complex: prioritization, delegation, NOF

quality improvement

A busy nursing unit is cited for having poor performance on infection control. You suspect it is due to lax hand hygiene and mention this to the nurse educator. A taskforce is established to address poor performance on infection control. Teamwork and Collaboration Safety Quality Improvement Evidence Based Practice

systems based practice

A fire started in the special procedures department. The alarm and fire protocol for the hospital was initiated. A nursing supervisor has asked for two staff members to help evacuate patients from the adjacent nursing units. Professionalism Leadership Systems Based Practice Informatics and Technology

teamwork and collaboration

A patient is being discharged from a long-term care facility to home with a nephrostomy tube in place. The patient will receive skilled and unskilled nursing care at home. Before he is discharged the nurse convenes a team meeting which included a conference call with the home care agency. Systems Based Practice Informatics and Techology Communication Teamwork and Collaboration

Assessment Diagnosis (/Analysis) Planning Implementation (/Interventions) Evaluation (an assessment also occurs here)

ADPIE

Help the client to eat a bland, moist, soft diet Helping the child to eat is within the scope of practice of the UAP. Determining extent of ulcerations, assisting with medications, assessing willingness are all the duties of the RN.

An 8-year-old child has stomatitis secondary to chemotherapy. Which task would be best to delegate to a nursing assistant? Report evidence of severe mucosal ulceration Assist the child in swishing and spitting an anesthetic mouthwash Assess the child's ability and willingness to drink through a straw Help the client to eat a bland, moist, soft diet

leadership

An elderly client is admitted to a rehab facility with a c-difficile infection. The client is weak and requires assistance for activities of daily living. The client has uncontrolled diarrhea requiring frequent skin care to maintain cleanliness and comfort and prevent skin breakdown. During rounds, the nurse reports she has re-assessed his skin and believes he needs the wound care nurse to re-evaluate him. The team agrees. Professionalism Leadership Systems Based Practice Informatics and Technology

safety

An older patient fractured her wrist as she was walking on an icy sidewalk. The nurse conducts a Morse Fall Scale and determines the patient is at high risk for falls. She initiatives fall prevention protocols. Teamwork and Collaboration Safety Quality Improvement Evidence Based Practice

Application of heat and cold Application of heat and cold is a standard therapy with guidelines for safe use and predictable outcomes, and an LPN will be implementing this therapy in the hospital under the supervision of an RN. Therapeutic touch requires further training, meditation requires an assessment of spiritual and cultural beliefs and TENS unit is usually applied by a physical therapist.

For client education about the use of non-pharmacological alternatives for pain, which topic could you delegate to an experienced LPN, who will function with your continued support and supervision? Therapeutic touch Application of heat and cold Meditation Transcutaneous electrical nerve stimulation (TENS)

1. Care is based on continuous healing relationships. 1. Care is customixed according to pt needs and values 3. the pt is the source of control 4. knowledge is shared and information flows freely 5. decision making is evidence-based 6. safety is a system property 7. transparency is necessary 8. needs are anticipated 9. waste is continuously decreased 10. cooperation among clinicians is a priority

IOM 2001

Assisting the client with preparation for a sitz bath. The UAP is able to assist the client with hygiene issues and knows and knows the principles of safety and comfort for this procedure. Monitoring the client, teaching techniques, and evaluating outcomes are nursing responsibilities.

In the care of the client with pain and discomfort, which task is most appropriate to delegate to the UAP? Assisting the client with preparation for a sitz bath. Monitoring the client for signs of discomfort while ambulating. Coaching the client to deep breathe during painful procedures. Evaluating relief after applying a cold compress.

1.Patient Centered Care, 2.Professionalism 3.Informatics and Technology 4.Evidence Based Practice 5.Leadership 6.Systems Based Practice 7.Safety 8.Communication 9.Teamwork and Collaboration 10.Quality Improvement. K-Knowledge A-Attitudes S-Skills

NOF competencies

-Betsy Leeman story. treated for breast cancer at dana farber. using experimental stem cell transplatation with cytoxan. hold stem cells from blood, kill cancer, then give back to pt. she got 4x the dose bc physician ordered dose wrong. complained she felt something was wrong but was overlooked and she died from heart problems dt OD of the cytoxan. error was found 10weeks after her death. internal medicine reports came out regarding safety/quality with recommendations

Origin of NOF and hx

1. pt-centered care 2. teamwork/collaboration 3. evidence-based practice 4. quality improvement 5. informatics 6. safety

