deciding to delegate: a decision support framework...
TRANSCRIPT
Northern Ireland Practice and Education Council for Nursing and Midwifery
DECIDING TO DELEGATE:A DECISION SUPPORT FRAMEWORK
FOR NURSING AND MIDWIFERY
Leading and inspiring nurses and midwivesto achieve and uphold excellence
in professional practice.
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Foreword ................................................................................2
Introduction and Context ....................................................3
Scope .......................................................................................4
Framework Overview ............................................................4
Definitionandpurpose ........................................................5
RequirementstoSupportDecisionstoDelegate NursingandMidwiferyTasksandDuties .........................5
NursingandMidwiferyDecisionSupport FrameworkforDelegation ....................................................7
DecisionSupportMatrix .................................................... 12
Appendix 1:UsingtheDecisionSupportMatrix: ScenariosinPractice ........................................................... 13
Addendum 1:ProductionoftheFramework ................ 16
Addendum 2:MembershipofTaskandFinish GroupSub-Group ............................................................... 19
Glossary............................................................................. 20
Leading and inspiring nurses and midwivesto achieve and uphold excellence
in professional practice.
| CONTENTS
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| FOREWORD
Wearedelightedtoprovidetoyou:Deciding to Delegate: A Decision Support Framework for Nursing and Midwifery. Thisframeworkhasbeenco-producedthroughahighlevelofengagementwithnurses,midwivesandotherprofessionalsacrossNorthernIreland.
Theworktoproducethisnewresourcehasbenefitedfromtheexperienceofawiderangeofindividualswhoaredelegatingtasksanddutieseverydaytoenableperson-centredcareandservicestobedeliveredinNorthernIreland.Inrecognitionoftheincreasingcomplexityofservicedeliveryandresponsibilityforthedeliveryofcarecrossingprofessionalboundaries,particularlybetweennursingandsocialwork/socialcare,wewereaskedtojointlyChairtheTaskandFinishGroupconvenedtocompletethisinitiative.Thisapproachaffordedanopportunitytounderstandtherolesandresponsibilitiesofeachoftheprofessionsandthechallengesandissuesfacedinthedelegationoftasksandduties.
TheconstructionoftheframeworkacknowledgedtheworkthattheCentralNursingandMidwiferyAdvisoryCommittee(CNMAC)hadcompletedinthepast,andtherevisionoftheNursingandMidwiferyCouncil(NMC)Codein2015,whichincludesclearmessagesabouttheresponsibilitiesofnursesandmidwiveswhendelegatingtasksandduties.
Thefocusofthisframeworkiscentredonthepersonbeingcaredforandtheneedforsafeandeffectivedelegationthatsupportsservicestoenableandpromotehealth,independenceandwellbeingintheplaceoftheperson’schoice,asfarasispossible.
Wecommenditsuseandlookforwardtoadvancingthenextstagesofthisimportantworkwhichwillconsideraframeworktosupportdelegationacrossprofessions.
Kathy FodeyDirectorofRegulationandNursing,RegulationandQualityImprovementAuthority(RQIA)(untilApril2018)
Colum ConwayChiefExecutiveofNorthernIrelandSocialCareCouncil(NISCC)(untilSeptember2018)
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Introduction and Context Section11oftheNursingandMidwiferyCouncilCode(NMC)1statesclearlythatregistrantsareaccountablefordecisionstodelegatetasksanddutiestootherpeople.Thatincludestheresponsibilitytoconfirm that the outcome of any task2 delegated meets the required standard3forthetask.
Theabilitytodelegatesafelyisacriticalrequirementandcompetenceforthe21stcenturyhealthcareworker.StakeholderfeedbackinNorthernIreland(NI)onthecurrentdecisionmakingprocessfordelegatingnursingandmidwiferytasksanddutiesidentifiedthatthedevelopmentofadecisionsupporttoolwouldpromoteconsistencyacrossallcareandservicecontexts.Consequently,thereisthepotentialforpatientsafetyandthequalityofcareandservicesprovidedtobeimproved.
ThepublicinNIarelivinglonger,oftenwithlong-termhealthconditionsandarehavingfewerchildren.Estimatedfiguresindicatethatby2026,forthefirsttimetherewillbemoreover65sthanthereareunder16yearolds4,whichwillpotentiallyhaveanimpactonthesupplyofaworkforceforthefuture.WhilstlongevityisameasureofthesuccessofourservicesinNI,italsobringschallengesintermsofthedemandsandpressureson
HealthandSocialCare(HSC)services.EfficientuseofHSCresources,thepaceofinnovation,existingworkforcerecruitmentchallengesandinefficientdeliverymodelsinformthecaseforchange,outlinedinthestrategicdirectionoftheministerialstatementwithinHealth and Wellbeing 2026: Delivering Together5.
TheadventofanewoutcomesbasedapproachinthedraftProgrammeforGovernment6putsanonusonallservicestoworktogether,acrosssilosandboundariestodeliverthebestoutcomesforthepopulationofNI.
Itisrecognisedthatlinksexistacrossthehealthandsocialcaresystemandinallsectors,relatingtothefuturedirectionofservices.Accordingly,thefocusofthisframeworkiscentredonthepersonbeingcaredforandtheneedtoreachagreementonaschemeofdelegationthatsupportsservicestoenableandpromotehealth,independenceandwellbeingintheplaceoftheperson’schoice,asfarasispossible.
