Delegation in Nursing Practice

Slide 1 www.tnaonline.org (615) 254-0350 Slide 2 Delegation in Nursing Practice Slide 3 Objectives Define the terms delegate, assign, and supervise Relate RN delegation to State of Tennessee Code as outlined by Board of Nursing Verbalize four common tasks appropriate for the RN to delegate to unlicensed staff 2009 Shelley Cohen Page 1 of 26

Slide 4 Objectives Verbalize four nursing tasks or functions unacceptable for the RN to delegate to unlicensed staff List three examples of environmental or workplace elements that determine delegation effectiveness Identify possible repercussions for the RN who elects to delegate outside the terms defined by the Board of Nursing Slide 5 Objectives List three examples of patient safety concerns that may result from inappropriate delegation Verbalize the five rights of delegation and provide examples of each that apply to your work setting Identify two resources available online for the RN related to delegation Slide 6 Target Audience All Registered Nurses licensed in the State of Tennessee 2009 Shelley Cohen Page 2 of 26

Slide 7 Author Sharon Cohen BS, RN, CEN Slide 8 Editors Sharon Adkins, MSN, RN Cheri Glass TNA Staff Slide 9 Introduction Assist Tennessee Registered Nurses with a review of delegation standards of practice Intended for nurses in all stages of learning In response to delegation assessment survey Essential for RNs to understand role in the delegation process 2009 Shelley Cohen Page 3 of 26

Slide 10 Tennessee State Code Tennessee Nurse Practice Act Tennessee Code, Title 63, Chapter 7 State laws that define the practice of nursing The Tennessee Board of Nursing Rules and Regulations of Registered Nurses, Chapter 1000 1 The Board of Nursing s interpretations of these state laws Slide 11 Delegation Terminology Primer Slide 12 Professional Nursing Requires substantial specialized judgment and skill Provide responsible supervision of patients Promote, restore, and maintain health or prevention of illness Administer medications and treatments Nursing management of illness, injury, or infirmity Identification of patient problems Understand the cause/effect of applying nursing procedures 2009 Shelley Cohen Page 4 of 26

Slide 13 Professional Nursing Tennessee Code Unannotated Title 63, Chapter 7 Nursing Counsel, manage, supervise and teach others Slide 14 Unlicensed Assistive Personnel (UAP) Function in an assistive role to both the RN and LPN CNA (certified nursing assistant) NA (nursing assistant) Medical technician Patient care technician Slide 15 Assignment Shifting the responsibility of an activity or task from one person to another Tim, RN, is the charge nurse of a 28 bed unit in a long term care setting. One of his responsibilities is to make assignments at the beginning of the shift. Reporting to him today are two LPN s and five Nursing Assistants. 2009 Shelley Cohen Page 5 of 26

Slide 16 Assignment Tim s assignment of patients to the LPNs also shifts the work responsibility and accountability to them, as they work under their own license. Nursing Assistants Considered Unlicensed Assistive Personnel (UAP) Tim cannot assign responsibility and accountability to them Tim remains responsible and accountable for any tasks he assigns them RN must be knowledgeable of expectations set by the Board of Nursing Slide 17 Delegate Passing responsibility for an activity/task to another, without the accountability Patsy, RN, is a staff nurse on a medical surgical inpatient unit. She is going to delegate vital signs on her patients to the nursing technician working with her today. Slide 18 Delegate The nurse technician s job requires them to perform this task. However, it is still Patsy who remains accountable to ensure that: The vital signs are taken Abnormal results are addressed Documentation is completed Any proficiency concerns with this task are addressed 2009 Shelley Cohen Page 6 of 26

Slide 19 Supervision Involves both assigning and delegating to another person Directing, guiding and influencing another person s performance Slide 20 Supervision Tim, the charge nurse from our assignment example, has an overall responsibility for supervision of the care of these patients during his shift. Not only will he make out an assignment for the shift, he will also maintain the accountability of staff reporting to him who are unlicensed. Slide 21 RN Remains Central 2009 Shelley Cohen Page 7 of 26

Slide 22 What Is Assisting? To help, aid or cooperate with The unlicensed staff may assist with Admission, transfer, discharge process Dressing/undressing patients Patient bathing and feeding Weighing patients, collecting urine Slide 23 How the RN Decides on Other Tasks Delegation Criteria: 1. Low potential for harm 2. The activity has minimal complexity 3. Problem solving/innovation involved is minimal 4. Outcome is highly predictable 5. Patient has ample opportunity to interact with RN 6. RN is available to supervise activity and its outcome Slide 24 Essential Elements Does this patient know who their RN is? Does this patient know which staff are unlicensed? 2009 Shelley Cohen Page 8 of 26

