Delegation Procedure

Standardization Toolkit

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Introduction

Increasingly, Support Workers are being required to assist with, or perform, certain aspects of care traditionally provided by regulated health care professionals.

The nurse is therefore expected to teach, supervise, or assign health care to the Support Worker.

Purpose

1.  To define terms used in delegation of care in order to ensure consistent communication.

2.  To identify the responsibilities of regulated and unregulated staff regarding the delegation of care.

3.  To provide a process to follow when making decisions about delegation of care.

4.  To provide a framework for delegation of tasks with standardized procedures and teaching materials.

Terms used in delegation of care to support communication

Delegation: Active process of transferring authority to a competent member of the health care team to perform a particular function or task in a specific situation

Delegator: person making the decision to delegate (RN or RPN/LPN)

Delegatee: health care staff receiving the delegation (support worker)

Terms used in delegation of care to support communication

Assigning: determining or allocating responsibility for particular aspects of care that may include both controlled and non-controlled procedures

Controlled Acts/ Restricted activities: activities that are considered potentially harmful if performed by unqualified persons. Each professional must therefore work within a scope of practice defined by a provincial governing body.

Terms used in delegation of care to support communication

•  Teaching: providing instruction and determining if a person is competent to perform a procedure (not the same as delegation because it does not involve the transfer of authority to perform a controlled act procedure)

•  Supervising: monitoring and directing specific activities of a Support Worker for a defined period of time. (can be direct of indirect)

Responsibilities

For example;

BC- delegable tasks are client-specific tasks Alberta- “Delegation” refers to the transfer of authority to perform nursing care in general Ontario- delegation is differentiated from “teaching”, “assigning”, or “supervising” and only refers to the controlled acts authorized to nursing.

Responsibilities

The Delegator Must:

-  have the knowledge, skill, and judgment to perform and teach the procedure competently

-  accept sole accountability for the decision that the Support Worker may perform the procedure considering all relevant factors

(ie. Risk and benefits to the client, predictability of the outcomes, safeguards and resources, and specific client or setting factors)

Responsibilities

The Delegator Must:

-  personally evaluate or ensure that a process is in place to evaluate the continuing competence of the person to perform the procedure

- make decisions that are in the best interest of the client

Making Decisions

The process for delegating and teaching the tasks involved in ADLs for clients include five principles of delegation.

1. Right context/circumstances: consider the clients physical, emotional, social, intellectual, and spiritual needs. Do you have the necessary tools to delegate the care and the client’s participation?

Making Decisions

2. Right Task: can the task be delegated? Are you allowed to delegate it? Can you competently delegate it?

3. Right person: Do you have concerns about delegating the task to the Support Worker? Does the Support Worker have concerns?

4. Right communications: Provide clear directions and instructions. Can the Support Worker clearly report back and understand the task, risks, and expectations?

5. Right resources: Does the Support Worker know who to contact and how to contact you? After delegation, have you assessed the Support Worker’s performance?

Making Decisions

Decision Tree: Teaching or Delegating the Performance of a Procedure Nurse  considers  teaching/delega2ng  procedure  

Am  I  competent  to  perform  the  procedure?  

Am  I  competent  to  teach/delegate  the  procedure?  

Have  I  considered:  risks  and  benefits  of  performing  procedure,  predictability  of  outcomes,  safeguards  and  resources  available,  and  other  client  specific  factors  

YES  

YES  

YES  

NO  

NO  

Do  not  teach/delegate  

Do  not  teach/delegate  

Can  I  safely  teach/delegate  considering  the  factors?  

YES  

Is  the  Support  Worker  available  with  potenFal  to  perform  procedure?  

YES  

Teach  the  Support  Worker,  determine  competence,  idenFfy  condiFons  for  performing  and  indicators  for  seeking  assistance  

NO  

NO  

NO   Do  not  teach/delegate  

Do  not  teach/delegate  

Is  there  a  mechanism  to  determine  ongoing  competence?  

