Care Plan Nursing

- i became a statistic today, a mortalitystatistic. no, it wasn't a car accident or a stroke. it happened right here in thehospital. inexperience killed me. and it wasn't the wrong medication or a botchedprocedure. i was the victim of faulty delegation. the mistake had nothing to dowith poor technique. but it was lethal, nonetheless. ♪♪ ♪[music]♪ - delegation, done effectively, is one ofthe most powerful tools a nurse can use. but faulty delegation can spell disasterfor the nurse, the client and the

employer. welcome to our program,delegating effectively: working through and with assistive personnel. this is thethird in our series on professional challenges, and it explores the vital roleof delegation in today's health care environment. in this video, we'll followthe story of mrs. campbell. as her story unfolds, you'll get a first-hand look athow critical the skill of delegation can be. throughout the story, a red flag willappear on the screen when an important step in the delegation process has beenbreached. then, vickie sheets, a nurse attorney and director of practice &regulation for the national council of state boards of nursing will comment onwhere the problem occurred and why.

delegation is a double-edged sword. whileyou can accomplish much more working through others than you can do alone,there are some inherent risks and liabilities whenever you delegate.preparation is the best prevention, and yet many nurses today still do not feeladequately prepared to delegate. - my assessment of new graduates' abilityto use delegation is that it's poor. it's not a strong component of nursingeducation, and it sometimes is a, is a difficult tool for them to be able to do,especially in the initial probably first six months. the problem is the disconnectbetween the theory and the actual practice, the ability to use the theory intheir clinical rotations as they

spend time as a student before theyactually become the graduate nurse or the nurse. - [narrator] delegation is the process oftransferring to a competent individual the authority to perform specific nursingtasks in a specific situation. these assistive personnel are usually unlicensedstaff members. in most states, they're listed on a registry. in some states,they're certified and in only a few states they're licensed. these helpers may bereferred to as nursing assistants, nursing aides or patient care technicians butregardless of the title, they're not nurses and are not authorized to practicenursing. their authority to perform

nursing tasks comes from the licensednurse through the process of delegation. delegation is built on mutual trust andrespect. each party is dependent on the other. the nurse depends on theassistant's skills in performing the assigned task, and the assistant dependson the nurse's availability and guidance. it is a symbiotic relationship. - we can't do our job without them, andthey can't do their job without us. we are their eyes, ears for the patient. - nurses don't own delegation. it is auniversal process used in the business world. but because of the critical natureof nursing practice, delegation in nursing

is addressed in most nurse practice acts.delegation in nursing is a legal as well as a managerial act. - delegation is a skill and like anyskill, in order to become proficient, you have to practice. it may come easy tosome, and others may struggle with it. unfortunately, many nurses are thrust intothe role of delegator without adequate preparation and experience. - as a nursing student, you actually doeverything yourself. you're taught with one or two patients. not only do you do themedications, but you do the complete care of that patient. so youdon't really have to delegate to your

ancillary staff. - i hadn't been in charge that many times,but it wasn't that difficult. i mean, you just make out the assignments based on thepatients you have with the staff that's available. that shift, we were shortstaffed, just myself, an lpn and two nursing assistants, ruth and michaela.since we were so short staffed, i gave the hardest patients to myself and to the lpn,jenny. - this is the first sign of a potentialbreakdown in the delegation process. delegation is more than handing outassignments. the delegating nurse must understand the importance of the processand allow enough time to complete all the

steps. skipping steps or scrimping on themis a recipe for disaster. - delegation is not abdication. nurses areresponsible to provide nursing care designed to meet their clients' needs.sometimes they delegate, and sometimes they choose to perform the carethemselves. regardless of who delivers the care, the licensed nurse remainsaccountable for completing the work and for achieving the desired client outcomes.being accountable means being answerable for the actions or omissions of self orothers within the context of delegation. assistive personnel are accountable forthe decision to accept the delegated task and for their performance of that task.they're accountable to themselves, the

delegating nurse and their employer.nurses have multiple levels of accountability. there's accountability forthe delegation decision itself as well as for the task that was delegated and forthe outcomes of that task. in addition, nurses are accountable to themselves, theclients entrusted to their care, the employer, the licensing board and thenursing profession as a whole for their actions taken or omitted as a nursingprofessional. in some states, delegation refers only to unlicensed personnel.licensed individuals practice within a legal scope of practice for which they'reaccountable. when a nurse delegates to an unlicensed person, there is theexpectation of additional scrutiny to

verify that there is a match between theclient's needs and the ability of the assistant to meet those needs. - the nursing assistants were always sohelpful, especially ruth. and they were generally very capable of meeting myneeds. [sigh] but tonight would be different. - i can't believe that linda called insick again. i know that stomach flu is going around, but without her we are gonnabe very short staffed. - [huff] i know what you mean. the lastthree days, i've been pulled to five west.

