, exclusion in 224.2

  40. 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.

  41. 224.6 General Criteria for Delegation • (6) RN shall either instruct the UAP in the delegated task or verify UAP’s competency • (7) RN must adequately supervise • (8) if the delegation continues over time, the RN must periodically evaluate the delegation of tasks

  42. 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

  43. 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

  44. 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 • Nob. Work side by side with TedThe task can be delegated; Ted has the experience and training; this is unnecessary. • Noc. Do not assign task to Ted as the patient is unstable The 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.

  45. 224.8 Delegation of Tasks Green Light Tasks • (a) Tasks) Most Commonly Delegated…. • (1) non-invasive and non-sterile treatments • (2) the collecting, reporting, and documentation of data (but not interpreting it) 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 patient in the facility

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