Exam 3 - Delegation
What is respondeat superior?
Legal doctrine that holds the employer or supervisor responsible for the actions of the employees or of those supervised; for example, under this doctrine, RNs are held responsible for the actions of unlicensed assistive personnel under their supervision.
Who is responsible for delegation?
Legally, the authority or power to delegate is restricted to professionals who are licensed and governed by a statutory practice act. However, not all RN functions can be delegated to assistive personnel because of restrictions in the nurse practice act and institutional policies.
According to the NCLEX, how should you approach delegation questions to UAPs?
Look for the lowest level of skill required for the task, look for the least complicated task, look for the most stable client, look for the client with the chronic illness.
What is the "right person" according to the five rights of delegation?
Assess and verify the competency of the health care team member. The task must be within the team member's scope of practice and they must have had the necessary competence/training. Continually review the performance of the team member and determine care competency. Assess team member performance based on standards, and when needed, take steps to remediate a failure to meet standards. Example: Right person - delegate LPN to give enteral feedings to a pt who has a head injury Wrong person - delegae AP to administer enteral feedings to a pt who has a head injury
What is the "right direction/communication" according to the five rights of delegation?
Communicate either in writing or orally the following: 1) data that needs to be collected 2) method and time line for reporting, including when to report concerns/assessment findings 3) specific tasks to be performed; client-specific instructions 4) expected results, time lines, and expectations for follow-up communication. Example: Right direction - delegate AP the task of assisting the pt in room 312 with a shower, to be completed by 0900 Wrong direction - delegate AP the task of assisting the pt in room 312 with morning hygiene
What are pt factors when making assignments?
Condition of the pt and level of care needed, specific care needs (cardiac monitoring, mechanical ventilation), need for special precautions (isolation precautions, fall precautions, seizure precautions), procedures requiring a significant time commitment.
What is delegation?
Designating ancillary personnel for the responsibility of carrying out a specific group of nursing tasks in the care of certain clients. Includes the understanding that the authorized person is acting in the place of the RN and will b e carrying out tasks that generally fall under the RN's scope of practice. However, the person taking on the RN level task must be qualified to perform the task within the nurse's state practice act.
What is an assignment?
Designating tasks for ancillary personnel that fall under their own level of practice according to facility policies, position descriptions, and if applicable, state practice act. RNs usually make assignments and delegate tasks, often to the same individuals. The concepts of supervision, authority, responsibility, and accountability are key to successful pt care. Supervision is required by the RN in both delegation and assignment.
What is the "right circumstance" according to the five rights of delegation?
Must assess the health status and complexity of care required by the pt. Match the complexity of care demands to the skill level of the health care team member, and consider the workload of the team member. Example: Right circumstance - delegate AP to assist in obtaining vital signs from a stable postoperative pt. Wrong circumstance - delegate AP to assist in obtaining vital signs from a postoperative pt who required Narcan for depressed respirations.
What is the "right task" according to the five rights of delegation?
Identify what tasks are appropriate to delegate for each specific pt. A right task is repetitive, requires little supervision, and is relatively noninvasive for a pt. Delegate tasks to appropriate levels of team members based on standards of practice, legal and facility guidelines, and available resources. Example: Right task - delegate AP to assist a pt who has pneumonia to use a bedpan Wrong task - delegate AP to administer a nebulizer treatment to a pt who has pneumonia.
Who are considered "unlicensed assistive personnel"?
Includes individuals who have been through some type of training program ranging from a few hours up to several months. May have a certificate but no licensure and therefore do not have legal status. Also called certified nursing assistant (CNA), nurse aide, home health aide, registered nurse assistant (RNA), nurse technician (NT), medication technician (MT), nursing assistant, patient care assistant (PCA), orderly, client attendant, and psychiatric attendant
What is the difference between assignment and delegation?
Assignment is the process of transferring the authority, *accountability*, and responsibility of pt care to another member of the health care team. It is performed in a downward or lateral manner with regard to members of the health care team. Delegating is the process of transferring the authority and responsibility to another team member to complete a task, *while retaining the accountability*
What is vicarious liability?
