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Annotated Bibliographies for Capstone Project

NUR 470 Delegation Assignment Name: Betsy Emmons Date: October 30, 2011 Differentiate between delegation, accountability, authority, and responsibility. Give clinical example of each. Effective delegation is one of the most challenging and difficult RN responsibilities. American Nurses Association (ANA) and National Council of State Board of Nursing (NCSBN) share the definition of delegation as; “the process for a nurse to direct another person to perform nursing tasks and activities. For instance, a registered nurse can delegate tasks to an unlicensed staff member such as; transfer a patient from bed to chair and measure intake and output. The RN can assign an LPN to a patient with colostomy that needs irrigation. Delegation is when the nurse transfers their authority but not their responsibility. It allows the nurse to request another team member to perform a specific nursing task, but the RN is always responsible for the manner in which it was delivered.

The duties of a registered nurse may be given to a licensed practical nurse or certified nursing assistant but the RN must always be in compliance with state licensure and training laws and certifications. Delegation is one of the most complex nursing skills and requires good clinical judgment and final accountability for patient care. The skill required of an RN is to understand what patients and families need and then to appoint the appropriate care givers in the plan of care in order to accomplish desired patient outcomes.

The RN tries to maximize the available resources for the patient while also managing clinical and financial outcomes. Nurses make careful decision about delegation, taking into consideration the skill level of the UAP, the risk/difficulty of the duty, and the patient’s condition (as mentioned). The nurse must be clear to UAP about the expectations, time frames, and any limitations prior to the delegation. The 2001, ANA Code of Ethics says that delegation relies on the RN’s judgment and competence of all team members, and the degree of supervision needed for the particular task.

The licensed nurse may assign and/or delegate nursing care activities to other licensed nurses or unlicensed assistive personnel (UAP) based upon their own license level, assessment of the client’s status, clinical competence of available licensed and unlicensed personnel, and the variables in each practice setting. Before assigning/delegating nursing activities to staff, the licensed nurse needs access to information about the RN-validated competencies for each individual. Accountability of delegation is when the nurse accounts for themselves and for others regarding their actions. ANA Code of Ethics, 2001). When a nurse is accountable they are legally liable and held responsible for all actions or inactions of self and others within setting. To assure accountability the nurse not only accepts responsibility for performance of the task, but they also verify that the delegate accepts accountability for carrying out the task correctly. The nurse must know state regulation and specific job description regarding what tasks the nursing assistant and licensed practical nurse are able to perform in order to uphold accountability.

An example of this would be when the LPN is assigned to auscultate and observe a patient’s abdomen to gather data regarding distention. The RN analyzes and synthesizes the data to develop care planning based on nursing diagnosis. The RN is accountable for the total assessment of a patient and the plan of care for specific outcomes. RNs assure appropriate accountability by verifying that the receiving person accepts the delegation and accompanying responsibility (NCSBN and ANA, 2006).

The acceptable use of the authority to delegate should be consistent with the nursing process; appropriate assessment, planning, implementation, and evaluation. The nursing process and decision to delegate must be based on cautious analysis of the patient’s needs and circumstances, the qualifications of the proposed delegate, the nature of the nurse’s delegated authority outlined in the law of jurisdiction, and the nurse’s personal competencies in the area nursing relevant to the task being delegated.

This is very critical and is the definition of authority when speaking of nursing delegation. The authority to delegate is a decision-making process which is based on the following criteria: The Nursing Practice Act, Permits delegation, authorizes tasks to be delegated or authorizes the nurse to decide delegation, delegator qualifications within the scope of authority to delegate, required education, skills, experience, documented evidence of current competency level, qualifications of appointed person, appropriate education, training, skills, and experience, documented evidence of current ompetency. An example would be an RN’s decision that an LPN with five years of long term care experience prior to working in orthopedics is a more qualified care giver for a 91 year old post operative arthroplasty patient than an LPN who is also available but who has less background in caring for geriatric patients. An RN may delegate to whom? In the State of Maine an RN may delegate tasks to be “supplemented and complemented” by a certified nursing assistant and a licensed practical nurse.

The task has to be listed in the Skills Checklist of Curriculum for Nursing Assistant Training. If the task is one of medication administration it must be listed in the Checklist of the Standard Medication Course for CNA’s. The RN has to inspect the CNA certificate of licensure prior to delegating any task to the CNA. Once this has been established the RN understands they must supervise the CAN; the degree of supervision is determined by the stability of the patient, the training level and capability of the CAN, and the specifics regarding the task being delegated.

With home care nursing the RN may delegate portions of medication administration after the RN has established that the patient and/or family is in agreement of this, that there is a consistent pattern of need, and that the CAN has proven appropriate skill and competency with such task. The CNA must have completed sufficient DHHS medication administration course curriculum. The med administration that cannot be delegated includes PRN meds, intrathecal route meds, IV and intramuscular, subcutaneous (excluding insulin), and gastrostomy routes or other invasive kinds of procedure.

