21Jones Leadership(F)-ch 21 348 1/15/07 6:45 PM Page 348 Skills for Being an Effective Manager tional nurses (LPN/LVN) are licensed nurses within federal and state statutes unless specifically differentiated Both RNs and LPNs might have authority to delegate care in circumstances defined by law and agency policy UAP can be a certified nursing assistant or home health aide or hold a different work title within almost any health-care setting UAP refers to “any unlicensed personnel, regardless of title, to whom nursing tasks are delegated” (NCSBN, 1997) ANA (1997) refers to UAP as an “unlicensed individual who is trained to function in an assistive role to the licensed registered nurse in the provision of patient/client care activities as delegated by the nurse.” Although states maintain registries and titling of trained UAP and provide certificates or registrations from the board of nursing, the most inclusive title is UAP See Box 21-1 for different titles that fall under the umbrella of UAP The operative phrase for UAP is “assist the nurse.” Assessment of the skills and strengths of UAP is essential to obtain the benefits of their assistance in the setting UAP have always worked in health care in some capacity, but the evolution toward formalizing training of UAP is fairly recent The Nursing Home Reform Act, adopted by Congress in 1987 as part of the Omnibus Budget Reconciliation Act, defined training and evaluation standards for UAP working in long-term healthcare facilities Other health agencies developed similar policies for a variety of care settings It is important for delegators to understand the scope and limitations of UAP based on training Content and duration of training are defined further by the Centers for Medicare and Medicaid Services—§484.36 (a)(1)—and includes observation, reporting, documentation skills, basic infection control, recognition of emergencies, and skills for personal hygiene and grooming (Box 21-2) Training, instruction, and testing for manual skills and written knowledge are conducted by public and private contractors with approval of state nursing boards The National Nurse Aide Assessment Program (NNAAP), developed by the NCSBN, operates in many states as a competency certification process Results are then reported to a board of nursing Students enrolled in basic nursing programs (associate and baccalaureate degree) often present as candidates for NNAAP testing Successful completion of the test means that students can be employed as UAP until graduating and passing the NCLEX Generally, UAP work to assist licensed nurses in caring for clients in hospitals, nursing homes, patient residences, long-term care facilities, and clinics Physician offices, schools, day-care centers, public health centers, and offices of other licensed professionals also employ UAP Because of the wide range of employment settings, the nurse should be cognizant of the training of UAP in his or her specific work setting “I can this or that faster/better/more skillfully by myself” is an attitude that prevents the nurse from taking full advantage of UAP skills Of course, the nurse has more overall knowledge, but UAP may have more experience with a particular type or age of client Care based on the knowledge of team members helps the nurse to take full advantage of strengths of other workers and promotes working relationships Working in a unit with other nurses Box 21-2 Box 21-1 Training for Home Health Aides (42 CFR §484.36) Names for UAP Attendant Assistive Personnel Certified Nurse Assistant (CNA.) Dietary Assistant Home Health Aide Medication Technician Nurse Aide Nursing Assistant Orderly (PCA) Patient Care Assistant Health-Care Assistant Personnel Unlicensed Assistive Registered Nurse Assistant (RNA.) Technician Duration: 75 hours classroom; 16 hours supervised practice Content: Reporting, documentation observation of patient, and reading and recording of temperature, pulse and respiration; basic infection control; basic body function; clean and safe environment; respect for privacy and property; personal hygiene and grooming; transfer techniques; range of motion and position; nutrition and fluid intake; and any other task that the HHA may choose to have the aide perform 21Jones Leadership(F)-ch 21 1/15/07 6:45 PM Page 349 Delegation: An Art of Professional Practice and UAP teams requires respect and judgment to avoid delegation to UAP who are already assisting other nurses The UAP can receive conflicting instructions or overlapping information, both of which can serve to confuse and disorganize Similarly, not expect the same kind of skill from UAP unfamiliar with the patient population in your area 349 practice limitations to the physician Physicians who delegate to advance practice nurses (APNs) retain responsibility for the task, whereas APNs who function independently within the state