Clinical Delegation

1. Clinical Delegation Wanda Rose PhD, RN,BC

2. Objectives • Define delegation. • Describe the role of the RN in terms of delegation. • Review model for delegation decision making process. • Discuss standing orders.

3. Delegation • “transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome” (ANA). • “transferring to a competent individual the authority to perform a selected task in a selected situation. The nurse retains accountability for the delegation.” ( NCSBN).

4. Accountability Being accountable means being answerable for what one has done and standing behind that decision and/or action.

5. Delegation is not merely handing out assignments or tasks It is entrusting and empowering the subordinate and Sharing of both responsibility and authority. However, even when responsibility and authority are passed on, the Registered nurse remains totally accountable for the end results.

6. ND NURSE PRACTICES ACT Chapter 43-12.1

7. Definition of Nursing Chapter 43-12.1 "Nursing" means the performance of acts utilizing specialized knowledge, skills, and abilities for people in a variety of settings. The term includes the following acts, which may not be deemed to include acts of medical diagnosis or treatment or the practice of medicine as defined in chapter 43-17:

8. a. The maintenance of health and prevention of illness. b. Diagnosing human responses to actual or potential health problems. c. Providing supportive and restorative care and nursing treatment, medication administration, health counseling and teaching, case finding and referral of individuals who are ill, injured, or experiencing changes in the normal health processes. d. Administration, teaching, supervision, delegation, and evaluation of health and nursing practices. e. Collaboration with other health care professionals in the implementation of the total health care regimen and execution of the health care regimen prescribed by a health care practitioner licensed under the laws of this state.

9. ND NURSE PRACTICES ACT Chapter 43-12.1 43-12.1-18. Nursing practice standards. The board shall adopt rules establishing standards for nursing practice.

10. ND Nurse Practice Act 43-12.1 43-12.1 allows the licensed nurse to delegate and supervise nursing interventions to individuals authorized by the board to perform those functions.

11. North Dakota Administrative Code 54-05-02Standards of Practicefor Registered Nurses • 54-05-02-02.1 Registered nurse responsibility to implement the nursing process. • Implement the plan of care and the nursing interventions for the client under the RN’s care by • Determining the responsibilities that can properly and safely be assigned as defined in section 54-05-02-02.2 • Determining the responsibilities that can safely be delegated as defined in chapter 54-05-04.

12. Chapter 54-05-04 Standards for Delegation 54-05-04-01Licensed nurses are directly accountable and responsible to clients for the nature and quality of all nursing care rendered. It is not the setting or the position title that determines a nursing practice role, but rather the application of nursing knowledge. Licensed nurses provide care through a variety of roles including:

13. Registered Nursing • Practice independently and interdependently through the application of the nursing process. • Assigning and delegating nursing interventions that may be performed by others.

14. Licensed Practical Nurses • Practice dependently under the direction of RN, APRN, or licensed practitioners through the application of the nursing process and the execution of diagnostic or therapeutic regimens prescribed by licensed practitioners.

15. Unlicensed assistive persons • Complement the licensed nurse in the performance of nursing interventions. • May not substitute for the licensed nurse • Responsible to the licensed nurse • Includes Medication Assistant

16. North Dakota Administrative Code 54-05-04Standards for Delegation • 54-05-04-03 Delegation process for nursing interventions. A licensed nurse may delegate a nursing intervention to a competent unlicensed assistive person if the licensed nurse utilizes a decision-making process to delegate in a manner that protects public health, welfare, and safety.

17. Delegation ProcessND Administrative Code 54-05-05-03 • Assessment of client and human and material resources. • Planning for delegation. • Implementation of the delegated nursing intervention by providing direction and supervision. • Evaluation of the delegated nursing intervention.

18. Accountability and responsibility within the delegation process.

19. Five Rights of Delegation Right Task Right Circumstances Right Person Right Direction/Communication Right Feedback

20. Right Task • Can the task be delegated? • Is the task fairly routine with predictable outcomes? • Is there minimal risk? • Does not require nursing judgment, including assessment, planning and evaluation.