A FRAMEWORK FOR DELEGATION OF NURSING AND MIDWIFERY PRACTICE
1 NursingandMidwiferyCouncil(2018) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives.London:NMC.Page10.
2 Ibid,n1.3 Ibid,n1.4 DepartmentofHealth.(2016).Health and Wellbeing 2026: Delivering Together.Belfast,DoH.5 Ibid,n5.6 NorthernIrelandExecutive.(2016).Draft Programme for Government Framework 2016 – 2021. Availablefordownloadat:https://www.northernireland.gov.uk/sites/default/files/consultations/newnigov/draft-pfg-framework-2016-21.pdf
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ScopeThenursingandmidwiferydelegationdecisionframeworkwill:
•satisfytherequirementsoftheNMCCode
•supportthedeliveryofpersoncentredoutcomesforcareandservice
•workinprimary,secondaryandcommunitycarecontexts
•supportpracticedelegatedtostaffworkingwithinanemployedcapacitye.g.domiciliary,healthcaresupportstaff,classroomeducationsupportstaff
•utiliseanapproachthatinformseffectiveandconsistentdecisionmaking
Framework OverviewTheFrameworkfordelegationofnursingandmidwiferytasksanddutiesispictoriallyrepresentedbelowat Figure 1: Decision Framework for Delegation of Nursing and Midwifery Tasks and Duties.
Therepresentationbelowoutlinestheframeworkasawhole,themainpurposeofdelegationbeingtheachievementofperson-centredoutcomes.Theframeworkrecognisesthatsafe,effective,person-centreddelegationofnursingandmidwiferytasksanddutiesissupportedbypolicy,procedureandgovernancearrangementswithinorganisations,andthataccountabilityandresponsibilitytooverseeanappropriateprocessfordelegationoftasksanddutieslieswithemployers,delegatorsanddelegatees,atdifferentstagesoftheprocess.
Figure 1: Decision Framework for Delegation of Nursing and Midwifery Tasks and Duties
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Definition and PurposeDelegationforthepurposesofthisframework,isdefinedastheprocessbywhichanurseormidwife(delegator)allocatesclinicalornon-clinicaltasksanddutiestoacompetentperson(delegatee).
Thedelegatorremainsaccountablefortheoverallmanagementofpractice,forexample,inaclinicalcontext:theplanofcareforaserviceuser,andaccountableforthedecisiontodelegate.Thedelegatorwillnotbeaccountableforthedecisionsandactionsofthedelegatee7.
TheNMChasestablishedthatonoccasionnursesandmidwivesmaydelegatetasksordutiestootherregisterednursesormidwives.Inthesecases,theremaybeparticularcircumstanceswhereaccountabilityforeachelementofpracticeisclearlydefinedandagreed.Thisdoesnotreflecttheusualpracticeenvironment,however,whereeachregisterednurseormidwifeactsautonomously.
Thepurposeofdelegationistoensurethemostappropriateuseofskillswithinahealthandsocialcareteamtoachieveperson-centred outcomes. In aclinicalcontext,delegationofnursingandmidwiferytasksanddutiesshouldalwaysbefocusedontheneedsandwishesofthepersonreceivingcareorservices,andnotbasedonprofessional,systemororganisationaldriversexternaltothecare/serviceprocess.
Requirements to support decisions to delegate nursing and midwifery tasks and duties Delegationofnursingandmidwiferytasksanddutiestakesplaceinacontext,whetherthatisinanorganisationthatprovidescareandservices,client’sownhomeorotherareawherenursesandmidwivespractice.
Thecontextofpracticehasanumberofimportantconsiderationstounderpineffectivedecisionstodelegate.Thatwillincludeattentiongiventoenvironmentalarrangements,whetherthatisclinicalornon-clinical;governancearrangements;andprofessional,legislativeandregulatoryrequirements.Thesecontextualarrangementssupportthedeliveryofsafe,effectivepersoncentredcareandservices,thatmeettheneedsofthepopulationofNorthernIreland.
Thisframeworkdefinesthreemainrequirementstobeconsidered,thatunderpinandensurethesafetyandeffectivenessofanydecisiontodelegatetakenbynursesandmidwives.Organisationsandindividualsemployingorsecuringtheservicesofnursesandmidwivesareaccountableandresponsibleforensuringappropriatearrangementsareinplacetosupportthesafe,effective,person-centreddelegationofnursingandmidwiferytasksandduties.
7 AdaptedfromthedefinitionwithintheAllWalesGuidelinesforDelegation(2010).
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Care and Practice environmentsareorganisedtosupporteffectivedecisionmakingprocesses.Thisrequirementincludes:
• ensuringsafenurse/midwifestaffingratios
• appropriatelyskilledanddevelopedstafftomeetrequiredstandards8
• appropriateprovisionofresourcestomeetrequiredstandards
• appropriateorganisationofcareorpractice
• appropriateenvironmentsforpractice,careandtreatmenttobeprovided.
Organisational governance arrangementsareinplacetosupporteffectivedelegationdecisions.Thisrequirementincludes:
• provisionofpoliciesandprocedures
• accessibilityforstafftoorganisationalpolicyandproceduredocumentsincludingclinicalandprofessionalstandards
• accessibilityofappropriatejobdescriptions
• accessibilityofappropriatelearninganddevelopmentopportunitiesforallstaff
• processesforimmediateraisingandescalatingofconcerns.
Professional, legislative and regulatory requirementsthatconferresponsibilityandaccountabilityonregisteredandnon-registeredstaffacrossandbetweenorganisationsareconsidered.Thisrequirementincludesconsiderationof:
• theNMCandotherregulatorycodesindecisionmaking
• accountabilityfordecisionstodelegate
• accountabilityfordeemingthedelegateecompetentatthepointofdecisionmaking
• accountabilityforconfirmingthatthedelegatedtaskhasmettherequiredstandardofoutcome
• thescopeofnon-delegabletasksanddutiesforexample:midwiferypractice,prescribinganddetentionundermentalhealthlegislation.
Thesafe,effective,person-centreddelegationofnursingandmidwiferytasksanddutiesassumesthattherequirementsoutlined,page5to6,havebeenconsideredandmet.UseoftheriskbasedDecisionSupportMatrixatTable 1,page12,ofthisdocumentisunderpinnedbythesupportingcontextdescribedwithintheseparagraphs.