Imputation of blame on a person for the actions of the other.
What are some examples of tasks that can be delegated to the LPN/LVN?
Monitoring pt findings (as input to the RNs ongoing assessment of the pt), reinforcement of pt teaching from a standard care plan, tracheostomy care, suctioning, checking NG patency, administration of enteral feedings, insertion of a urinary catheter, medication administration (excluding intravenous medications in several states)
How are delegation decisions based?
On individual pt needs, facility policies, and job descriptions, the state nurse practice act, and professional standards. Nurses must follow the ANA codes of standards in delegating and assigning tasks.
What are task factors RNs must consider before delegating pt care?
Predictability of outcome potential for harm complexity of care need for problem solving and innovation level of interaction with the pt.
What are health care team factors when making assignments?
Knowledge and skill level of team members, amount of supervision necessary, staffing mix (RNs, LPNs, AP), nurse to client ratio, experience with similar clients, familiarity of staff member with unit.
What are the guidelines for delegation?
*Assess the pt* - pts who are relatively stable and not likely to experience drastic changes in health status are most suitable for delegation. Tasks must also be relatively uncomplicated and routine, must be performed without variation from policy or procedure, and should not require the use of nursing judgement while being performed. *Know staff availability* - Must know the availability of staff and education and competency levels of the peronnel to be delegated. Must be matched with the level of care required by the pt. *Know the job description* - if the RN delegates to a UAP for a complicated postoperative pt and a major complication develops r/t the UAPs lack of competence the RN will also be held legally liable for the poor outcome. When the RN determines the pts needs match the skills and abilities of the UAP or LPN, only then should the person be assigned. *Educate the staff member* - Must educate the UAP about the task done if UAP is unfamiliar with task, the RN is required to demonstrate how the task is done then document the training. Must also tell the UAP what is expected in the completion of the task and what complications to watch for and report to the RN. *Predictable and uncomplicated*
What are barriers to effective delegation?
*Internal barriers (person delegating)* - lack of experience delegating, lack of confidence in others, personal insecurity, demanding perfectionism, poor organizational skills, indecision, poor communication skills, lack of confidence in self, fear of not being liked by everyone, micromanaging management style *External barriers (circumstances or person being delegated to)* - unclear policies about delegation, policies that do not tolerate mistakes, management by crisis model for facility, unclear delineation of authority and responsibilities, poor staffing, lack of competence, over-dependence on the person delegating, unwillingness to accept responsibility for one's own practice, immersion in trivia and gossip, and work overload.
What are the five "rights" of delegation?
*Right task* - do the tasks delegated follow written policy guidelines? *Right person* - does the person have the proper qualifications for the tasks? *Right direction or communication* - are the instructions and outcomes clearly stated? When should the person report changes? *Right supervision or feedback* - how can the delegation process be improved? are the pt goals for care being achieved? *Right circumstances* - are the tasks that are being delegated possible without independent nursing judgments?
What are ways to develop delegation skills?
*clear communication* develop good communication and interpersonal relationship skills. Make eye contact with the other person, be pleasant, and ask for suggestions. Avoid allowing the person to whom the tasks are being delegated to control the exchange by intimidation or resistance. Make a written list of responsibilities expected from the person. *simulation exercises* allows the student or RN to make mistakes and learn from them. Feedback is essential to the education process and allows participants to self evaluate their interpersonal, communication, and decision-making skills. *careful supervision* Monitors the delegatees while they are providing care and helping them when they require assistance.
What should the nurse do if they receive an inappropriate assignment?
1) bring the inappropriate assignment to the attention of the scheduling/charge nurse and negotiate a new assignment. 2) if no resolution is arrived at, take the concern up the chain of command 3) if a satisfactory resolution is still not arrived at, an unsafe staffing complain in the form of an Assignment Despite Objection (ADO) or Document of Practice Situation (DOPS) should be filed with the appropriate administrator 4) Failure to accept the assignment without following the proper channels may be considered abandonment.
What is indirect delegation?