QSEN 2007

rn 1.assessment first 2. diagnosis/analysis 3. planning 4.implementation 5. evaluation PN 1. data collection first 2. planning 3. implementation 4. evaluation Analysis = a detailed examination of anything complex in order to understand its nature or to determine its essential features : a thorough study doing a careful analysis of the problem; a statement of such an examination; separation of a whole into its component parts retrieved Analysis Definition & Meaning - Merriam-Webster Diagnosis = the art or act of identifying a disease from its signs and symptoms; investigation or analysis of the cause or nature of a condition, situation, or problem; a statement or conclusion from such an analysis retrieved from Diagnosis Definition & Meaning - Merriam-Webster

RN vs LPN process

The nurse remains accountable for the patients' care. The nurse remains accountable for the care of patients during delegation to the UAP. The UAP may be untrustworthy, but the reason the nurse checks on the patients is because the accountability belongs to the nurse. The nurse could take a report from the UAP and report that to the next shift. The nurse transfers the authority for the delegated care to the UAP.

The nurse has assigned the vital signs and daily weights of her patients to the unlicensed assistive personnel (UAP) on duty for that shift. It is still important for the nurse assigned to the patient to reassess each patient throughout the shift because: The nurse remains accountable for the patients' care. The UAP is not trustworthy. The UAP cannot report to the next shift. The nurse maintains the authority to care for the patients.

Assist the client with oral hygiene Oral hygiene is within the scope of duties of a UAP. It is the nurse's responsibility to observe response to treatments and to help the patient deal with loss or anxiety. The UAP cannot develop a care plan. They may contribute to it, but not initiate a care plan.

The nurse is caring for a client with esophageal cancer. Which task could be delegated to a UAP? Assist the client with oral hygiene. Observe the patient's response to feedings. Facilitate expression of grief or anxiety. Develop the nursing care plan for "Risk of aspiration."

B. Administering insulin on time.

The nurse is caring for a diabetic patient and must accomplish all of the following tasks. Which of the following is the nurse's priority? A. Referring the patient to a diabetic exercise class. B. Administering insulin on time. C.Teaching the patient how to count carbohydrates. D.Performing diabetic foot care.

C. A patient with a respiratory rate of 8 and and O2 Saturation of 60

The nurse is caring for a group of patients. Which of the following patients situations should the nurse consider his or her first priority? A. The patient experiencing chest pain B. The patient with a blood pressure of 60/40 C. A patient with a respiratory rate of 8 and and O2 Saturation of 60 D. The patient experiencing stridor

Patient centered care

The nurse is working on the night shift and is caring for a patient with a stroke and a recent bout of pneumonia. The patient's wife asks if he can rest a little bit longer. The nurse asks if she can quickly check a couple of things and then return in 30 minutes. Patient Centered Care Professionalism Leadership Systens Based Practice

Delegate this task to the LPN since the UAP may not have been educated on the task. First assess the situation. Did the UAP get behind and need help? Did the UAP not understand what was expected of her? Did she do it but not chart it? Did she do it but not chart it in the correct place? Once you have asked the UAP if they have needed assistance then you proceed from their answer.

Toward the end of the shift, an LPN reports to the RN that the recently hired UAP has not totaled the client's I&O for the past 12 hours. Which action should the nurse take? Confront the UAP about not completing the intake and output measurements. Delegate this task to the LPN since the UAP may not have been educated on the task. Ask the UAP if assistance is needed to complete the I&Os. Notify the nurse manager to include this on the UAP's evaluation.

At times UAPs are not comfortable performing a task even though their job description and training indicates they are capable. In this situation a UAP may decline to perform a task. When this occurs, the UAP is may be perceived as "difficult" or a "problem." Other times the UAP is truly inexperienced and uncomfortable but that need for affiliation with the group prevents them from communicating their inability. This why the nurse should always inquire about the UAPs comfort level with the patient, situation, or task before delegating.

UAP continued 1

Under delegation often occurs when nurses are insecure with delegation. Can be when the nurse, who should be delegating a task, simply refuses to do so. May be because the nurse does not trust the UAP or believes it is just simpler for them to do it themselves. Sometimes under delegation happens after a task has been delegated but the nurse rescinds the authority to perform the task, or hovers over the UAP too closely. This tends to erode trust and can make future work situations uncomfortable.