8 Each‘task’willhaveadescribedoptimalstandardofprocessandprocedurewhichmustbeachievedtoensuresafety,qualityandperson-centredness.
Theyarethat:
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Nursing and Midwifery Decision Support Framework for Delegation. Considering: Accountability, Responsibility and Process.Anydecisiontodelegatenursingandmidwiferytasksanddutiesusingthisframeworkisunderpinnedbysevenelementsthatshouldbeappliedtoeachdecision.Theyare:
a.Accountability
b.Responsibility
c. Processwhichcomprisestheright:
i. Task
ii. Circumstance
iii.Person
iv. Direction
v. Supportandevaluation
Onmanyoccasionsthedecisiontodelegatewillbeastraightforwardone,withclarityoneachelementoftheframeworkprovidinganobviouschoicetodelegate.Thesedecisionsshouldoptimisetheskillofthenursingormidwiferyteamandenhancepersonalexperience.
Onotheroccasions,thedecisiontodelegatewillrequireanumberofrobustarrangementstobeinplacebeforedelegationoftasksanddutiesmayoccur,includingdescribedmechanismstoprovideevidencetothedelegatorthattheidentifiedoutcomesofthedelegatedtaskhavebeenachieved.
Accountability
Accountabilityinthecontextofnursingandmidwiferydelegationmeansthataregisterednurseormidwifeisanswerableforchoices,decisionsandactionsmeasuredagainstaspecifiedstandardorstandards.
Forthosewhoaredelegatingnursingand/ormidwiferytasksanddutiesthisincludesaccountabilitytoconsiderandadhereto:
•Professionalstandards
•Employmentstandards
•thedelegationdecisionmakingprocess
andforconfirming
•thesafety,qualityandexperienceoftheoutcomeagainstthedescribedstandard.
Forthoseindividualswhoareacceptingthedelegatedtaskorduty(delegatee),beingaccountablefortheirownactionsincludesadherenceto:
•thedescribedprofessionalstandards
•employmentstandards
•actingwithinorganisationalpoliciesandprocedures.
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ResponsibilityInthecontextofdelegationofnursingandmidwiferytasksanddutiestakingresponsibilitymeansthataregisterednurseormidwifeshouldbepreparedandabletogiveanaccountofhisorheractionsforanydecisiontodelegate.Delegatorsanddelegateeshaveresponsibilitiestosupportaframeworkfordecisionmakingtodelegatenursingand/ormidwiferytasksandduties.Theyincludethat:
The delegator has
•authoritytodelegatethetask
•competencerelatingtothetask9
•undertakenanassessmentofneedpriortodecisionmakingandobtainedanyrequiredconsent
•undertakenariskassessmentastowhetherornotthetaskisdelegableintheparticularcircumstance
•providedcleardirectiontothedelegatee,checkingcompetenceandunderstandingtocarryoutthetask
•providedthenecessarylevelofsupervisionforthedelegatee
•ensuredaprocessisinplacetoenableregularandongoingreviewandevaluationoftheoutcomeofthedelegatedtaskinthecontextoftheongoingassessmentofclientschangingneeds.
The delegatee
•confirmsacceptanceofthetask
•communicatestheoutcome(writtenand/orverbal)
•understandsthefactorsthatinformthedelegationdecisionmakingprocess
•communicatesorreportsrelevantchangestothedelegatorwhichmayimpactonsafetyortheoutcome,takingintoconsiderationthedelegationdecisionmakingfactors
•maintainshis/herowncompetence
•workstothetermsofhis/heremployment
•workstotheorganisationalpoliciesandstandardsincludingraisingandescalatingconcerns
•adherestorelevantcodesofpractice.
9 Aregistrantmaybeunfamiliarwithparticulartasksordutiesduetohis/herscopeofpractice–whereupdatingmayberequiredduetoachangeinpracticeprovision.ThisFrameworkreflectstheneedfornursesandmidwivestobecompetentinthetaskordutythemselvesbeforedelegatingtosomeoneelse.
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ProcessAccountability and responsibility underpinthedecisionmakingprocesstodelegatenursingormidwiferytasksanddutiestoanothermemberofstaff.Thisprocesshasfiveelementstoconsidertoassistdecisionmaking,particularlyforthosedecisionswhichmaybemorecomplex.
Forthepurposesofthisframeworkthefiveprocesselementshavebeencalledthefive‘Rs’–remindingnursesandmidwiveswhoaremakingdecisionsaboutdelegationtoconsiderwhetherornotconditionsforeachelementare‘right’toenabledelegationtooccursafely,efficientlyandinaperson-centred manner.
Theyare:
Confirmingtheright taskrequiresconsiderationwhetherornottheactivity:
•iswithintheauthorityofthedelegatortodelegate
•isperformedinsystematicstepsthatrequirelittleornomodification
•canbeperformedtogiveapredictableoutcomewithinagreedparameters
•doesnotinvolveassessment/decisionmakingbeyondthescopeofthetask.
Confirmingtheright circumstance requiresconsiderationof:
•theconditionofthepersonreceivingcare
•thepersonbeinginvolvedinthedevelopmentof,andisinagreementwith,his/herperson-centredplanofcare.
Confirmingtheright person to delegatetorequiresconsiderationofwhetherornotthedelegatee:
•hastherequiredknowledgeandskillstocarryoutthetaskcompetently
•hasthenecessarytimetoundertakethetask
•isconfidenttocarryoutthetask.
Providingandconfirmingtheright directionrequires:•apersoncentredplanofnursingormidwiferycare,basedonanassessmentofnursing/midwiferyneedsguidedbyappropriateriskassessments,whichhasbeendevelopedandagreedwiththepersonreceivingcare
•clearperson-centredcommunicationaboutthe:› delegatedtask› standardofoutcomebasedonprofessionalandorganisationalstandards,policiesandprocedures
› timerequirementforreview.