nurse practice act are responsible for the outcomes of their decisions During surgical procedures, a nurse might function as a first assistant with definitive education and experience or perform a delegated task usually assigned to a second physician Delegating to Nurses To be promoted, a nurse manager must have competent personnel to step into her position In health care, advancement in the workplace often starts in the same work area Here, supervisors have an opportunity to select from among the staff for promotion to management levels within their supervisory sphere Selecting the right person requires creative thinking: Who is reliable? Who has the most appropriate experience? Who will take acceptable risks? Who understands the workload? Who wants to succeed? Delegation can help the manager to assess the ability and potential of staff nurses, provide motivation through new challenges, and contribute to development of other skills on the team As you become comfortable in an employment position, discuss your interest and willingness to accept management tasks with your supervisor As a new employee, you might be the delegatee for many activities, especially during the orientation period Accepting delegated tasks assumes that you have the time, authority, knowledge, and skill to complete the job, but the delegator may not transfer the responsibility to get something done Accepting delegated activities can leave you with little time left for your own workload; consequently, delegated jobs may require that you negotiate performance requirements If you are delegated the job of “Arrange for a meeting of all staff on the unit,” what does that mean? Do you set the time? The location? The agenda? Do you provide substitute staff during the meeting time? Do you order refreshments? Understanding the anticipated outcomes and possessing adequate information and authority for successful completion are crucial considerations Physicians, too, might choose to delegate a medical task to an RN without consideration of the skills, education, and experience of that nurse This situation can create communication problems and a risk to client safety if the nurse is not clear about Physician Assistant Delegation Where delegation of patient orders or treatment plans becomes less clear is when a physician assistant (PA) is the delegator A PA works in collaboration with an MD or DO and generally evaluates and treats patients in clinics, medical offices, and sometimes in hospitals When the PA delegates orders to an RN, what is the responsibility of the RN to carry out the order? Does he treat PA verbal and written orders as if those directives came from the physician? Does he contact the physician to validate the order? Does he nothing because the order is not given and signed by the physician? The answer to the nurse’s response to a PA delegator is based on the medical, nursing, and PA practice acts in the state/province In any event, the response is to something and not ignore the order for patient treatment Lack of response to a patient treatment order can result in issues of negligence or malpractice Questions about the authority of a prescribing professional can be referred to a unit supervisor until clear guidelines exist for the work setting If you happen to be the supervisor, the physician of record can be contacted for clarification APN Delegation Delegation is clearly an empowerment issue The nurse is empowered, by statute and often by agency policy, to give direction to others However, along with the power to direct others remain the authority and responsibility to see that the delegated activity is safely and correctly performed This principle exists for nurses who delegate to UAP or for APNs who give verbal or written orders for other nurses to perform such activities as treatment or medication administration The authority of the APN to delegate medical orders depends upon the state/provincial regulations In Minnesota, for example, a Memorandum of Understanding between an APN 21Jones Leadership(F)-ch 21 350 1/15/07 6:45 PM Page 350 Skills for Being an Effective Manager and a physician defines delegated responsibilities related to the prescription of drugs, related devices, and activities (MN Statutes 2005, 148.171, subd.6, 13, 15) The relationship of the hospital or nursing home to an APN determines the extent to which patients can be admitted and treated independent of a physician order If you are working in a setting where APNs routinely manage care for patients, that information will be part of the unit orientation Again, when you are unclear about assuming a delegated task, refer the issue to the supervisor Appropriate tasks for delegation to UAP must fall within the delegator’s scope of practice unless otherwise prohibited and should meet all five criteria: Standardized procedure, Technical in nature, Routine