UAP continued 2

A patient who needs enemas and antibiotics to control GI bacteria Administering antibiotics and enemas is within the scope of practice of the LPN. Although some states may allow blood to be given by an LPN, in general, administering blood, providing preop teaching, and assisting with central line insertion are the responsibilities of the RN.

When assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be most appropriate to assign to an LPN under the supervision of a team leader RN? A patient with severe anemia secondary to GI bleeding A patient who needs enemas and antibiotics to control GI bacteria A patient who needs pre op teaching for bowel resection surgery A patient who needs central line insertion for chemotherapy

A child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures. The set of circumstances is least complicated for the child with the fracture and this would be the best client for the new and relatively inexperienced RN. The child will likely have a good response to pain medication and this will relieve some of the anxiety. The other three children have complex social and psychological issues related to pain management.

Which pediatric pain client should be assigned to a newly graduated RN? An adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient-controlled analgesia (PCA) device to a long-acting oral analgesic; he has been continually asking for an increased dose. A child who is receiving palliative end of life care; the child is receiving analgesics around the clock to relieve suffering, but there is a progressive decrease in alertness and responsiveness. A child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures. A child who has chronic pain and whose medication and nonpharmacological regimen has recently been changed; the mother is anxious to see if the new regimen is successful.

D. The patient experiencing stridor. Room 101: The patient with chest pain may be experiencing myocardial ischemia or injury. This is a circulation problem. Room 102: The patient with a blood pressure of 60/40 is experiencing a circulation problem. Room 103: A patient with a respiratory rate of 8 and an oxygen saturation of 60%. This is a breathing problem. The airway is clear and the patient is breathing however, it is not enough to keep up with the demand. Room 104: The patient experiencing stridor. Stridor is a harsh sound that occurs when the airway is becoming obstructed. If the airway is not patient oxygen will not get to the lungs. This is an airway problem and is the priority. If it is not taken care of immediately, breathing will stop and the heart rate and blood pressure will plummet. If this occurs the patient will most certainly die.

You are the charge nurse. The following patient situations are happening concurrently. Which patient is the priority? Room 101: The patient is experiencing chest pain. Room 102: The patient with a blood pressure of 60/40. Room 103: A patient with a respiratory rate of 8 and an oxygen saturation of 60%. Room 104: The patient experiencing stridor. A. The patient is experiencing chest pain. B. The patient with a blood pressure of 60/40. C. A patient with a respiratory rate of 8 and an oxygen saturation of 60%. D. The patient experiencing stridor.

A nurse is beginning his shift caring for a patient who is stable and two days post abdominal laparotomy. When caring for post operative patients nurses work very hard to prevent common complications. These complications are potential problems because they have not yet occurred. The nurse will routinely include them in the care for that patient. In this example, the nurse plans to assess his patient and while doing that will assist the patient to use the insentive spirometer and cough and deep breathe. On this day, while assessing the patient, the nurse observes that there is a fair amount of serous drainage on the dressing. He decides to change the dressing before doing those tasks that would prevent the patient from developing post-op pneumonia. He chooses to do this because the dressing is an actual problem and the post-op pneumonia is a potential problem.

actual vs potential problem

A Nurse needs to accomplish many planned tasks that compete for attention. Sometimes it's helpful to take care of things that can be done quickly before things that are more time consuming. For Example: The nurse has several post-op dressing changes and another patient on contact precautions who needs his wound-vac dressing changed today. The wound vac dressing is more complex and involved than the others. It also means the nurse will have to don PPE and be in the contact precaution room and unavailable to the other patients. In this case the nurse should complete the smaller, less complex dressing changes first. Doing this will shorten the "to do" list. If the nurse does the wound vac dressing first, it's possible there might be unforeseen complications that would prevent the nurse from accomplishing the other more routine dressing changes.

decsribe Doing Something First Because It Can be Done Quickly

Unlicensed Assistive Personnel are non-credentialed individuals hired by an organization to help meet the needs of patients. The scope of practice for UAPs is determined by the organizations that hire them.

decsribe Unlicensed Assistive Personnel

A patient with a respiratory rate of 8 and an oxygen saturation of 60% is not breathing normally. This is a breathing problem. A patient with a blood pressure of 60/40 also has a circulation problem. The patient with chest pain may be experiencing myocardial ischemia or injury. This is a circulation problem. Stridor is a harsh sound that occurs when the airway is becoming obstructed. If the airway is not patent oxygen will not get to the lungs. This is an airway problem and is the priority. If it is not taken care of immediately, breathing will stop and the heart rate and blood pressure will plummet. If this occurs the patient will most certainly die.