Providingandconfirmingtheright support and evaluation requiresthatthedelegatorputsinplaceasystemorprocessto:
•enableadviceinlinewiththepersoncentredplanofnursingandmidwiferycare
•enabletheraisingandescalatingconcernsappropriately
•determinetheoutcomeofthedelegatedtask.
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Risk Based Decision Support Itisimportanttorestatethat on many occasions the decision to delegate will be a straightforward one, clarity on each element of the framework providing an obvious choice to delegate, that optimises the skill of the nursing or midwifery team and enhances personal experience. A nurseormidwifewhodelegatestasksanddutiesmustbeablegiveaccountastowhyadecisionwastaken.Thisframeworkwillprovidestructureforevidencingdecisionstodelegatepracticeandalsotopromptthinkingaboutreviewofoutcomes.
Oneachoccasionwheredelegationofnursingandmidwiferytasksanddutiesoccurs,thedelegatorworkswithinaframeworktosupportdecisionmakingoutlinedwithinthisdocumentatpages5to9.Inapplyingthisframework,anumberofrequiredassumptionsaresatisfiedbeforeadecisionistakentodelegateataskordutytoanindividualorindividuals.
Thisdoesnotmeanthatawrittenrecordofeverydecisiontodelegateisnecessary.Aperson-centredplanofnursingormidwiferycareandevaluativesummarymustcontainsufficientinformationinrelationtodelegatedtasksanddutiestosupportdecisionmaking,includingevidenceofadiscussionwiththepersonreceivingnursingormidwiferycareandwherecapacityispresent,consent.Otherevidencethatsupportsnon-clinicaldelegationdecisionswillbefoundin,forexample,annualobjectives,professionalsupervisionrecords,actionplansorlearninganddevelopmentplans.
Onsomeoccasions,thedecisiontodelegatewillrequireanumberofrobustarrangementstobeinplacebeforedelegationoftasksanddutiesmayoccur,includingadescriptionofwaysinwhichevidencemightbeprovidedtothedelegatorthattheidentifiedoutcomesofthedelegatedtaskordutyhavebeenachieved.
Whereadecisiontodelegaterequirescriticalanalysisanddirection,itwillbehelpfultousethematrixdescribedat Table 1,page12.Thematrixassumesthatthefactorswithintheaccountability and responsibility sectionshavebeenconsideredandincorporatesthefiveelementsoftheprocesssectionoftheframework,thatis,therighttask, circumstance, person, direction and support and evaluation.
Thedecisionsupportmatrixconsiderstheelementsoftheframeworkacrossthreedomainsof:potentialforpatient/clientharm,complexityofcareandpredictabilityoftheoutcome.Thedomainscanalsobetranslatedfornon-clinicaldecisionmaking,describedsimplyas:potential for harm withtheexceptionoftheinclusionofthecriterion stability of condition of the person receiving care.
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How to Use the Decision Support Matrix
Havingworkedthroughtheassumptionstoassurethatappropriatearrangementsareinplace,anurseormidwifewishingtomakeadecisiontodelegateshouldthinkthrougheachoftheeightcriteria(fordetailsofthecriteriarefertoTable 1,page12)toconsiderthesubjectmatterofthedecision.Responsestothecriteriaaresituatedwithinthreecolumnsdependingonthelikelylevelofrisk:greenforlowrisk,amber,mediumriskandredhighrisk.
Whereconsiderationofthedecisionleadstoresponsessituatedentirelywithinthegreen–lowriskcolumn,thetaskordutymaybedelegated.
Whereconsiderationofthedecisionleadstoresponsessituatedwithinthegreenandambercolumnsonly,thetaskordutymaybedelegatedwithmitigatingsupportiveactionsrequired.Professionaljudgementandcriticalthinkingshouldbeusedbythenurseormidwifetoensurethatanydecisiontodelegateissupportedappropriately.Onoccasion,followingconsiderationofthefacts,itmaybethatadecisionistakennottodelegate,orindeedtodelegatetoanotherperson,whoisforexample,moreconfidenttoundertakeaparticulartask.
Whereconsiderationofthedecisionleadstoanyresponsessituatedwithinthered–highriskcolumn,thetaskordutymustnot bedelegatedatthistime.Wherecircumstanceschangeacrossthecriteria,thedecisiontodelegatecanbereviewedandtakenatadifferentpointintime.Similarly,mitigatingsupportiveactionsmayleadtoadifferentdecisionatalaterstage,forexampledelegationtoacolleagueorpeerwhohastherequiredknowledge,skillsandconfidence.
Theuseofthematrixwillenablecriticalthinkingrelatingtodecisionstodelegatenursingandmidwiferytasksordutiestherebyprovidingopportunitiesforreflection,discussionandsolutionfocusedthinkingbetweenstaffmembers.
Anumberofscenarioshavebeendeveloped,asaresultofaperiodoflivetestingwhichtookplacefollowingtheinitialdevelopmentoftheframework.Theyhavebeenproducedtoactasaguideintheuseoftheframeworkandthedecisionsupportmatrix.TheycanbefoundatAppendix 1,page13.ConclusionThisdocumentsetsoutadecisionsupportframeworkfordelegationoftasksanddutiesbyregisterednursesandmidwivesinNorthernIreland.
Itdescribesrequirementstosupportdelegationinarangeofpracticeenvironmentsandconsiderationsunderwhichadecisiontodelegatecanbetaken.
InMarch2018,theCentralNursingandMidwiferyAdvisoryCommitteetotheChiefNursingOfficer,agreedtheframeworkforusebynursesandmidwivesinNorthernIreland.
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TABL
E 1:
DEC
ISIO
N S
UPP
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MAT
RIX
Ass
umpt
ions
:1.
Accoun
tabilityan
drespon
sibilityha
vebeenconsidered
and
assured
.