i hope i don't get pulled again tonight. - well, i don't see how that couldpossibly happen. we barely have enough people here to cover our own patients. i'mgonna have to be in charge and take patents. here's your assignment. ruth,here's your task list. mrs. campbell is still very weak, but she's gettingstronger every day. since she's so sedentary the doc-- - [jenny] karen, i need to talk to youright away. and wanda's waiting for you to do a narcotics count. she's gotta gethome. her kid's sick. - [karen] okay. ruth, look this over andsee if you have any questions. if you do,

we can discuss them after i get back fromcounting narcotics. - what karen was going to say just as shewas interrupted was that the doctor had started me on a blood thinner so iwouldn't get blood clots in my legs. [huff] but she never finished her sentence. andthen she simply got too busy. - delegation is not task assignment. it'smuch more. delegation is a problem-solving process just like the nursing process and,just like the nursing process, it can break down at any point. - it usually isn't just one mistake thatcauses the problem in delegation.

generally, a mistake in one of the stepsinitiates a downward spiral, sort of like the domino effect. the good news, however,is that the spiral can be halted with early identification. better yet, it canbe prevented by following the steps in the delegation process. - [narrator] the nursing process involvesassessment, planning, implementation and evaluation. the delegation processinvolves assessment, delegation, monitoring and evaluation. assessment isthe first step. it provides the foundation for effective implementation. without thisstep, there can be no delegation. assessment is driven by the five rights:the right task, the right circumstance,

the right person, the right direction andcommunication and the right supervision. let's look at each of these componentsindividually. can the task be delegated safely? certain functions cannot bedelegated. these include client assessment, evaluation, client familyeducation, nursing care, planning and nursing judgment. judgment is theintellectual process that the nurse exercises in forming an opinion andreaching a clinical decision based upon analysis of the evidence or data. forexample, an assistant may act as a nurse's eyes and ears and collect observationaldata from the client such as vital signs. however, it is the nurse who determineswhether the client has a fever, what

intervention, if any, is required and ifthe physician should be notified. the part of the nursing process that is delegatedmost frequently is intervention. for example, when a client has a fever, theassistant may be assigned the task of giving the client a sponge bath andencouraging the client to drink a certain amount of fluids during the shift. what isthe client's condition? and how frequently is it changing? - no, i wasn't really that sick. i hadbeen admitted because my doctor had adjusted my thyroid medication, and i washaving a problem with fatigue and weakness. but i was stable but still alittle wobbly on my feet.

- along with the client's condition, thenurse needs to assess whether the required resources are available to provide theneeded care. andrew carnegie once said "the secret of success is not in doingyour own work but in recognizing the right man to do it." is an assistant the rightlevel of personnel to perform the task? frequently, the answer to this questiondepends on the complexity of the procedure and the technology involved in the task.many times in making assignments, the nurse takes a share the wealth approach,assigning clients so that there is equity in the workload rather than focusing onpriorities of care and client outcomes. ♪♪ - i can't believe you assigned me mr.ringwald, mrs. jones and mr. lawson in

addition to all the other patients yougave me. mr. ringwald is incontinent. he's got diarrhea from a tube feeding. i'llnever get out of that room. i have the toughest patient load. i think ruth shouldhandle mr. ringwald, especially since i have so many treatments to do. - let me see the assignment. okay. ruthcan help you with mr. ringwald, but you're gonna have to help me supervise her. i'vegot my own patient load, and i'm in charge. you know how you have that little voice inyour head that tells you when you shouldn't do something? well, i didn'tfeel right about the decision, but i

didn't know what to do. i didn't want tomake any enemies, not tonight. i couldn't afford a conflict. i needed all the help icould get. - allowing another team member to haveundue influence in your decision making undermines the delegation process.decisions should be based on the client needs, not a staff member'sdissatisfaction with an assignment. a nurse should pay attention to his or herdis-ease. if you're uncomfortable with a decision or situation, it should bereassessed. - [narrator] can the nurse provide theassistant with appropriate direction and communication? effective delegationrequires clear, concise, correct and