decsribe different types of problems

"Delegation From Wikipedia, Delegation is the assignment of responsibility or authority to another person (normally from a manager to a subordinate) to carry out specific activities. It is one of the core concepts of management leadership. However, the person who delegated the work remains accountable for the outcome of the delegated work. Del·e·ga·tion, deləˈɡāSH(ə)n/noun noun: delegation; plural noun: delegations 1. a body of delegates or representatives; a deputation."a delegation of teachers" synonyms: deputation, legation, mission, diplomatic mission, commission; More delegates, representatives, envoys, emissaries, deputies; ​contingent ​"the delegation from South Africa"​ 2. the act or process of delegating or being delegated."prioritizing tasks for delegation" synonyms: assignment, entrusting, giving, devolution, deputation, transference "the delegation of tasks to others"

delegation definitions

For example a nurse may have just medicated a patient and plans next to check the IV on different patient in another room. As she is about to leave the room, she remembers this patient must have his Foley catheter emptied and recorded. This task falls into the category of routine monitoring. It is not critical and it could wait. The nurse however decides to empty the catheter now rather than wait. In this example the nurse did what was most convenient.

describe Doing What's Convenient

Licensed Practical Nurses or Vocational Nurses attend nursing education programs that are 12 to 18 months in length. They must demonstrate minimal safety by taking and passing the National Council Licensure Examination-PN®. Generally speaking, LPN/LVNs provide care to stable patients whose outcomes are predictable. The differences between what an LPN/LVN can do and what an RN can do, is dictated by the Board of Nursing and varies from state to state.. Some state boards are very prescriptive and list what nursing tasks may or may not be delegated to LPNs. In other states, like Massachusetts the regulations are very broad.

describe LPNs

Most states do not allow LPNs to perform initial patient assessments, initiate plans of care, or provide initial patient education. In most states LPN/LVNs may contribute to these activities but the ultimate responsibility lies with the RN. Additionally, the majority of states do not allow LPN/LVNs to perform telephone triage. The primary inconsistencies appear to center on intravenous therapy. Most states allow LPN/LVNs to assess IV sites and regulate the flow of fluids. But several states do not permit LPN/LVNs to give IV medications or Total Parenteral Nutrition. Many states do not allow an LPN/LVN to start or restart an IV. The majority of states prohibit LPN/LVNs from administering blood products, although many states do allow them to monitor the patient during a transfusion.

describe LPNs continued

1. patient-centered care 2. professionalism 3. leadership 4. systems-based practice 5.informatics and technology 6. communication 7. teamwork and collaboration 8. safety 9. quality improvement 10. evidence-based practice

describe MA NOF competencies 2010

self-actualization self-esteem love and belonging safety and security physiological needs At the very bottom of the pyramid are physiological needs. These are essential for life and if threatened, can cause harm to the patient. Physiological problems include cardiac, respiratory, tissue perfusion, elimination, metabolic, fluid & electrolyte, and physiologic regulation, are nursing priorities. Physiological problems are most often the priority the nurse should address first.

describe Maslow's Hierarchy of Human Needs

-Nurses are given the authority to delegate from their State Boards of Nursing. -Delegation takes place when the RN, who holds the authority for nursing care delivery, transfers responsibility for the performance of a task to nursing assistive personnel while retaining accountability for a safe outcome (ANA, 2012). -When the nurse delegates a task to a UAP or LPN he or she transfers the authority to carry out that task to another person. -By agreeing to perform this task, the UAP or LPN accepts the responsibility to carry the task out. At this point the nurse has simply given the authority and responsibility to another person. -However it is essential the nurse remembers he or she remains accountable for the safety and outcome of this delegation.

describe The Fine Art of Delegation

In 2005 the Robert Wood Johnson Foundation (RWJF) began the Quality and Safety in Nursing Education project to tackle the challenges of preparing future nurses to improve the quality and safety of patient care. That same year, in Massachusetts the Department of Higher Education partnered with health care industry stakeholders to address the Commonwealths future health care needs. In 2008 the Robert Wood Johnson Foundation (RWJF) and the IOM together began to study the nursing profession and in 2010 published The Future of Nursing, Leading Change, Advancing Health. It called for nursing to take a leadership role in a changing health care system.

