Today’s Decision-Making and Delegation

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 • The essential element in decision-making; supports effective and appropriate actions!

5. Steps in the Decision-Making Process • Data gathering • Analysis • Establishing goals/Outcomes and Plan Actions • Implement chosen alternatives • Evaluate Outcomes • Resources • Textbooks • Policy and procedure manual • Experienced colleagues • Other decision-making tools!

6. 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 Fidelity: carry out the agreement and responsibilities one has undertaken: faithful to the clients Veracity: to tell the truth… Sources of Ethical Guidance Supporting ethical decision-making by patient and families

7. Decision-Making Tools • Listing Pros and cons • Algorithms • Clinical pathways • Thinking hats-different perspectives

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

11. What is critical thinking anyway?? • A complex thinking process that is • Disciplined and self-directed • Based on mastery of many thinking skills and abilities • Best developed when applied to actual or simulated real world situations • Involves thinking about the thought process as it is occurring • Evaluates the solution or decision against a standardized set of criteria

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

13. Why is it so important? • Critical thinking skills are needed to • Decrease patient mortality and morbidity rates • Decrease failure to rescue rate

14. 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

15. 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?

16. 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

17. 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?

18. 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

19. 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

20. 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

21. 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.

25. Why the need to delegate? • Shortage of RN’s • Cost containment • Sicker patients • Shorter length of stay • Increased number of UAP’s • Encourages team building

26. 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

28. 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

29. 5 Rights of Delegation (NCSBN) Right Task Right Direction Right Circumstances Right Supervision/ Evaluation Right Person

30. 5 Rights of Delegation (NCSBN) • Right task – Nurse Practice Act, Job Descriptions • 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?

31. 5 Rights of Delegation (NCSBN) 3. Right Person – • Who is competent to perform task? • Job description? Training? Scope of practice? 4. Right Directions/Communication • Clear, Concise, Complete • Who, what, when, where, why, how? • Include parameters and timeframes • 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

32. 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

33. Delegation There is no blanket delegation of tasks

34. 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

35. 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

36. 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?

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

38. Rule 224 Rule 224

39. BNE 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

40. 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?

41. 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.

42. 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

43. 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

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. 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

45. 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.

46. 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

47. 224.8 Delegation of TasksMore Green Light Tasks • (a) Tasks) Which are Most Commonly Delegated…. • (5) personal hygiene and elimination, including vaginal irrigations, sitz baths and cleansing enemas • (6) feeding- cutting up of food or placing of meal trays • (7) socialization activities • (8) ADLs • (9) reinforcement of health teaching planned and/or provided by the RN

48. 224.8 Delegation of Tasks • (b) Discretionary Delegation Tasks…Yellow Light 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 can 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

49. 224.8 Delegation of Tasks • (b) Discretionary Delegation Tasks… • (1) may be delegated 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 !

50. 224.8 Delegation of Tasks • (c) Nursing TasksProhibited from Delegation Red Light Tasks!! • (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