Slide 25 Scenario Jennifer has worked as a nursing assistant for more than 10 years in this intensive care unit. The nursing staff have grown to trust her and have great regard for her work ethic and knowledge she has gained over the years. Slide 26 Scenario Tonight she is responding to the call bell of one of the patients, Mr. Tomlinson. Upon entering the patient s room, the family approaches Jennifer and states, Nurse, can you please tell us how our father is doing tonight? You happen to be entering the room as this takes place and hear Jennifer provide an update of this patient s condition to the family. Slide 27 Evaluation Did Jennifer clarify her role in that she was not the nurse? She is not qualified, nor is it her job, to update anyone on a patient s status or condition. 2009 Shelley Cohen Page 9 of 26

Slide 28 Scenario John is supervising four nurse technicians that work for a home health agency. He has his own patient assignments that each require a visit from him today. Slide 29 Scenario He is paged by Sara, one of the technicians who informs him that the family of Mrs. Jones have asked her to review the new dietary restrictions for the patient. John will not be able to make a home visit to this location today. He asks Sara if she is comfortable reviewing the handout sheet he left behind. He also relates that he will be there tomorrow and can answer questions the family may have at that time. Slide 30 Evaluation Sara is not qualified for this level of patient teaching. John has inappropriately delegated a nursing function to an unlicensed person. 2009 Shelley Cohen Page 10 of 26

Slide 31 Scenario This long term care facility places RN team leaders to oversee the assignments and work of the unlicensed staff it employs. A new team leader, Sara, noticed during her orientation that one of her preceptors delegated some functions to unlicensed staff that made her uncomfortable. Slide 32 Scenario Sara approaches her manager with her concerns, and the manager tells her welcome to the real world. She assures her that as long as the staff are trained and no patients have had experienced a bad outcome, then there is no problem. Using examples of applying splints prior to an RN evaluating the patient, and a resident appearing to be having an MI with no RN evaluation, she expresses her concern for these practices. Slide 33 Evaluation As an RN, Sara has obligations under the Tennessee Board of Nursing s Rules and Regulations to delegate only those nursing measures which a person is qualified/prepared to perform. 2009 Shelley Cohen Page 11 of 26

Slide 34 Scenario Andrea is a school nurse responsible for students at four different locations in her county. Today she is onsite at the high school providing screenings and two educational classes for students and the staff. Slide 35 Scenario She receives a call from Sue, the school secretary at site #3, who is concerned about a child in her office having an asthma attack. Sue has received her annual training to assist children in self administration of inhaled asthma medications. She updates Andrea on the situation and has notified the child s mother. Slide 36 Evaluation The State of Tennessee has specific statute addressing unlicensed personnel in the school setting and their involvement with assisting students with certain medication administration. The following website outlines the specific content of these laws: http://health.state.tn.us/downloads/healthy SchoolsGuidelines.pdf 2009 Shelley Cohen Page 12 of 26

Slide 37 Right Task Five Rights of Delegation Right Circumstance Right Person Right Direction/Communication Right Supervision/Evaluation Slide 38 The Do s of Delegation Assume responsibility for delegated tasks Verify competency prior to delegating Determine how available you will be to supervise Use clear and specific communication skills Be open to questions from those you delegate to Adhere to organizational policy and procedure Slide 39 The Don ts of Delegation Do not delegate nursing process Assessment Planning Evaluation Nursing judgment Do not delegate based on how well you know someone Do not delegate anything that requires critical thinking skills 2009 Shelley Cohen Page 13 of 26

Slide 40 Function ANA and NCSBN Is the delegated task within the job description of the unlicensed staff member? Exposure Is the task something the unlicensed person is exposed to as part of the daily care of the patient? Procedure A step by step process is available in writing that describes the appropriate manner for this task to be performed. Slide 41 Consistency ANA and NCSBN The task requires little or no modifications Outcome The patient outcome is predictable by the RN Critical Thinking No ongoing assessment, interpretation, or decision is required Slide 42 Most Important Criteria Is delegation of this task or function in the patient s best interest? 2009 Shelley Cohen Page 14 of 26