describe The Future of Nursing

Delegation requires the nurse to know the capabilities and qualifications of the UAP. It is essential the nurse match the task to be performed with the suitable staff member. To be certain that care is being delivered optimally, the nurse must continually monitor and supervise throughout the delegation process. Trust and respect are essential components of delegation. The nurse needs to be able to trust the UAP will carry out their work as directed. The UAP has to respect that the nurse is knowledgeable and has authority to delegate.

describe UAPs and delegation

Acute conditions, on the other hand, have an abrupt onset and may rapidly progress. Acute problems are unpredictable and we may not have all the information needed to decide upon a course action. Therefore acute problems are more urgent and are the priority.

describe acute conditions

Chronic conditions are persistent disease processes. These problems are not new problems for a patient. Usually the patient has experienced a chronic condition for a fairly long period of time. Because of this, patients usually have develop some level of adaptation to the condition.

describe chronic conditions

The Nurse of the Future will interact effectively with patients, families, and colleagues, fostering mutual respect and shared decision making, to enhance patient satisfaction and health outcomes.

describe communication

The nurse should provide clear, concise instructions. Include the activities to be performed and the timeframe in which they should be performed. The nurse should tell the delegate what the expected outcome should be and outline any potential complications that could occur. It should be stressed that should anything deviate from the norm, it needs to be reported immediately to the nurse. The nurse should also specify when the delegatee should update the nurse on the task's progress.

describe communication

The purpose of delegation is to meet the patient's goals Increased acuity of patients Increased RN responsibilities in the management of the nursing unit/organization Accelerated pace and changing health care environment.

describe delegation

The Nurse of the Future will identify, evaluate, and use the best current evidence coupled with clinical expertise and consideration of patients' preferences, experience and values to make practice decisions. (Adapted from QSEN, 2007).

describe evidence-based practice

Does this threaten the ability to sustain life? Conditions that threaten the patient's survival include problems with airway, breathing and circulation, trauma, sudden change in level of consciousness, and chest pain. In these conditions are level one problems and the nurse must act immediately. What if my patient experiences more than one life threatening problem concurrently. Within level one conditions, problems with airway, breathing, and circulation take precedence over all others.

describe how to determine which physiological need is the priority

The Nurse of the Future will use information and technology to communicate, manage knowledge, mitigate error, and support decision making (QSEN, 2007)

describe informatics and technology

Only RNs can do initial assessments and develop a plan of care. Never delegate assessment or evaluation to a UAP. LPNs can provide ongoing assessments but the Registered Nurse must do the initial assessment, develop the plan of care, and evaluate the outcome of that care. For these activities the nurse may NOT transfer authority and therefore may not delegate. Evaluation and assessment both involve data collection. The difference is when the nurse collects and how the nurse uses the data.

describe initial assessments

The Nurse of the Future will influence the behavior of individuals or groups of individuals within their environment in a way that will facilitate the establishment and acquisition/achievement of shared goals.

describe leadership

All other physiological problems are either level two or level three problems. Level two problems are all other physiological problems that are not emergencies. If left untreated they may cause further deterioration in the patient but they are NOT critical. Level three problems are all other problems that are not level one or level two problems. Level three problems include coping, self-concept, patient education and routine monitoring.

describe level 2 and level 3 problems

Medical mistakes are the third leading cause of death in the United States. Only heart disease and cancer kills more Americans.

describe medical mistakes

Nurses quickly become aware of the unit specific work habits, mores, and patterns of behavior that are acceptable where they work. This fear of not fitting in can have a profound effect on delegation. It can cause the nurse to be reluctant to delegate for fear of criticism from other nurses or the UAP. Fear of being disliked and not wanting to make others feel like subordinates can prevent nurses from delegating tasks. This is particularly true of new nurses who often closely identify with unlicensed personnel. Also, new nurses are often uncertain about what needs to be done and may be unable to effectively explain directions in detail to a UAP. Experienced nurses also have characteristics that can cause barriers to delegation. Some people prefer to work alone. Other nurses do not possess the organizational or leadership skills

describe nurses and delegation

Often times nursing roles seem to overlap and all of this becomes very confusing. It is impossible for every nurse seeking licensure to know the details of every nurse practice act in every state. But for a nurse to practice safety he or she is advised to heed the following advice: Ignorantia juris non exactas Ignorance of the law is no excuse. Remember it is the responsibility of the delegating nurse to know and comply with the regulations of the state where he or she is practicing.