task, Unlikely risk, and Predictable results (STRUP) ■ Student Delegation Can a student nurse accept delegation from an RN who is not a faculty member? What are the consequences of refusing to complete a delegated task? The student role is fraught with ambiguities: the student wants a variety of clinical experiences but might not have covered the content in class, or a long time might have elapsed since learning academic content relative to the clinical practice Before entering the clinical setting, faculty members should provide clear guidelines to students on accepting delegated tasks not yet addressed in the curriculum Guidelines might include options for the student: contact the faculty to ask permission to proceed with the task; ask the delegator to observe the student doing the task; ask if the task can be delayed until the faculty is present; assist task completion with the staff person Each situation will vary RIGHT TASK One reason to delegate is that each nurse has finite time and energy to care for clients, maintain the environment, and communicate with other health professionals Tappen (2001) uses a framework of time management to explain delegation When a nurse has responsibility for 5, 8, or 20 patients, routine and repetitive aspects of care can be assigned to “a competent individual with the authority to perform in a selected situation a selected nursing task included in the practice of professional nursing as defined by state statute in the Nurse Practice Act” (Colorado Revised Statutes, 2004) Inappropriate delegation or otherwise unauthorized performance of nursing tasks by UAP could lead to legal action against the licensed nurse and the UAP by the board of nursing and employer ■ ■ Standardized procedure: A standardized procedure is taught in training classes, written in an agency manual in a “how to” approach, and performed the same way by persons with similar training Often, one standardized procedure, such as Bed Bath, is coupled with another, such as Changing Bed Sheets, to become a series of standardized procedures that comprise Personal Hygiene Standardization does not mean that UAP cannot vary procedures, sequence, or combination for the individual client Technical in nature: Technical tasks require little decision making about performance of the task However, the ability to recognize normal from abnormal condition of the client and usual from unusual response to the task is part of UAP-tested competency UAP need to recognize client response, determine if the task can be safely completed, and seek clarification as to how to continue if there is a question about safe care Examples of technical tasks are listed as Personal Hygiene training (Box 21-3) Routine task: Routine implies that the task is recurring for both the client and the UAP UAP are experienced in completing the task; the client has experienced the task previously There is no task that is routine the first time Box 21-3 Personal Hygiene Training for Home Health Aides Home Health Services General Provisions: 42 Code of Federal Regulations §484.36 (2004) Bed bath Sponge, tub, or shower bath Shampoo, sink, tub, or bed Nail and skin care Oral hygiene Toileting and elimination Safe transfer techniques and ambulating Normal range of motion and positioning Adequate nutrition and fluid intake 21Jones Leadership(F)-ch 21 1/15/07 6:45 PM Page 351 Delegation: An Art of Professional Practice ■ ■ that you perform it Even Measuring Intake and Output becomes routine only after the training is completed, competency is tested, and accuracy is established Even the most routine tasks become “new” when the equipment changes Unlikely risk: The stability of the client’s condition predicts risk Here, focus is on delegator knowledge of the person and the task Unlikely risk of adverse or unexpected events during the task also relates to safety An unlikely risk does not mean that a bad event never happens, only that the delegator considers the likelihood of an unusual event The nurse delegates Personal Hygiene to UAP and does not expect the client to fall from the bed, incur an infection, or choke on candy Similarly, UAP are not expected to incur low back strain, fall on a water spill, or be assaulted by the client Problems happen Conscientious supervision and active listening to UAP concerns can aid in delegating situations that pose an unlikely risk to client and worker Predictable results: Before delegation of any activity, the nurse anticipates the result of the activity Outcomes of tasks assigned to UAP need to be predictable Assignment of Personal Hygiene for a group of clients can be predicted and easily assessed Are the clients clean? Is there an odor about anyone? Is hair combed? Is the area clean and orderly? Are clients safe in their environment? Review all tasks for delegation to ensure that personnel receive the