Slide 43 Delegation and Effective Communications Are you approachable as the RN? Are you making yourself available? Are you assessing the unlicensed staff person s need for any clarifications? Slide 44 Delegation and Effective Communications RN Unlicensed Staff Does the unlicensed person: Ask questions? Inform the RN when unable to complete a task? Ask for additional training? Seek clarification of what you delegate? Slide 45 Scenario Annette and Richard are nurse aides on duty today at a skilled facility. Their RN Charge Nurse Roger has shared with them that two nurses called in sick. He suspects it will be several hours before any on call replacements arrive. Roger has asked Annette and Richard to use their judgment as to whether or not their assigned patients for discharge require his assistance. 2009 Shelley Cohen Page 15 of 26

Slide 46 Evaluation Wait a minute. It is the UAP that is supposed to be doing the assisting process! This is an example of inappropriate assignment of nursing judgment to an unlicensed person. Slide 47 Tennessee Board of Nursing Rules and Regulations of Registered Nurses Chapter 1000 1.13 (l): Defines unprofessional conduct, negligence, habits or other cause Assigning unqualified persons to perform functions of licensed persons or delegating nursing care functions and tasks and/or responsibilities to others contrary to the Nurse Practice Act or rules and regulations to the detriment of patient safety Slide 48 CAUTION! Not only is this an issue of patient safety, but Roger s nursing license may be in jeopardy 2009 Shelley Cohen Page 16 of 26

Slide 49 Tennessee Nurse Practice Act TCA 63 7 115 (a) (1) The board has the power to deny, revoke, or suspend any certificate or license to practice nursing or to otherwise discipline a licensee upon proof that the person Slide 50 Tennessee Nurse Practice Act TCA 63 7 115 (a) (1) Assigned unqualified persons Delegated outside of Nurse Practice Act Failed to supervise those they delegate to or assign functions to Failed to act in safeguarding patients from incompetent practices Failed to report, through proper channels, known facts related to incompetent, unethical, or illegal practices of any health care provider Slide 51 Scenario The charge nurse of this surgical center has delegated to Demetri, the nurse technician, to ambulate all of his post op patients at least once tonight. 2009 Shelley Cohen Page 17 of 26

Slide 52 Scenario Demetri has no problem ambulating patients, as he has been in this role for two years now. He is confident in his abilities and the charge nurse demonstrates great trust for his skill. Slide 53 Evaluation The first post operative ambulation of a patient does not have a highpredictability of outcome. Therefore, the charge nurse should not be delegating this function unless a licensed person is also in attendance. Once it is established the patient ambulates well independently, delegating this task would be acceptable. Slide 54 Scenario Tube feedings that do not include medications are part of the job description for unlicensed staff of this oncology unit. Sheryl is a nurse technician who is assigned a patient with a new feeding tube placed yesterday. 2009 Shelley Cohen Page 18 of 26

Slide 55 Scenario It was noted during shift report that today will be the first day the patient receives nutrition via the feeding tube. The charge nurse Elliot tells Sheryl to let him know when she is ready for the first feeding. He will be with her during and after the procedure to assess how the patient tolerates this. Slide 56 Evaluation This is an example of an appropriate delegation and supervision by the RN to an unlicensed staff member. Slide 57 Situation The hospice supervisor Cheryl, has notified staff that she will be out of the office for two hours at a meeting. Her cell phone will be shut off, but staff can leave messages. She is the only RN on duty this weekend covering staff, which includes seven hospice caregiver technicians. 2009 Shelley Cohen Page 19 of 26

Slide 58 Situation Suzanne, one of the caregiver technicians, is at the home of a patient in need of a dressing change. She was taught how to do this during orientation, however her first application requires oversight of the RN supervisor on duty. She calls Cheryl and leaves her a message. Ninety minutes later she has not called back, and Suzanne decides to proceed with the dressing change anyway. Slide 59 Evaluation Part of the delegation process requires supervision. Cheryl s action in turning off her cell phone made her unavailable to supervise. The level of supervision needed will vary with the situation. In this case, the organization has already determined by policy that delegation of the first dressing change requires visual supervision. Slide 60 Evaluation of the Delegation Process We have never had any problems with any of the tasks we delegate to our techs. How do you know? 2009 Shelley Cohen Page 20 of 26