describe nursing roles

The organization is responsible for the administrative processes that support delegation. Facilities must develop policies and procedures for delegation of tasks. Job descriptions must be clearly defined. Institutions must develop educational opportunities for unlicensed workers and document their competence and continued competence to deliver safe patient care. Inadequate staffing or a staffing mixes that does not support proper UAP supervision do not allow the nurse to delegate appropriately. Health care facilities that fail to plan ahead and continually manage from crisis to crisis, do not allow nurses enough time to develop strategies that would allow them to delegate properly. Missed care and patient complications as a result of improper delegation are no longer eligible for reimbursement. Therefore, the institution must not only evaluate how delegation affects patient care but also how it affects finances.

describe organization

Over delegation occurs when the nurse gives too much authority or responsibility to the UAP. UAP assumes some of the duties only the nurse should perform. The patient may receive sub-optimal care or even be harmed. A patient may experience a change in condition that cannot be recognized by the UAP. When this occurs situations can quickly become out of control. At times, the UAP is assigned too many tasks. UAP may become overwhelmed and begin to take short cuts. Care that should have been provided may be omitted. Unlicensed Assistive Personnel may become too fatigued to perform optimally. When this situation continually occurs, UAPs become resentful and feel over worked. UAP may request to not be partnered with nurses who are known to frequently over delegate. Nurses with this type of reputation may find themselves having a difficult time fostering a sense of teamwork with UAPs.

describe overdelegation to UAP

Patients are now viewed as consumers and as their own costs rise, they begin to demand more. Health care institutions expect nurses to not only deliver high quality evidence based care to their patients, they expect nurses to efficiently coordinate their care with others, manage the workflow environment, communicate across disciplines, utilize information and technology and become true leaders in their profession. As a result the work of nursing has never been more complex.

describe patient costs and institutions

Think of it like this Physiological = Keeping the patient alive. Safety = Preventing injury or protecting the patient from harm. Belongingness = Promoting relationships and support systems

describe physiological, safety, and belongingness

•LPNs have been formally educated in science of nursing. •They are licensed nurses. •They can perform ongoing assessments-not initial ones. •They can provide input to the plan of care but do not have final authority or accountability. •They may administer oral, topical, and inhaled medications but in many states IV medication administration is limited. •They may regulate the flow of IV solution. •They are able to document most aspects of patient care.

describe points to remember

What Ever Comes First This happens when the nurse reacts as things occur. The nurse does not plan for any potential obstacles. New nurses often do this because they don't have the experience needed to anticipate problems. Experienced nurses prioritize the most urgent needs first but always have one eye focused on potential problems that might crop up. People Pleasing This nurse would rather be overworked than tell other's what to do. Delegation makes some nurses uneasy. A nurse should not delegate everything nor should he or she do everything. This fine balance can be tricky. Often times this nurse has an overwhelming need to fit in. This need is common not only in new nurses but also in experienced nurses who are new to a unit or organization. Remember the purpose of delegating and asking others for help is to meet the needs of the patient.

describe prioritization pitfalls

he Nurse of the Future will demonstrate accountability for the delivery of standard-based nursing care that is consistent with moral, altruistic, legal, ethical, regulatory, and humanistic principles.

describe professionalism

The Nurse of the Future will provide holistic care that recognizes an individual's preferences, values, and needs and respects the patient or designee as a full partner in providing compassionate, coordinated, age and culturally appropriate, safe and effective care.

describe pt centered care

The Nurse of the Future uses data to monitor the outcomes of care processes, and uses improvement methods to design and test changes to continuously improve the quality and safety of health care systems. (QSEN, 2007).

describe quality improvement

Are appropriate equipment and resources available? If the nurse asks the UAP to have the patient sit in a chair and the patient requires a mechanical lift to do so, is it available? Will the UAP have the right supervision to accomplish the task? Will the nurse be able to over see the UAP? Most would agree that feeding a patient is a usually within the role of a UAP. What if the UAP is asked to feed a patient, will the nurse be available should the patient begin to aspirate? Is the environment favorable for delegation in this situation? A chaotic nursing unit or one where there is one or more emergencies occurring may not be ideal circumstances for delegating. Even the physical environment needs to be considered. Would if be safe to have a patient crutch walk if equipment is scattered throughout the hallway where the patient will be walking.