appropriate level of delegation The delegation decision model (Fig 21-1) can serve as a guide Delegate, not “dump.” Dumping can be a perceptual or a real issue Clarification of roles and open discussions of dumping less desirable assignments can promote understanding (Cohen, 2004) Repeated assignment of difficult clients or boring, unchallenging, nonclient duties to the same UAP can result in frustration Refusing Delegated Task Refusal to administer an inappropriate medicine or to carry out a procedure that may place the patient at risk or cause harm are common occurrences Medication orders that create risk for patient wel- 351 fare include routes, dosage, frequency, and the drug itself A Dutch study by di Bie and others cited refusal of orders by nurses because the nurses did not perceive that they had the authority needed to a risky procedure (2005, p 765) Interestingly, although fewer than 30% of the survey nurses experienced problems, most of the refusals, both actual and contemplated, involved medication policy RIGHT CIRCUMSTANCES When one nurse cares for one client, there is little need to delegate care True or false? False Complexities of science and technology have changed the concept of “private duty” nursing except in the realm of home care Even nurses in critical care units require assistance with the multiplicity of client, housekeeping, and non-nursing tasks Delegating tasks that not require decision making, assessment, or evaluation allows the nurse to concentrate on complex interventions What are the right circumstances in which to designate other care providers? The right circumstance for delegation is whenever a task can be appropriately completed by UAP or whenever an opportunity arises for education of another nurse in clinical or managerial experiences Often, a delegating situation permits on-site observations of staff and the opportunity to answer questions and improve performance Often, the ultimate goal of health care is cost containment The nurse can extend practice influence to more clients through delegation, thereby reducing the cost of routine client care to the agency Experienced nurses seem able to delegate through emergencies in client care or staffing Minute-to-minute “on-the-fly” delegation is not innate; it is learned through experiences during previous circumstances and knowledge of the capabilities of personnel in the setting (Hoban, 2003) Failure to delegate prevents the recent graduate or nurse who has changed jobs from having the opportunity to participate in a variety of situations and events that translate into experience Failure to delegate results in expensive overtime and fatigue on the part of employees As the RN delegator in the role of managing client care or managing all unit activities for a shift, consistent inability of staff to complete workload on time 21Jones Leadership(F)-ch 21 352 1/15/07 6:45 PM Page 352 Skills for Being an Effective Manager Assessment completed by Licensed Nurse for client nursing needs YES NO DELEGATE DO NOT DELEGATE Tasks for care needs within Nurse Scope of Practice YES NO DELEGATE DO NOT DELEGATE Delegating Nurse directly responsible for client care YES NO DELEGATE DO NOT DELEGATE Task DOES NOT require nursing judgment, evaluation, or decision making YES NO DELEGATE DO NOT DELEGATE Task technical, routine, and written procedure states predictable results with unlikely client risk YES NO DELEGATE DO NOT DELEGATE Client stable in familiar setting YES NO DELEGATE DO NOT DELEGATE UAP has appropriate training and documented competency YES NO DELEGATE DO NOT DELEGATE UAP willing and able to accept delegation YES NO DELEGATE DO NOT DELEGATE Nurse delegator available for supervision YES NO DELEGATE DO NOT DELEGATE FIGURE 21-1 Delegation decision model (Adapted from Arkansas State Board of Nursing [1996] Delegation Model Arkansas State Board of Nursing, Rules and Regulations.) can be a symptom of lack of delegation or poor delegation Cost factors are apparent when valued employees look for other health-care jobs that are more “chal- lenging” with “greater opportunity.” Additionally, work that is not challenging leads to complacency and boredom; opportunities are missed to sharpen professional decision-making skills, and mistakes ... nurse and the UAP by the board of nursing and employer ■ ■ Standardized procedure: A standardized procedure is taught in training classes, written in an agency manual in a “how to” approach, and. .. bed Nail and skin care Oral hygiene Toileting and elimination Safe transfer techniques and ambulating Normal range of motion and positioning Adequate nutrition and fluid intake 21Jones Leadership( F)-ch... Minnesota, for example, a Memorandum of Understanding between an APN 21Jones Leadership( F)-ch 21 350 1/15/07 6:45 PM Page 350 Skills for Being an Effective Manager and a physician defines delegated