Slide 61 Evaluation of the Delegation Process Develop process for ongoing evaluation Have feedback mechanism in place for UAP staff Evaluate job duties on an ongoing basis for appropriate tasks/functions being delegated Educate charge nurses/team leaders on their roles as they relate to effective delegation Is there current documentation of competency? Determine if patient needs are being met in a timely, safe fashion Slide 62 Decision Trees Is there a law/rule that supports what I intend to delegate? Is the patient already being assessed by the RN? Does the task fall within the recommended criteria? Slide 63 Decision Trees Has this UAP demonstrated competency to perform this task? Does the skill level of this UAP match the care level needs of the patient? Are there organizational policies or procedures to support your decision? 2009 Shelley Cohen Page 21 of 26

Slide 64 Decision Trees Are you as the RN available for the necessary supervision? Is there two way communication between yourself as the RN and the person you are delegating to? Slide 65 Empowering Nurses and Patients The RN remains accountable for the delegated functions performed by unlicensed staff. A current knowledge base of these rules is fundamental for safe patient care and good decision making skills. Slide 66 Empowering Nurses and Patients Do you know your organizational policies related to UAP? Have you recently reviewed Tennessee Nurse Practice Act and Board of Nursing s Rules and Regulations? Are you involved with improving the skills of UAP and their ongoing competency? Do you know where to find written competency validation for the staff you delegate to? 2009 Shelley Cohen Page 22 of 26

Slide 67 Conclusion The role of the Registered Nurse encompasses a wide array of responsibilities. Many of these are defined by the employer and their work setting and may originate with some regulatory authorities such as The Joint Commission. Slide 68 Conclusion The Tennessee Board of Nursing (BON) plays a pivotal role in the RN delegation decision making process. Working knowledge of BON rules is essential for safe nursing practices as well as safe patient care. Slide 69 Nursing Practice In Tennessee Access the Tennessee Nurses Association website for direct links to: www.tnaonline.org Tennessee Code Nurse Practice Act Tennessee Board of Nursing Rules and Regulations Delegation and Supervision Guidelines 2009 Shelley Cohen Page 23 of 26

Slide 70 Shelley Cohen BS, RN, CEN Shelley Cohen, BS, RN, CEN, will graduate in December, 2009 with a Master s in Nursing. Her capstone project for this program was a collaborative process with the Tennessee Nurses Association (TNA). A TNA member since 1999, Cohen worked alongside Sharon Adkins, MSN, RN,TNA Executive Director who served as her preceptor. Slide 71 Shelley Cohen BS, RN, CEN An author of multiple articles and books, Cohen is the educator and consultant for Health Resources Unlimited. Her complete CV can be found at www.hru.net. For the past 12 years since founding this company, she has provided expertise in the areas of triage and nurse leadership development. Slide 72 Shelley Cohen BS, RN, CEN She is also President of DoubleCreek, a non profit serving the needs of foster children in the state of Tennessee. 2009 Shelley Cohen Page 24 of 26

Slide 73 References American Nurses Association (2009). ANA principles for delegation. Retrieved July 6, 2009 from http://www.nursingworld.org/mainmenucategori es/thepracticeofprofessionalnursing/nursingstan dards/anaprinciples/principles for Delegation/PrinciplesforDelegationhtml.aspx Buchwach, Debbie (2009). Helping new nurses with the fine art of delegation. Strategies for nurse managers. 9 (7), 5 7. Marblehead, MA: HCPro. Slide 74 References National Council State Boards of Nursing (2005). Working with others: A position paper. Retrieved July 6, 2009 from http://www.ncsbn.org/1625.htm. Tennessee Board of Nursing (2007). Rules of the Tennessee board of nursing, Chapter 1000. Retrieved June 29, 2009 from http://www.tnaonline.org. Slide 75 References Tennessee Code Annotated (2008). Title 49 Education, Chapter 5. Retrieved August 12, 2009 from http://www.diabetes.org/uedocuments/adtn code49.5.415.pdf. Tennessee Code Unannotated (2009). Nursing Title 63, Chapter 7. Retrieved June 29, 2009 from http://www.tnaonline.org. 2009 Shelley Cohen Page 25 of 26

Slide 76 References Tennessee Department of Health (2007). Guidelines for use of health care professionals and health care procedures in a school setting. Retrieved August 14, 2009 from http://health.state.tn.us/downloads/healthyschoolsgui delines.pdf Tennessee Nurses Association (2009). Delegation and Supervision. Guidelines for Registered Nurses working with unlicensed assistive personnel. TNA Committee on nursing practice. Retrieved June 29, 2009 from http:www.tnaonline.org Slide 77 www.tnaonline.org 2009 Shelley Cohen Page 26 of 26