YES  

Ensure  that  a  monitoring  mechanism  is  in  place  

Do  not  teach/delegate  

Adapted  from  CNO,  working  with  Unregulated  Care  Providers,  2011  

Framework, standard procedures, teaching materials

When delegation of task is required: 1)  CCM/CCS will arrange visit for delegation with

client and Support Worker 2)  CCM/CCS will provide Support Worker with “fact

sheet” (pre-reading materials) 3)  CCM/CCS will delegate according to “procedure

checklist” 4)  CCM/CCS will have client and Support Worker

sign documentation and keep copy of paperwork in chart

Delegation of Care 4.25F January 2013

Delegation of Care 4.25F January 2013

When teaching, remember to promote: D·I·P·P·S

D- Dignity I- Independence P- Preferences P- Privacy S- Safety

Fact Sheet

Example:

Fact Sheet for Delegations PERFORMING RANGE-OF-MOTION EXERCISES Range-of-motion (ROM) Exercises: range of motion is achieved by moving a joint to its full extent possible without causing pain and ROM exercises involve exercising the joints through their complete range of motion. ROM exercises can be: ►Active ROM: done by the client independently ►Passive ROM: exercises are done by another person who moves the joints of the client through their ROM ► Active-assistive ROM: exercises are done by the client with some help from another person   Range-of-motion movement occurs naturally during activities of daily living such as bathing, eating, and walking. These all involve joint movements. Client who are ill or who are required to stay in bed get very little activity and therefore require ROM exercises. ROM exercises can cause injury such as muscle strain, joint injury, and pain if they are not done properly. It is therefore very important that you follow the following which will be reviewed during the delegation session with your Supervisor. ►Exercise only the joints you are instructed to exercise ►Expose only the body part being exercised ►Use good body mechanics ►The joint should be moved slowly, smoothly, and gently every time ►Never force a joint beyond its range of motion or to the point of pain

Delegation checklist PRE-­‐PROCEDURE   PROCEDURE   POST-­‐PROCEDURE  

□  Iden2fy  the  client      □  Explain  the  

procedure  to  the  client      □  Prac2ce  hand  hygiene        

□  Collect:  exercise  instruc2ons  as  prepared  by  physiotherapist      

□  If  possible,  raise  bed  to  a  comfortable  height  and/or  consider  body  mechanics      

□  Provide  for  privacy      

□  Place/assist  the    client    to  the  supine  posiFon      □  Expose  the  body  part  to  be  exercised  by  fan  folding  

top  linens  toward  the  client’s  feet  and  cover  the  client  with  a  blanket      □  Perform  rouFne  ROM  exercises  as  per  instrucFons  prepared  and  taught  by  a  physiotherapist  or  delegated  to  you  by  your  Supervisor  

           

□  Provide  for  safety  and  comfort      

□  cover  the  client  and  remove  the  blanket/towel      □  Return  bed  to  lowest  posiFon  and  

remove  privacy  measures      □  PracFce  proper  hand  hygiene  

   □  Report  and  record  your  acFons  and  observaFons      

_____________________________________________________________________________________

PERFORMING RANGE-OF-MOTION EXERCISES

Fact Sheet- example 2 Fact  Sheet  for  DelegaFon  ASSISTING  WITH  MEDICATIONS  MedicaFons  are  drugs  and  other  substances  used  to  prevent  or  treat  diseases  or  illnesses.  As  a  PSW,  you  may  be  responsible  for  assisFng  your  clients  with  their  medicaFons.  Your  role  may  involve  one  or  more  of  the  following  as  delegated  by  your  Supervisor  and  outlined  on  the  delegaFon  form:  Reminding  the  client  to  take  a  medicaFon  Bringing  medicaFon  containers  to  the  client  Bringing  pre-­‐poured  medicaFons,  prefilled  syringes,  blister  packs,  or  doseWes  (pill  boxes)  to  the  client  Reading  the  prescripFon  label  to  the  client  Loosening  or  removing  container  lids  or  opening  blister  packs  Checking  the  dosage  against  the  medicaFon  label  Providing  water  or  other  fluids,  as  needed  Supervising  the  client  as  he  or  she  places  the  medicaFon  into  the  hand,  measuring  spoon,  or  cup  Steadying  the  client’s  hand  while  he/she  places  medicaFons,  administers  eye  drops,  etc.  DocumenFng  that  you  assisted  a  client  with  his/her  medicaFon  You  are  not  responsible  for  monitoring  the  outcome  of  the  drug  therapy  but  must  report  any  changes  in  the  client’s  condiFon  or  behaviour  to  your  Supervisor.    The  client’s  medicaFon  can  be  stored  in  a  blister  pack,  doseWe  or  the  client’s  family  may  prepare  the  medicaFon  by  placing  the  medicaFon  in  a  bowl/  cup/  or  container.  A  blister  pack  is  prepared  by  a  pharmacy.  A  doseWe  is  prepared  the  client,  the  client’s  family,  or  a  nurse.  It  is  not  your  responsibility  to  do  this.    The  client’s  medicaFons  should  be  well  established  but  drug  allergies  and  anaphylaxis  can  occur  at  any  Fme.  Contact  your  Supervisor  right  away  if  your  client  develops  a  rash,  appears  puffy,  has  nasal  drainage,    complains  of  itchy  eyes,  presents  with  a  fever,  wheezing,  extreme  weakness,  or  nausea,  and  vomiFng.  Anaphylaxis  is  the  body’s  way  of  fighFng  or  aWacking  a  drug  and  is  life-­‐threatening.  In  some  cases,  anaphylacFc  shock  can  occur  within  seconds  and  signs  and  symptoms  include:  sweaFng,  shortness  of  breath,  low  blood  pressure,  irregular  pulse,  respiratory  congesFon,  swelling  of  the  larynx,  hoarseness,  dyspnea  (difficulty  breathing).  In  this  event,  you  must  call  911  immediately.  If  you  believe  that  you  have  made  a  medicaFon  error,  you  need  to  report  this  to  your  Supervisor  right  away.  You  should  also  report  if  you  have  found  an  error  that  your  client  or  someone  else  has  made.  It  is  your  Supervisor’s  responsibility  to  assess  the  situaFon  and  to  determine  the  next  course  of  acFon.  Deliberate  failure  to  report  a  medica1on  error  is  possible  grounds  for  immediate  dismissal  (losing  your  job)  or  being  charge  in  a  court  of  law.  You  can  be  in  more  trouble  if  you  fail  to  report  the  error  than  from  making  the  error  itself!    