2.
Ape
rson
cen
tred
planofnursing
ormidwife
rycareisinplace,based
onan
assessm
ento
fnursing
/midwife
ry
need
sgu
ided
byap
prop
riateriskassessm
ents,w
hichhasbeen
deve
lope
d an
d ag
reed
with
thepe
rson
receivingcare.W
herecap
acityiscom
prom
ised
,the
planshou
ldbegu
ided
bythepe
rson
’sknow
npreferen
ces,
orbythepe
rson
(s)w
ithparen
talrespo
nsibility/le
galgua
rdian.
3.
Processesareinplaceto
allowim
med
iateescalationofneedorcon
cern,sho
uldthecircum
stan
cearise.
Pote
ntia
l for
[pat
ient
/clie
nt] h
arm
Low
Ris
k of
Har
m
Med
ium
Ris
k of
Har
mH
igh
Risk
of H
arm
Canthelim
itsofthe
taskbeclearlyde
scribe
dwith
outd
ecisionmaking?
Clea
r ta
sk li
mit
s –
Doe
s no
t in
volv
e de
cisi
on
mak
ing
beyo
nd t
he s
cope
of t
he t
ask
Task
has
lim
its
that
may
cha
nge
wit
hin
desc
ribe
d pa
ram
eter
s us
ing
deci
sion
sup
port
Crit
ical
and
ana
lyti
cal d
ecis
ion
mak
ing
nece
ssar
y
Hasth
ede
legateeap
prop
riateknow
ledg
e,
skillsan
dconfi
dencetocarryoutth
etask?
Com
pete
nt a
nd C
onfi
dent
Requ
irin
g so
me
addi
tion
al k
now
ledg
e an
d sk
ills
deve
lopm
ent
and
/or
exp
ress
ed n
eed
for
som
e ad
diti
onal
sup
ervi
sion
Not
com
pete
nt a
nd /
or n
ot c
onfi
dent
Wha
tlevelofp
erson-centredcommun
ication
toth
ede
legateeisreq
uired?
Sim
ple
com
mun
icat
ion
requ
ired
abo
ut t
he
task
and
exp
ecte
d ou
tcom
eSo
me
com
plex
com
mun
icat
ion
requ
ired
abo
ut
the
task
and
exp
ecte
d ou
tcom
eCo
mpl
ex c
omm
unic
atio
n re
quir
ed a
bout
the
ta
sk a
nd e
xpec
ted
outc
ome
Com
plex
ity
of c
are
Unc
ompl
icat
edM
ediu
m le
vels
of c
ompl
exit
y H
ighl
y Co
mpl
ex
Canthetaskbepe
rformed
insystematicsteps?
Yes
Yes
- som
e w
ith
deci
sion
s re
quir
ed b
etw
een
step
sN
o –
crit
ical
and
ana
lyti
cal d
ecis
ion
mak
ing
nece
ssar
y be
twee
n st
eps
Doe
sthetaskreq
uirem
odificatio
n?N
oSo
me
wit
h d
irec
ted
deci
sion
sup
port
Ye
s - C
riti
cal a
nd a
naly
tica
l dec
isio
n m
akin
g ne
cess
ary
Pred
icta
bilit
y of
the
out
com
eH
ighl
y pr
edic
tabl
eM
ediu
m le
vels
of p
redi
ctab
ility
Lo
w p
redi
ctab
ility
Isth
eou
tcom
eofth
etaskpredictab
le?
Yes
Pred
icta
ble
unde
r ce
rtai
n co
ndit
ions
No
Isth
econd
ition
ofthe
personreceivingcare
stab
le?
Yes
- Sta
ble
Pron
e to
fluc
tuat
ion
wit
hin
pred
icta
ble
desc
ribe
d lim
its
No
- Uns
tabl
e
Aretheretim
elyfeed
backm
echa
nism
sto
confi
rmth
eou
tcom
e?Ye
sYe
s bu
t a
dela
y m
ay o
ccur
in fe
edba
ck o
f ou
tcom
e –
som
e m
itig
atio
n m
ay b
e ne
eded
No
Key:
Allgreen
–
delegate
One
or
mor
e am
beran
dno
red–profession
al
judg
emen
tand
mitigatin
gactio
nre
quir
ed
One
ormorered–
donotdelegate
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EXAMPLE OF LOW RISK:DELEGATE TASK
YES NOMAYBE
✔ ✘DECISION
AmyapproachesDeliaandexplainsthatLindaneedstobeaccompaniedtothebathroomasthisisherfirsttimeoutofbedpost-operatively.DeliadiscusseswithAmyherexperienceofundertakingsimilartasksinherpreviousplaceofemployment.DeliaassuresAmythatsheunderstandstheneedtoraisethealarmifLindafeelsunwellatanystageanddescribeswhatshewoulddointhateventtoAmy’ssatisfaction.AmydelegatesthetaskofaccompanyingLindatoDeliaandrecordsthisinLinda’snursingrecordwhensheisevaluatingthenursingplanofcare.
ASSESSMENT
Lindais46yearsoldandhasbeenadmittedtoadaysurgeryunittohavehergallbladderremovedbylaparoscopy.Shereturnstothewardareafollowinganuncomplicatedprocedurewithtwosmallwoundsthatarecoveredwithsurgicaldressings.Shewishestogetoutofbedandwalktothebathroompostprocedure,priortodischarge.
ASSESSMENT
StaffNurseAmyisresponsibleforLinda’scarebeforeandafterherprocedure.Anursingassessmentpriortotransfertotheatrehadnotrevealedanynursingneedsbeyondpreandpost-operativecareincludinghealtheducation.Lindawasfullyindependentpriortoadmission.AmyhasbeenmonitoringLindasinceherreturnfromrecovery.Allvitalsignshavebeenwithinappropriateranges,basedonLinda’spre-assessmentinformationandbaselinemeasurementsonthemorningofsurgery.Linda’swoundsaredryandshehashadpainmedicationadministeredorallywhichhasrelievedherpain,followingtheprescriptiononherpost-operativemedicationschart.