21. Right Circumstance • Does the complexity of the task match the competency of the delegate? • How available is supervision? • Direct supervision • Indirect supervision

22. Right Person • Is the person competent to perform this task? • Training • Experience • Competency How will you know? • Teach • Observe • Verify

23. Right Direction/Communication Clear Concise Correct Complete Is there access to written instructions? Does it identify the specific task? Does it identify the timeline? Does it identify the outcome you would like?

24. Right Feedback/Supervision How are you monitoring performance? Are you available for follow-up or questions? What provisions do you have for feedback? How will you measure client’s response and goal attainment related to delegated interventions? Do you give feedback based on outcome of the task? Did you document your findings?

25. 54-07-05-01 Medication Administration Unlicensed assistive persons who have completed a prescribed training program in medication administration or who have been delegated the delivery of a specific medication for a specific client may perform the intervention of giving or applying routine, regularly scheduled medications to the client. The medication assistant III may perform the intervention of administering medications to the client in an ambulatory health care setting. The licensed nurse must be available to monitor the client’s progress and effectiveness of the prescribed medication regimen. Delegation of medication administration in acute care settings or for individuals with unstable or changing nursing care needs is specifically precluded by these rules.

26. 54-07-05-04Medication AdministrationSupervision • 1. In a licensed nursing facility, the licensed nurse must be on the unit and available for immediate direction. • 2. In an ambulatory health care setting where the licensed nurse delegates the intervention of giving medications to another individual, the licensed nurse must be available for direction. • 3. In any other setting where the licensed nurse delegates the intervention of giving medications to another individual, the licensed nurse must establish in writing the process for providing the supervision in order to provide the recipient of the medication appropriate safeguards.

27. Summary Delegation is a legal and management concept and a process that involves assessment, planning, intervention, and evaluation in which selected nursing tasks are transferred from one person in authority to another person, involving trust, empowerment, and the responsibility and authority to perform the task. In delegation, communication is succinct, guidelines are clearly delineated in advance and progress is constantly monitored in which the person in authority remains accountable for the final outcomes.

28. Standing Orders • Written protocol/instruction • Details of condition • Patient/population to whom it applies • Dosage and administration guidelines • Contraindications to the medications • Instructions to be given • Follow-up • Non patient/client specific • Approved and signed by medical director

29. Standing Orders Based on established clinical practice guidelines . Suited for routine situations. Enable nurses to assess the care needs of their patients and to initiate appropriate action without delays that may occur when physician contact is required. Empower nurses to implement certain procedures and activities on behalf of physicians, enabling more immediate interventions, and ultimately improving patient care. Save valuable time for patients, physicians and nurses.

30. Advantages of Standing Orders Increases patient access to treatment. Provide a safe and effective method of extending the role of the nurse. Efficient and effective tools for routine situations.

31. Barriers to Standing Orders Deviations occur Lack of communication when deviation occurs Lack of knowledge and skills of health practitioner following the standing orders.

32. Standing Order/Protocol Development 1. Determine a common clinical issue that would benefit from a standing order. 2. Establish a multidisciplinary team. 3. Review national and individual practice guidelines. 4. Complete a literature search for articles centered on evidence based practice. 5. Contact the state board of nursing to review state laws regarding standing orders. . Figure 1. Steps to Initiate a Standing Order Note. Based on information from Maxwell, 2005.

33. Standing Order/Protocol cont. 6. Contact the facility’s continuous quality-improvement committee for facility guidelines. 7. Meet regularly as a work group to review the process. 8. Develop the standing order. 9. Pilot test. 10. Finalize the standing order. 11. Obtain administrative approval. 12. Provide ongoing, focused staff and patient education. 13. Audit and update standing orders on a regular basis

34. Implementing Standing Orders Recommendations Preprinted order sets. Must be documented as an order in the patient’s medical record (Centers for Medicare & Medicaid Services, Oct. 24, 2008) Place copy of the standing orders in the chart. Signed by the practitioner responsible for the care of the patient after implementation of standing order .

35. Summary Finally, for successful implementation and long-term adherence, healthcare professionals should develop a plan to educate staff and patients about use of the standing order and audit and update the order regularly.