The RN can delegate to LPN/LVN’s dressing changes, and can be assigned the most stable patient with the most predictable outcome. They can not do any assessment or patient teaching. If a patient is being discharged, the RN can not delegate that patient to a LPN/LVN because discharge duties require patient teaching which must be performed by RN. A LPN/LVN is able to administer PO medications/SubQ and IM injections, and perform suctioning as long as the patient is deemed LPN/LVN’s can do dressing changes, and can be assigned the most stable patient with the most predictable outcome.

They can not do any assessment or patient teaching. The following tasks can be delegated by RN to the LPN with good judgment; auscultate/listen, checks, reinforce/remind, observe/collect data, specimens, set up basic equipment, teach standard practices (hand washing/hygiene), and conduct cath/blood glucose readings. The RN can delegate to the CNA duties such as; ADL’s, ambulating, bathing, feeding if the patient is stable, turning, collection of urine, input and output.

The RN can delegate tasks such as reminding the patient to do something such as precaution measures or skills previously taught by other health care staff. The CNA is able to receive delegations such as detaching suctioning equipment, removing a Foley catheter, gather equipment, but they are not able to connect or insert a catheter. Identify and give an example of two of the five rights to consider in the process of delegation. The five rights of delegation allow the licensed nurse to delegate tasks to other nurses or to UAP’s as long as criteria is met and the patient’s safety and well-being is not at risk.

The five rights are; right task, right circumstances, right person, right direction/communication, and right supervision/evaluation. The Nurse Practice Act allows for RN’s to delegate tasks to LPN’S, CAN’s, and UAP’s as long as certain criteria is met and the RN understands they remain responsible for the task and the outcomes. The right task is one that the RN believes will be carried out safety for the particular patient given their current condition. The task does not require nursing judgment or nursing process.

Tasks that can be delegated frequently recur in the daily care of patients on the unit. These tasks are not complex, and do not require critical thinking or application of the nursing process. An example is the RN who delegated the task of performing an insulin injection for a stable diabetic patient using a pre-filled syringe to a certified nursing assistant who has successfully completed the DHHS approved agency course curriculum and the patient and patient’s family has with signature authorized this task to be done within the scope of the home care setting.

The right supervision is when the RN provides direction, guidance, and influences the outcome of an individual’s performance of a task. The nurse may not actually perform each task assigned, however, they do monitor the environment and process in which the task is delegated and the outcome of the task. This is often done at the beginning of a shift when the RN outlines the plan for the day for each patient and then gives direction as to how the plan needs to be carried out.

There are checkpoints during the day, at this time the RN provides feedback upon receiving updates. Another example of right supervision is when the RN, LPN, and nursing assistant discuss how the specific nursing care is to be prioritized and completed while identifying expected patient outcomes for the shift. For instance, a patient’s therapeutic goal for the shift might be for the patient to ambulate the length of the hall 30 minutes after the pain medication has been administered, with a pain rating no greater than 2 on a scale of 1 to 10 at the end of the walk.

The nursing assistant would report observations and the pain scale rating to the RN who would then determine if the plan for pain control is adequate. The right supervision in this case was done through a pairing where all team members participated and the RN ultimately held responsibility for the outcome while providing guidance. Reflect back on a recent clinical in relation to what was effective delegation and what was ineffective delegation. Give at least one example of each – remember to protect facility, caregiver, and patient confidentiality.

I have experienced an effective delegation in my clinical which resulted in positive outcomes. My clinical instructor provided right supervision for me while I administered medication to my patient. My instructor was in the room when I was administering the medication and assessing the patient. The patient was very cooperative and gave permission for me, a student nurse, to provide clinical nursing care at the beginning of the shift, and again while I was performing the assessment and preparing to administer the an IM injection.

I discussed with the patient that I have administered this medication before and described in a clear concise manner of what the process entails. In accordance to the five rights of delegation (right task, right circumstances, right person, right direction/communication, right supervision) the delegated care was appropriate. After five minutes the patient’s blood pressure dropped from 155/100 to 130/90 and she rated her pain 5out of 10, on a scale from 1-10… Within the next five minutes her blood pressure dropped down to 121/80 and rating her pain 3out of 10.

The last five minutes her blood pressure was 90/66 and she claimed mild discomfort, no pain. An ineffective delegation during another clinical was when I was told by a staff nurse to “take the blood pressure of a 92yr old female patient who has pneumonia, and find out if her lung sounds have improved. ” The staff nurse explained that the CNA had not charted the blood pressure but did document the other vital signs for that particular time. The CNA had gone home and the charting was incomplete. This is an example of a poorly delegated task, one that violated the five rights, particularly the Right Person.

Although I effectively complete the task of taking the patient’s blood pressure and listening to upper and lower lung sounds, and I was able to accurately report the data to the staff nurse as delegated, delegation was not appropriate for me. I was the student nurse who had not performed the other tasks documented by the CNA, and my data was being used to complete another staff’s assessment. I was not comfortable with this; I felt I was being put in an unethical situation. I did not enter the data and my assessment was recorded under the CNA’s name. This was a learning experience which I later discussed with my clinical instructor.

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