AmyconsidersthedecisionsupportframeworkandrealisesthattheonlyquestionsheisunsureofiswhetherornotDelia,arecentlyappointedSeniorNursingAssistant,isconfidenttotakeonthetaskunsupervised.
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APPENDIX 1: USING THE DECISION SUPPORT MATRIX: SCENARIOS IN PRACTICE
EXAMPLE OF MEDIUM RISK:PROFESSIONAL JUDGEMENT REQUIRED
ASSESSMENT
AnassessmentismadebytheDistrictNursingSister,Ginawhomanagestheteam,andaplanofnursingcaredescribedworkingwithJohntoagreeanappropriatelevelofcare.Usingthedecisionsupporttool,Ginarealisesthatmostoftheindicatorsforthetaskofcaringforthevalvecouldpotentiallybe‘green’allowingdelegationtooccur,iftheteamhadtheknowledge,skillsandconfidencetocarryoutthetask,theprocessforthetaskperformedinstepsandtheoutcomeconsistentlypredictable,linkedtothestabilityofJohn’scondition.Bothregisteredandun-registeredstaffwithintheteamarenotcompetentincaringforalaryngectomyvalveandthestabilityofJohn’sconditionisnotknown.Thevisitswillberequiredindefinitelywhichwillhaveanimpactonthecapacityoftheteam.
YES NOMAYBE
✔✘
ASSESSMENT
Johnisa58yearoldmanwhohashadalaryngectomyvalveinplacefor22years.HiswifeJoanhascarriedoutthetwicedailycleaningofthevalvebecausehehasalwaysfounditdifficulttomanagehimself.Joanhasrecentlydevelopedsightdifficultiesandisnolongerabletocleanthelaryngectomyvalve.Therearenootherfamilymembersabletoprovidecare.JohnhasbeenreferredtotheDistrictNursingteam.
DECISION
Thedistrictnursingteammembersagreedthattheywerenotcompetentincareofalaryngectomyvalve.Threemembersoftheteamattendedalocalcaresettingofexcellenceinpracticetoundertaketraining.ThisensuredallregisteredstaffwerecompetentincareoflaryngectomyvalveBEFOREconsideringdelegationtoaSeniorNursingAssistant(SNA).Thecurrenttrustpolicydidnotincludecareofalaryngectomyvalveinacommunitysetting-whichrequiredchanging.AprocesstoassureandmonitortheongoingcompetenceofSNAswasapprovedandimplemented.Registeredstaffcarriedoutthetaskforaperiodoftimetoassessthepredictabilityoftheoutcome,thesystematicstepsintheprocessandthestabilityofJohn’scondition,beforedelegating.HavingassuredandrecordedallofthisinformationthetaskwasdelegatedtocompetentSNAteammembers,withregularreviewbytheDistrictNursingteam.
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EXAMPLE OF HIGH RISK:DO NOT DELEGATE
ASSESSMENT
Ben,theDeputyChargeNurse,isresponsibleforErnest’scareonshift.HereceiveshandoverfromMonicaonnightshift,andrealisesthatErnestwillneedsignificantassistancewithhispersonalhygiene,mobility,nutritionalandpsychosocialneeds.WorkingwithhimontheteamisAshaaseniornursingassistant.Theyarelookingafter8peopletogether,witharangeofacuityanddependencyneeds.BenknowsAshahasworkedinthewardteamfor5yearsandisveryusedtoworkingwithpeoplewhohaveexperiencedstroke.ShehasundertakentraininginspecialistmovingandhandlingtechniquesandiscompetenttoassistErnest.Ben’sinitialassessmentleaveshimuneasyaboutdelegatingErnest’spersonalcaretoAsha.
YES NOMAYBE
✔ ✘
ASSESSMENT
Ernestisan84yearoldmanwhohasbeenadmittedtohospitalwithanextensionofapre-existingstrokehehad12monthsago.Heisorientatedandalthoughdrowsymostdays,hehascapacityandisabletoprovideconsentforcareandtreatment.Hehasbeenaggitatedsinceadmissionduetothefurtherlossofmovementhehasexperienced,andmildslurringofhisspeech.HispressurepointswereassessedonadmissionandErnestwasdeemedhighriskforpressuredamagewithaBradenScoreof10.Heisexhibitingsignsofdepressionrelatedtohisrehabilitationandisrefusingtobeassistedoutofbed.
DECISION
Bendecidestousethedelegationdecisionsupporttooltoreflectonhisinitialprofessionaljudgement.HedecidesthatanursingassessmentofErnestisrequiredwhilstundertakingthetasksassociatedparticularlywithhispersonalhygieneneedsandskinassessment.ThistaskrequiresalevelofclinicaljudgementthatisoutsideofAsha’scompetence.HeassureshimselfthathecannotdescribealloftheelementsthatAshaneedstolookforinasuccintinstruction,andadditionally,givenErnest’slowmoodandaggitation,apsychosocialassessmentcanbeundertakenwhilstcaringforhispersonalneeds.BendecidesnottodelegatethetasktoAsha.
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InJune2014theCentralNursingandMidwiferyAdvisoryCommittee(CNMAC)agreedthatthepracticeofdelegatingnursingandmidwiferytasksanddutiesinNorthernIrelandrequiredfurtherexploration.Subsequently,arangeofactivitiesweretakenforwardbytheHealthandSocialCare(HSC)ClinicalEducationCentre(CEC),andNorthernIrelandPracticeandEducationCouncilforNursingandMidwifery(NIPEC)underthecommissionoftheChiefNursingofficer(CNO),DepartmentofHealth(DoH).AnumberofprioritieswerepresentedtoCNMACinDecember2015,todetermineimmediateandfutureaction,ensuringthattheprocessofdelegationofnursingandmidwiferytasksanddutiesatalocalandregionallevelwouldmeettherequirementsoftheNursingandMidwiferyCouncil(NMC)Code10andsupportthehighestpossiblelevelofpatient/clientsafety.Theprioritiesincluded:
• Areview/refreshoftheexistingDelegationFrameworkfornursingandmidwiferyStaff11withinamulti-disciplinaryapproachifpossible.