describe right circumstance

Does the nursing assistive personnel have the appropriate knowledge, skills and abilities to accept the delegation? This requires the nurse to understand the abilities of the UAP. If the UAP and the RN have worked together for a period of time, the nurse usually know the UAP's abilities. If not the nurse needs to ask the UAP if they have performed the task before and feel capable. Does the ability of the UAP match the care needs of the client? Even if the task is routine, and the patient stable, if he UAP is not experienced and verbalizes to the nurse that she has never performed this procedure on a "real patient." The nurse should now recognize that this UAP would not be the best choice to perform this task at this time

describe right person

How Complex is the TASK Some tasks have multiple steps and are very obviously complicated to perform. The nurse must be aware that other tasks that seem on the surface to be simple can have subtle complexities. Ambulating a patient can have an unpredictable outcome if say, for example the patient has just had an epidural catheter removed and it is the first time the patient has gotten out of bed. How Predictable is the Outcome If the task is ambulation, is the outcome predictable? The outcome of ambulation alone is predictable. It is not known if the patient will tolerate ambulation with the epidural in place. In our ambulation example the nurse would deem delegating the ambulation of those particular patients to a UAP as potentially unpredictable. "

describe right task

The Nurse of the Future will minimize risk of harm to patients and providers throughout both system effectiveness and individual performance. (QSEN, 2007)

describe safety

The nurse needs to monitor the progress of the task. The nurse needs to provide feedback from the delegatee and provide feedback to the delegatee. If at anytime the patient becomes unstable or the nurse notices the task is not being performed properly, he or she needs to intervene. Supervision also includes proper documentation. It should be noted that if a nurse determines that he or she would be unable to properly supervise a delegatee, then delegation should not occur.

describe supervision

Imagine a patient is in a motor vehicle accident and is admitted to the emergency room. The patient has a closed fracture of her femur but is also has a blood pressure of 70/40 and a heart rate of 120. This patient is in shock. Shock is a systemic problem and if left untreated, could be fatal for the patient. The fracture is clearly an important consideration but will not immediately jeopardy the patient's ability to sustain life. The emergency room team will stabilize the patient by treating the shock first. Once that is addressed they can then treat the fracture. The femur fracture is less of a priority A good way to think of this is to remember of the old adage life over limb.

describe systemic or localized

The Nurse of the Future will demonstrate an awareness of and responsiveness to the larger context of the health care system, and will demonstrate the ability to effectively call on microsystem resources to provide care that is of optimal quality and value (Adapted from ACGME, n.d.).

describe systems based practice

The Nurse of the Future will function effectively within nursing and interdisciplinary teams, fostering open communication, mutual respect, shared decision making, team learning, and development (Adated from QSEN, 2007)

describe teamwork and collaboration

"The goal of delegation is to achieve desired patient outcomes. In nursing, delegation is a complex skill that requires the nurse to use high-level clinical reasoning to determine if delegation is appropriate for that patient, and if can be done be safely. The registered nurse (RN) therefore, assigns select and appropriate activities to an individual." The American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN) define delegation as "The process for a nurse to direct another person to perform nursing tasks and activities (NCSBN & ANA, 2006)."

describe the goal of delegation

The first step of delegation is to determine if the task is within the delegating nurse's scope of practice. There are four key questions the nurse should ask 1. Is the task considered something the nurse's scope of practice allowed? 2. Do the state's nursing regulations give the nurse the authority to delegate? 3. Does the healthcare organization allow for delegation of this task? 4. Does the nurse have the clinical judgment needed to make delegation decisions? Only when the answer to all four questions is "Yes" should the nurse proceed to the next step of delegation, assessment.

describe the steps of delegation

Some nursing responsibilities have a time component to consider. A range of time is more flexible than a specific time. A nurse may have 7:30 medications to give and must also draw blood for the patient in the morning. These two tasks need to be done within the same timeframe. If the blood has not been drawn and 7:30 is rapidly approaching, the nurse should give the 7:30 medication first. This task's has less flexibility and should be the priority problem. In order to properly prioritize the nurse needs to understand how disease, procedures and medications impacts prioritization

describe time and prioritization

For example many times we hear the patient is scheduled for discharge today. Other times we may hear that a patient is being transferred to a rehabilitation center at a very explicit time, say 11:30. Let's look at this more closely. Patient A is to be discharged home today. It could be any time during the day. It may be early morning or late afternoon. However, patient B has a very specific time and he is being transferred by ambulance. His time is less flexible. So which patient should the nurse prepare for discharge first?

