Review standards / position statements of the following agencies before delegating any nursing tasks
State board of nursing
Interpretations / position statements of specific board or nursing
Standards of nursing organizations: ANA, NLN, and NCSBN
Policy of health care institutions
Use critical thinking in management situations
Definition of delegation: a process by which responsibility and authority for performing tasks are transferred from one individual to another who accepts that authority and responsibility
Responsibility: an obligation to accomplish a task
Accountability: accepting ownership for the results or lack of
Authority: right to act or empower
Principles of delegation
A nurse can only delegate those tasks for which that nurse is responsible, according to the specific state's nurse practice act
The delegator remains accountable for the task
Along with responsibility for a task, the nurse who delegates must also transfer the authority necessary to complete the task
The delegator knows well the task to be delegated
Delegation is a contractual agreement that is entered into voluntarily
Consider the scope of practices of nursing personnel
baccalaureate prepared nurses are equipped to care for individuals, families, groups and communities in both structured and unstructured health settings
associate degree prepared nurses are equipped to care for individuals in a structured health care environment
RNs cannot delegate to unlicensed personnel:
initial assessment of patients
evaluation of patient data
nursing diagnosis/nursing care planning
licensed practical or vocational nurses (LPN/VN) are equipped to assist in implementing a defined plan of care and to perform procedures according to protocol. Assessment skills are directed at differentiating normal from abnormal. Competence is in caring for physiologically stable patients with predictable conditions.
unlicensed assistive personnel (UAP) have the most limited scope of practice. They can assist in a variety of direct patient care activities such as bathing, transferring, ambulating, feeding, toileting, obtaining measurements such as vital signs, height, weight and intake and output. They can also perform indirect activities such as housekeeping, transporting and stocking supplies.
Steps to delegation
Define the task
Determine the delegate
is the task within the scope of practice of the delegate?
scope of practice is defined
nurse practice acts: each state defines what nurses may do
standards of practice: the American Nurses Association (ANA) defines standards of practice
organizational policies and job descriptions
does the ability of this caregiver match the needs of the task?
Communicate clearly about expectations regarding the task
state clearly who will do what by when and how, where and why it will be done
state clearly the outcomes you expect
Reach mutual agreement about the task to be completed
the delegator validates with the delegate that an understanding exists regarding what is to be done and the outcomes that are expected
discuss potential problems and solutions
Monitor the task and provide guidance as needed
was the task completed according to specifications?
was the desired outcome obtained?
in the desired time?
Provide feedback to individual on outcomes performance
review with the delegate what went right as well as what went wrong with the process
Administered by the board of nursing in each state
The nurses must know how their state defines professional misconduct
For professional misconduct, the state board of nursing imposes penalties (in order of severity)
Standards of Nursing Practice and Standard of Care
The American Nurses Association (ANA) publishes its Standards of Nursing Practice, which defines the responsibilities of the RN to all clients for quality of care
Each institution sets standards of care, both across the institution and for specific clinical populations
Definition: legally, a breach of the duty to provide nursing care to the client. A form of malpractice. The unintentional failure of an individual to perform or not perfom an act that a reasonable person would or would not perform in a similar set of circumstances. Malpractice is professional negligence.
Negligence involves four legal concepts:
Duty: nurses have a legal obligation to provide nursing care to clients
must meet a reasonable and prudent standard of care under the circumstances
must deliver care as any other reasonable and prudent nurse of similar education and experience would, under similar circumstances
Breach of duty: failure to provide expected, reasonable standard of care under the circumstances (includes errors of omission or commission)
relationship between the breach of duty and the resulting injury
the injured party must prove that the nurse's action or omission led to the injury
Damages: the injury and the monetary award to the plaintiff
example: Mr. X sues Nurse Jones for negligence. Mr. X must prove that Nurse Jones committed a breach of duty and that the breach of duty was the proximate cause of Mr. X's damages.
The impaired professional
Remember that the impaired nurse is compromising client care
Be sure that the problem exists and can be proven
Communicate specific concerns to appropriate persons such as nurse manager or risk manager
Document incidents in terms of behaviors, specific times, dates - be objective
File a report according to the policies and procedures of the institution
Definition: actions that overstep established interpersonal boundaries to meet the needs of the nurse
Guiding principles in determining professional boundaries
nurse is responsible for setting and keeping boundaries
nurse must avoid simultaneous professional and personal relationship with a client
nurse must avoid flirtation
Confidential information may only be released by signed consent of the client
Unauthorized release of client data may be an invasion of privacy
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides clients with access to their medical records and more control over how their personal health information is used. Provides privacy protection for consumers of health care.
You must release information when a court orders, or when statutes require it (as in child abuse or communicable diseases)
Special regulations apply to release of information about psychiatric illness or HIV
Must be witnessed and on file - the only employee of a health care organization who may be the signing's legal witness is a clinical social worker; it is at the discretion of each health care facility as to whether or not this is done. A policy should be written. Always check the policy of your facilty.
Durable power of attorney - appoints a decision maker
Living will - specifies what life prolonging the person wishes
Do not resuscitate (DNR) status
Refusal of treatment - competent clients may refuse treatment, even life-sustaining treatment
Freedom from safety devices/restraints
Physical restraints/safety devices require a signed, dated physician's order specifying the type of restraint/safety device and a time limit
Types of restraints/safety devices
Use the least restrictive form of restraint/safety device
Nursing practice is governed by legal restrictions and professional standards.
What a nurse can do depends on the nurse practice act in the state in which the nurse is licensed.
Each state defines what constitutes professional misconduct.
The state board of nursing has the authority to impose a penalty for professional misconduct.
Penalties include probation, censure, reprimand, suspension or revocation of the license.
Standards of nursing practice apply to all nurses in all practice settings.
Standards of care are based on facility policy and procedure, nursing education, experience, and publications of professional nursing associations and accrediting groups.
To avoid negligence:
Know the standard of care
Deliver care that meets the standard and follows the facility’s policies and procedures
Document care accurately and in a timely manner
The only employee of a health care organization who may be the legal witness to the signing of an advance directive is a clinical social worker. It is at the discretion of each health care facility as to whether or not this is done. Always check the policy of your facility. A relative or heir to the estate should never be the witness to the signing of an advance directive.
Ethics guide the nurse toward client advocacy and the development of a therapeutic relationship.
Ethical dilemmas result from conflicts in values.
An effective leader modifies his/her style according to the situational requirements.
Final responsibility for any delegated task resides with the RN.
The RN must monitor delegated tasks and evaluate the outcomes.