• Considerationofassessmentofriskalongwithguidanceandtheeffectiveuseofatrafficlightsystemthatisexplicitregardingactivitythatshouldnotbedelegated.
NIPECwascommissionedbytheCNOtoleadtheproductionofanapproachtodelegationofnursingandmidwiferytasksanddutiesthataddressedthosepriorities.KathyFodey,DirectorofRegulationandNursing,RegulationandQualityImprovementAuthority(RQIA)andColumConway,ChiefExecutive,NorthernIrelandSocialCareCouncil
(NISCC)wereaskedtojointlychairaTaskandFinishGrouponbehalfoftheCNO.ThefinalproductwastobereportedtoCNOviaCNMAC.
WorkingwiththeCo-Chairs,theleadofficerinNIPECproducedaprojectplanandoutlinemethodology,whichincludedtheconveningofaworkshopattendedbyawiderangeofrepresentationacrossstatutory,non-statutory,education,policyandstaff-sideorganisations.Thepurposeoftheworkshopwastobringtogetherarangeofnursingandmidwiferycolleaguesfromacrosssectorstodiscusstheirunderstandingofdelegationinnursingandmidwifery,ideastosupporteffectivedelegationandthentestanoutlineframeworkwhichwasbasedonbestevidenceinthisarea.Withaviewtotheintersectionofnursingandmidwiferycareandserviceswithsocialcare,anumberofsocialworkcolleaguesattendedtheeventtolistenandcontributetothediscussion,toenablefuturethinkingforsocialcaresettingsandinter-professionalteams.
Theintentionwastodrawontheconsiderableworkwhichhadtakenplacebyothercountriestodate,evidencedthroughpublicationsandframeworksalreadyinexistenceandengagewithdelegatesregardingproposalsforanoutlineframework.Colleaguesengagedinarangeofexercisestostimulatediscussionandcommentontheoutlineprovided,includingscenariotestingofadecisionsupportmatrix.AtvariouspointsthroughoutthedaytheCo-ChairsandProjectLead,NIPEC,facilitatedfeedback.
ADDENDUM 1: PRODUCTION OF THE FRAMEWORK
10 Ibid,n1.11 CentralNursingAdvisoryCommittee.(2009).Central Nursing Advisory Committee Delegation
Decision Making Framework.Belfast,DHSSPSNI.
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DelegateswereinvitedtooptintomembershipofaTaskandFinishSubGrouptotaketheworkforward.NameswereofferedbyindividualsandweresubsequentlyagreedbyExecutiveDirectorsandCNO.MembershipoftheSubGroupisatAddendum 2,page19.ThisgroupwasconvenedinearlyJanuary2017torefinetheframeworkbasedonthefeedbackobtainedthroughtheOctober2016workshop.Followingaperiodofreviewandfinalisation,theframeworkwastestedinarangeofnursingandmidwiferypracticesettingstoenablefinalrefinementandfeedback.
Overwhelmingly,theregisterednurseswhoengagedintestingthedraftframeworkfoundituseful.Manystatedthattheyfeltthestructureandclarityofthematrixempoweredautonomousdecisionmaking,enablingthemtoarticulatearationaleastowhytheyhadmadeparticulardecisionstodelegatenursingtasksandduties.
Throughoutthetestingphasesitwasapparentthattherewereanumberofcomplexschemesofserviceprovisiontowhichthedelegationframeworkmightapplyandforwhichacollectivesolutionshouldbeconsideredtosetinplaceprinciplesforaregionalcross-agency,multi-professionalapproach.
Asmallnumberofactionswereidentified,therefore,relatingtonecessarynextstepsthroughforconsiderationbytheTaskandFinishSubGroup,CNMACandtheChiefNursingOfficer.
ThefirstphaseanddecisionsupportframeworkwerepresentedtoCNMAC23rdMarch2018forapproval.
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EVIDENCE THAT INFORMED THE PRODUCTION OF THE DECIDING TO DELEGATE DECISION SUPPORT FRAMEWORK
TheDecidingtoDelegateframeworkworkedforwardfromevidencegatheredfromascopingexercisecarriedoutbytheHealthandSocialCareClinicalEducationCentre(HSCCEC)12andaworkshopeventhostedjointlybyNIPECandHSCCECtotheCentralNursingandMidwiferyAdvisoryCommittee(CNMAC)inDecember201513.
Inadditiontothesereports,arangeofliteratureandresourcesinformedthethinkingrelatingtotheproductionoftheframeworkincluding:
AustralianNursingFederation.(2011).ANF Guidelines: Delegation by registered nurses and registered midwives. Availablefordownloadat:http://www.anmf.org.au/documents/policies/G_Delegation_RNs_RMs.pdf
Gillen,P.andGraffin,S.(2010).NursingDelegationintheUnitedKingdom.OJIN:The Online Journal of Issues in Nursing. 15(2).Manuscript6.
Hasson,F.,McKenna,H.andKeeney.S.(2013).Delegatingandsupervisingunregisteredprofessionals:thestudentnurseexperience.Nurse Education Today.33:229–235.