A list of tasks that certain health care personnel can perform that is produced by the health care facility. It is really a form of covert institutional licensure. Lists of activities from the facility that allows non-nursing personnel, who do not have the education of the RN, to carry out professional nursing functions is a de facto permission to practice nursing without a license. Indirect delegation places RNs in a precarious legal position. It takes away much of the authority of the RN to delegate personnel tasks under the doctrines of respondeat superior and vicarious liability.
What is direct delegation?
A specific decision made by the RN about who can perform what tasks.
What are some examples of tasks that can be delegated to the assistive personnel?
ADLs (bathing, grooming, dressing, toileting, ambulating, feeding (without swallowing precautions), positioning, bed making), specimen collection, Intake and output, and vital signs (on stable pts).
What is the "right supervision/evaluation" according to the five rights of delegation?
Nurse must - 1) provide supervision, either directly or indirectly (assigning supervision to another licensed nurse) 2) provide clear directions and understandable expectations of the tasks to be performed (time frames, what to report) 3) monitor performance 4) provide feedback 5) intervene if needed (unsafe clinical practice) 6) evaluate the pt and determine if pt outcomes were met 7) evaluate pt care tasks and identify needs for quality improvement activities and/or additional resources. Example: Right supervision - after completing the admission assessment, an RN delegates to an AP the task of ambulating a pt Wrong supervision - prior to performing an admission assessment, an RN delegates to an AP the task of ambulating a pt.
What is a dependent practitioner?
Provider of care who delivers health care under the supervision of another health care practitioner: for example, a physician's assistant is supervised by a physician, or an LPN is supervised by an RN. Most state practice acts don't give delegation authority to dependent practitioners. Also, professionals who delegate specific tasks retain accountability for the proper and safe completion of those tasks and take responsibility for determining whether the assigned personnel are competent to carry out the task. One exception is when the person who is assigned a task also has a license and the task falls under the person's scope of practice; then again, the RN is responsible only for supervision of the other licensed person.
When does supervision of a delegated task occur?
Supervision occurs after delegation. A supervisor oversees a staff's performance of delegated activities and determines if: 1) completion of tasks is on schedule, 2) performance was at a satisfactory level, 3) abnormal or unexpected findings were documented and reported, 4) assistance is needed to complete assigned tasks in a timely manner, and 5) assignment should be re-evaluated and possibly changed.
What is the act of supervision?
The process of directing, monitoring, and evaluating the performance of tasks by another member of the healthcare team. RNs are responsible for the supervision of pt care tasks delegated to assistive personnel and licensed practical nurses
How does the ANA define delegation?
The transfer of responsibility for the performance of an activity from one individual to anotehr while retaining accountability for the outcome. They stress teh belief that , even though the leader or manager delegates a task to another employee, he or she remains accountable for the care that is provided.
According to the NCLEX, what can't LPN/LVNs do?
They cannot do admission assessments, IV push medications, write nursing diagnoses, do most teaching, do complex skills, take care of pts with acute conditions, take care of unstable patients.
Who takes responsibility for a delegated task?
When a delagatee accepts a delegated task, assistive personnel accept the responsibility attached to it. Delegatees do not practice on the RNs licence. They practice on their own license or if unlicensed, within their own education level. Assistive personnel, when they accept the delegated task, are responsible for their own actions in performance of a task. When the RNs accept responsibility for delegating an assignment appropriately, they become accountable for the delegation process. Accountability looks to see if the RN used his or her nursing knowledge, critical thinking, and clinical judgement skills in delegating tasks. Example: if the RN delegates to an assistive personnel who is appropriate for the task and they accept the task and are qualified to do it, then they screw it up and the pt dies, the nurse has satisfied her responsibiliy for finding a qualified person to accept the task and the responsibility lands on the assistive personnel
Are there certain situations where delegating increases the risk for liability?
Yes, when delegating, try to avoid the following: 1) assigning tasks that are highly invasive or have the potential to cause significant physical harm to clients 2) assigning tasks that are designated under the scope of practice or standards of care as belonging exclusively to the RN (admission assessments/care plan development) 3) assigning tasks that the person is not trained for or lacks the knowledge to complete safely. 4) assigning tasks when there is inadequate time to safely monitor or evaluate the practice of the person performing the tasks.