complete communication. communicatedirectly the expectations regarding the task, who will do what by when and how,where and why it will be done. the nurse provides directions which may includepriority of activity, expected timelines, guidelines for consulting with the nursemid activity, reportable conditions and guidelines for reporting the completion ofthe task and its outcomes. the nurse also clarifies his/her role as a delegator andsupervisor of the task. - what will facilitate bettercommunication between the nurse and the nursing assistant? we have, here at sinai,the morning report and the nursing techs are included. someplaces i've worked, they're not included,

and that's really very hard. thatcauses a segregation of techs and nurses. but when you come together in themorning, if you have any kind of difficulty, i believe that that's whereyou can, you know, you can voice, you know, whatever problem you may be havingwith a patient or with a situation. - the importance of clearly articulatingexpectations both for performance of the task and the expected client outcomescannot be overemphasized. the next step in the delegation process is the actualdelegation itself. this involves informing the assistant about the task to bedelegated, reaching mutual agreement about the task to be performed and transferringthe authority to perform the task. once

you've determined that the task isappropriate for the assistive level, you must delegate the task to an individualwho is capable of performing it safely. the effective delegator assigns tasksconsistent with the individual's scope of practice. - scope of practice is defined by thenurse practice act in each state. standards of nursing practice such asthose written by the american nurses association and other specialty nursingorganizations, as well as the policies and job descriptions of the employinginstitution also help to guide delegation decisions. the underlying premise of safedelegation is in assuring the competency

of the assistant. even if the task iswritten within the scope of the person's job description, the individual may not becompetent to perform the task safely and accurately. - [narrator] many organizations require acompetency checklist that assures that the individual's competency in specific areashas been validated. when in doubt, refer to the individual's competency checklistbefore delegating a task. you are only as strong as your assistant's weakest skill.when working with assistive personnel, it is important to remember their role:assistant. that means they can contribute to the care provided, but the nurse can'tjust hand off a client to them, though

needs to go into what parts of theclient's care are appropriate for the assistant to perform and what must bereserved for the nurse. all registered nurses can delegate. however, whether ornot lpn or lvns can delegate varies from state to state. assistive personnel cannotdelegate. ♪♪ - dana, i'm swamped. i've already cleanedmr. ringwald up twice, and here we go again. it looks like i'm gonna be in thisroom all evening. i haven't even had a chance to check on mrs. c. could you do itfor me? - sure thing. how you doing, mrs. c? - oh, i'm fine dear, but can you help meto the bathroom?

- um, just a minute. let me go get yournurse. - oh, i, i, i can't wait. please just giveme a hand. i, i can't make it on my own. - mrs. c, i'm only a volunteer. i'm notreally supposed to do that. let me go get your nurse. just wait a minute. ruth, mrs.c. has to go to the bathroom. can you help her? - i'm in the middle of a mess right now.can you take her? - [sigh] i'm not supposed to. - please. just this once. it'll be okay.just stay next to her to steady her. she'll be fine. she doesn't need a lot ofhelp.

- delegation is between the nurse and theassistant. it stops there. the assistant is not authorized to re-delegate to someoneelse. - [deep breath] i really had to go to thebathroom. [laughs] that nice little girl came to help me, butshe told me not to get up without her. well, i waited, but she didn't come back. to tell you thetruth, my bottom was getting numb. well, i thought i could make it back to mybed on my own. [deep breath]

and the last thing i remember, i wasreaching for my walker. - [narrator] the next step in thedelegation process is the monitoring phase. this step involves monitoring theactual performance of the task and providing guidance and redirection asneeded. this is the area that can be the most troublesome in the delegationprocess. we delegate the task, we define expectations, and we send assistants offon their merry way to complete the tasks. we have every intention of supervisingthem; however, we get busy. time slips by and before you know it, the shift is over,and we've yet to touch base with them. or we monitor the process but do notreconfirm that the assistant is capable of

taking care of the changing needs of theclient. the assistant gets in over his or her head, and we fail to recognize thepotential harm to the client. this is skating on professional thin ice. - initially, i wasn't overwhelmed but bythe time mr. ringwald had soiled himself for the third time, i was up to my elbowsin a big mess and in more ways than one. so i asked a volunteer to check on mrs.campbell. i didn't think it would be a problem. then i heard a loud thunk. when igot to her room, she was in the bathroom on the floor. ♪♪ ♪♪ mrs. campbell, are you all right? help!anybody, help!