NationalHealthScotlandFlyingStartProgramme:Delegationavailableat:http://flyingstart.scot.nhs.uk/learning-programmes/communication/delegation/
NationalLeadershipandInnovationAgencyforHealthcare(2010).All Wales Guidelines for Delegation.Llanharan,NLIAH.Availableat:http://www.wales.nhs.uk/sitesplus/documents/829/All%20Wales%20Guidelines%20for%20Delegation.pdf
NursingandMidwiferyCouncil.(2018).The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. London:NMC.Availablefordownloadat: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf
RoyalCollegeofNursing.(2011).Delegation: A Pocket Guide.London,RCN.
RoyalCollegeofNursing:AccountabilityandDelegation:https://www.rcn.org.uk/professional-development/accountability-and-delegation
Ruff,V.A.(2011).Delegation Skills: Essential to the Contemporary Nurse. MasterofArtsinNursingTheses.Paper21.
Stonehouse,D.(2015).Theartandscienceofdelegation.British Journal of Healthcare Assistants.9(3):150–153.
12 HSCClinicalEducationCentre.(2015).Summary Report on the Delegation of Nursing Care for Central Nursing and Midwifery Advisory Committee. Belfast,CEC.
13 HSCCECandNIPEC.(2015).RegionalWorkshopToConsiderAspectsOfTheDelegationOfNursingCare:ReportToCNMAC.Belfast,NIPEC.
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NAME ORGANISATION
Finlay,Heather DoH
Wallace,Verena DoH
Martin,Jillian DoH
Higgins,Patricia NISCC
Rodigues,Ethel UNITE
Martin,Garrett RCN
Hughes,Breedagh RCM
UNISON
Pelan,Aisling BHSCT
Rafferty,Esther BHSCT
Devlin,Nuala BHSCT
Brown,Fiona NHSCT
Hume,Allison NHSCT
Pullins,Suzanne NHSCT
Burke,Mary SHSCT
Hamilton,Grace SHSCT
Holmes,Sharon SHSCT
Kelly,Linda SEHSCT
McRobertsSharon SEHSCT
Mills,Paul SEHSCT
Taylor,Janet SEHSCT
ElaineCole SEHSCT
McGarvey,Brian WHSCT
McGrath,Brendan WHSCT
Witherow,Anne WHSCT
Brown,Oriel PHA
Devine,Maurice CEC
Watson,J-P Ind&Vol
ADDENDUM 2: MEMBERSHIP OF TASK AND FINISH GROUP SUB-GROUP
Responsibilities of Sub Group Membership:• Contributetotheachievementoftheaimsandobjectives
• ParticipateinplannedactivityrelatedtotheproductionoftheFramework
• Participateinrespectful,opendebate
• Welcomeandprovideconstructivechallenge
• Consultwithindividualsofappropriateexpertiseasrequiredinformingtheproductionoftheframework
• Activelyparticipateintestingthefinaldraftframework
• Manageinformationrelatedtotheworkplanresponsibly,ensuringconfidentialitywhenrequired
• AttendallmeetingsrequiredtodevelopafinaldraftFrameworkforcirculationtothewiderTaskandFinishGroup
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Term Used Term Descriptor
Appropriate Suitableorproperinthecircumstances.
Carer Acarerisanyonewhocares,unpaid,forafriendorfamilymemberwhoduetoillness,disability,amentalhealthproblemoranaddictioncannotcopewithouttheirsupport.
Capacity Theabilityorpowertodoorunderstandsomething.
Competence Theknowledgeskillsattitudeandabilitytopracticesafelywithoutdirectsupervision.
Competent Havingthenecessaryability,knowledgeorskilltodosomethingsuccessfully.
Consent Permissionforsomethingtohappenoragreementtodosomething–inhealthcarethisisaccompaniedbytheboundariesofinformedagreement,i.e.anindividualhasbeenprovidedwiththeappropriateinformationtomakeadecision.
Delegate Toentrustataskordutytoanotherperson.
Delegatee Competentpersonwhoagreestoacceptthetaskordutydelegatedtothembythenurseormidwife.
Delegator Nurseormidwifewhodelegatesataskordutytoacompetentotherperson.
Midwife ApersonwhohasundergonetrainingandeducationtomeettheNursingandMidwiferyCouncil(NMC)standardsforpre-registrationorpost-registrationmidwiferypractice,anddeemedcompetenttojointheNMCregister,thereafterrenewingtheirregistrationeverythreeyearsthroughrevalidation.MidwivescommittoupholdingprofessionalstandardswithintheNMCCodeofpracticeandbehaviours.
Non-registered ApersonwhohasnotbeentrainedandeducatedtotheNursingandMidwiferyCouncil(NMC)standardsforpre-registrationnursingormidwiferyandisthereforenotapartoftheNMCregister.
Nurse ApersonwhohasundergonetrainingandeducationtomeettheNursingandMidwiferyCouncil(NMC)standardsforoneormoreofthefourpre-registrationnursingspecialisms:adult,children’s,learningdisabilitiesandmentalhealth,anddeemedcompetenttojointheNMCregister,thereafterrenewingtheirregistrationeverythreeyearsthroughrevalidation.NursescommittoupholdingprofessionalstandardswithintheNMCCodeofpracticeandbehaviours.
GLOSSARY
Thefollowingdescriptorsaredefinedwithinthecontextofthisdocument
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Term Used Term Descriptor
Protocol Theacceptedorestablishedcodeofprocedureorbehaviourinanygroup,organisation,orsituation.
ScopeofPractice Theareaofsomeone’sprofessioninwhichtheyhavetheknowledge,skillsandexperiencetopractisesafelyandeffectively,inawaythatmeetsthestandardsoftheirrespectiveregulatorand/oremployeranddoesnotpresentanyrisktothepublicortothehealthprofessional.
ServiceUser Apersonwhousestheservicesofahealthprofessionaloranyotherrelevantservice.
Skill Theabilitytodosomethingwell;expertise.
Supervision Theactiveprocessofdirecting,guidingandinfluencingtheoutcomeofanindividual’sperformanceofatask.
Taskorduty Apieceofworktobedoneorundertaken.
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January2019