describe vague timing

Immediately above physiological needs are safety and security needs. These needs focus on protecting the individual's environment and obtaining resources. Nursing care emphasizes safety and reducing the risk for harm, but this category also includes things like shelter and employment. Safety is extremely important to consider when caring for patients however, in many situations something that threatens the physiological well-being of a patient is often more of an immediate priority. Above that is belongingness. Human beings have an inherent need to make and keep positive connections with others. This includes the need for love, friendship, and family. These relationships are important because they allow us to have a sense of being part of something larger than ourselves. However, belongingness is a psychological need, and this need does not take precedence over the physiological or safety needs of a patient.

maslows 2

Esteem is an emotional need and is next on Maslow's Hierarchy. It addresses the desire to be respected by others, and have a sense of confidence and self-esteem. It fulfills the need humans have to be valued for their accomplishments or contributions. At the top of the hierarchy is self-actualization. It addresses the need for humans to fulfill their potential through personal growth. By doing this people can become their best selves. Both esteem and self-actualization address psychosocial needs. While nurses care for whole patient, and nursing care strives to maximize the patient's potential, physiological, safety, and belongingness needs (in that order) are the priorities.

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Falling Victim to the Complainer or Whiner In this situation the nurse takes care of the problem of the person who is most vocal. At times it can be a demanding patient. Other times the nurse prioritizes based on the needs of the outspoken staff member. These "squeaky wheel" individuals can become distractions. Humans have a tendency to remove this irritation rather than set limits or politely explain why their need is not being dealt with immediately. If the nurse keeps the patient as the center of attention he or she will be less prone to base prioritization decisions based on the one who complains the loudest.

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Martyrdom Similar to the people pleaser, this happens when the nurse saves all the unwanted tasks for themselves. They too are poor delegators when it comes to unpleasant or time consuming problems. They also may have a need for others to like them. They might even receive praise from others for being such a "great member of the team" or a "terrific worker." Everyone likes to be praised for their efforts but becoming the martyr can have a negative impact also. It can cause the nurse to become fatigued or fall behind in his or her work and improperly prioritizing.

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Waiting for Perfection The perfectionist delays prioritization because they are looking for the ideal solution. They perseverate over the smallest details. They are often unsure of their ability and the fear of making a terrible decision paralyzes them. They may excessively seek advice from others. New nurses naturally do this but eventually their decision making and prioritization ability improves. When it does not these nurses can be frustrating to work with. Their perfectionism delays others and their continual advice seeking becomes draining.

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Procrastinating This is when people delay decision-making. It may occur because of poor time management ability or uncertainty. They seem to never make a timely decision. This can cause havoc on the unit and cause the work environment to become chaotic. They frustrate other staff who may feel they need to pick up the slack. Waiting for Devine Intervention This person is waiting to be inspired in order to make a decision. This person does not methodically go the work of prioritization. Their decisions are often delayed or poor because they seem to be made on a whim. Like the perfectionist they too seem to be paralyzed when it comes to prioritizing. Often the divine intervention they seek comes in the form of someone making the decision for them.

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Referring the patient to an exercise group will help the patient manage his disease properly. When a patient is given control over management of their disease they become more autonomous. Gaining autonomy promotes self-esteem. While exercise will have a physiological effect on his diabetes, this choice addresses the patient's esteem needs. Teaching the patient how to count grams of carbohydrates will help the patient manage his disease and become more autonomous. Becoming more self-sufficient promotes self-esteem. Insulin is either not produced at all or the insulin that is produced is inadequate to meet the needs of the patient. When the nurse gives insulin on time it meets a physiological need that the pancreas is unable to meet.

question rationale

Performing diabetic foot care is meeting a physiological need. It is done to prevent a complication of diabetes and therefore it will prevent harm from coming to the patient. This is problem that addresses the safety needs of the patient. It is also not an actual problem but a potential problem

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In order to safely delegate the nurse must: 1. Know if the task is within their scope of practice. 2. Assess the patient and determine if they are stable. 3. Know if the task is permitted by their facility. 4. Delegate only routine tasks with predictable outcomes. 5. Determine if the UAP is qualified to perform the task. Need to consider two more things: communication and supervision

review how to safely delegate

Is There a Potential for Harm? Ambulation has a moderate potential for harm. Sometimes you cant predict who may fall. Its not down if the patient will tolerate ambulation with the epidural in place. In our ambulation example the nurse would deep delegating the ambulation of those particular patients to a UAP as potentially unpredictable

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prioritization

to rank in order of importance

gaps in: confidence communication conflict resolution bedside experience

what are some common themes problems