- [jenny] what's the problem? oh, my god.what happened? - well, i don't know, dear. one moment iwas on the john and the next thing i knew, i was on the floor. - [jenny] go get karen. let me take a lookat you. do you know where you are? - [karen] uhh, how is she? - she seems to be okay. she's has a smallbump on the side of her head. i don't know what she hit it on. she doesn't seem toremember what happened. nothing else seems to be hurt. - all right. well, let's get her back tobed. you get her vitals, and i'll call the

doctor. keep an eye on her, and don't lether get out of bed again. ruth, take her vitals and do neuro checks every half hourfor a couple of hours, and keep me posted. - when there is a change in the client'scondition, the nurse must reassess the situation to determine if the abilities ofthe assistant are still compatible to the client's needs. in this situation, theyweren't. it is also critical to verify the assistant's understanding of thedirections. karen did not validate that ruth understood the importance ofobserving the client nor did she provide any direction regarding reportableconditions. - assignments are not written in stone.they can and should be changed based on

the dynamics of the client's condition.continuity of care should never supersede client safety. here's some situations thatindicate that the delegation should be reconsidered. 1) the client's conditionhas changed; 2) there is evidence that the work is not being completed as outlined;3) the assistant fails to report back to you, or 4) the assistant is givenadditional tasks to complete. ♪♪ - [ruth] jenny, mrs. campbell'scomplaining of a headache. - did you tell karen? - i went looking for her, but she's alltied up with a new admission. she told me to find you.

- well, i'm just as busy as she is. all right. are her vital signs okay? whatabout her neuro checks? - she seems fine. just a little tired andworn out from all the commotion. but her pupils are equal. they react to light. ithink she's just tired. - well, i'm busy right now. grace isgiving meds on your patient. go ask grace to give her something for pain. - i couldn't tell her i was losing ground.i was slipping away slowly but surely. my pupils were reacting, but sluggishly. mypulse pressure was widening. [ sigh]

unfortunately, no one picked up on it. thenursing assistant just didn't have the knowledge base or the experience to seethe subtle changes in my condition. she couldn't put the pieces of the puzzletogether to see the big picture. oh, i was in trouble, and i needed help. - [narrator] the final step in thedelegation process is evaluation, what went right, what went wrong. delegationdecisions and client outcomes must be continually evaluated. this includesdetermining how the process went and whether the desired client outcomes wereachieved. if not, then why not? it also includes an evaluation of the delegationdecision-making process and the

delegator-assistant relationship. providefeedback to the individual regarding his or her performance. review with theassistant what went right and what went wrong with both the task and the process.discuss how the process could have changed to improve the outcome. - what happened here? - well, mrs. c. fell about five hours ago.we found her on the floor in the bathroom. she must have tried to get up by herself. - uhh. - she had a small bump on the side of herhead, but she seemed okay. she was alert

and oriented at the time. - okay, did you notify her doctor? - yes, i called and left a message-- - good. - with his service. and i didn't think itwas an emergency, but i called her family, too. - [jenny] she complained of a headachearound six p.m. she had something for pain then. - okay. let me see her chart. and when didyou say she fell?

- around four p.m. - okay. where are her vitals? the lastentry says six p.m. that's three hours ago. - [ruth] you said "take them every halfhour," and i did. and when she got her pain meds, she wanted to rest. so ichecked in on her, but she seemed to be asleep. i wasn't gonna wake her to takethem. then i got busy with mr. ringwald, and i didn't get back. i just never gotback. - i think we have a serious problem here.you better call her doctor, stat. can i see your stethoscope?

- it happened so fast. by the time i gothelp, the bleeding in my brain had already done too much damage. i never regained consciousness. - this tragic client outcome waspreventable, and so were the professional outcomes. both the rn and lpn had theirlicenses disciplined. the nursing assistant was terminated. the lawsuit isstill pending. desired outcomes of the delegation process include protection ofclient safety, achievement of desired client outcomes, reduction of health carecost, access to appropriate levels of health care, delineation of the spectrumof accountability for nursing care and

decreased nursing liability. we can seethat in the case of mrs. campbell, many of these outcomes were not achieved. in fact,just the opposite occurred. the delegation process was in jeopardy from the start.however, there were numerous points at which the downward spiral could have beenhalted. reestablishing the delegation process at any one of these points couldhave averted this disaster. - the inability to delegate effectivelyhas led to the downfall of many leaders, from presidents to charge nurses.ineffective delegation can be risky business. you wouldn't jeopardize yourclient and yourself by performing a clinical procedure without the necessaryskills. the same holds true for

delegation. the steps of the delegationprocess become your professional safety net when working through others. - delegation in nursing is an art and ascience. it is an art because it requires solid nursing judgment. it is a sciencebecause there are specific steps to be followed that ensure positive outcomes.applying the science while practicing the art of delegation will serve the nurses'clients, the employer, the profession and the community at large who depend upon thenurse to administer safe, effective nursing care. ♪♪