Delegation checklist- example 2

ASSISTING  WITH  ORAL  MEDICATIONS  

PRE-­‐PROCEDURE   PROCEDURE   POST-­‐PROCEDURE  

□  Iden2fy  the  client      □  Explain  the  procedure  to  the  

client      □  Prac2ce  hand  hygiene  and  assist  client  with  hand  hygiene      □  Collect  medica2on(s),  standard  

measuring  spoon  or  device,  and  glass  of  water  or  liquid      □  Provide  for  privacy  if  required  

For  MedicaFons  from  a  PrescripFon  Container:  □  Check  and  read    label  on  each  container  for  the  client  if  assistance  required  

   □  Loosen  lids  on  container(s)  if  the  client  cannot  do  so.    

   □  Place  the  container  where  the  client  can  reach  it  or  hand  the  container  to  the  client.  With  the  client  

wearing  his/her  eyeglasses  if  needed,  have  him/her  read  the  medicaFon  name  to  you.      For  MedicaFons  from  a  Blister  Pack:  

□  Check  blister  pack  label  and  ensure  you  have  the  correct  blister  pack,  right  day,  and  right  Fme  of  day      

□  Instruct  the  client  to  open  the  blister  pack  by  pushing  the  soa  plasFc  “bubble”.  Have  the  client  do  this  over  a  dish  or  bowl.      

□  *If  the  client  cannot  manually  push  open  the  “bubble”,  you  can  do  this  for  the  client.      

For  all  MedicaFons:  □  Help  the  client  pour  the  correct  amount  of  liquid  medicaFon  or  count  the  correct  number  of  pills.  

   □  Give  a  sip  of    water  to  moisten  the  mouth        

□  Support  the  client’s  hand,  if  needed,  to  pour  the  medicaFon      

□  Encourage  the  client  to  drink  a  full  glass  of  water  aaer  he/she  has  taken  the  medicaFon.    Lowering  the  chin  can  ease  the  swallowing  process.  

   □  *  If  the  medicaFon  is  to  be  dissolved  under  the  tongue,  have  the  client  place  the  medicaFon  under  his/her  tongue  and  remind  him/her  not  to  chew  or  swallow  it.  Do  not  give  fluids  while  it  is  dissolving.  

   □  Securely  close  the  containers  aaer  use    

□  Have  the  client  record  the  medicaFon(s)  taken    when  applicable      □  Store  materials  in  their  proper  locaFons      □  PracFse  hand  hygiene      □  Report  and  record  you  acFons  and  observaFons  

Procedures to date:

•  Assisting with medications a)  Oral b)  Suppository/ Enema c)  Eye drops and ointments d) Ear drops e)  Transdermal patches f)  Inhalers

Procedures to date:

•  ROM Exercises •  Stocking Application •  Applying dry non-sterile dressings •  Assisting with Urinary Elimination a)  Assisting with urinary catheters b) Changing leg bag to night bag c)  Providing catheter care d)  Condom catheter care

Testimonial

• Hi Melissa : Just a quick e-mail to say how helpful I have found the delegation tool kit. It is user friendly and provides a quick reminder of all the steps that we should be following without having to think about it. It is fast and concise with all of the steps listed. Previously I would have to try and search out materials but you have made my task of teaching and delegating a lot easier. Will look forward to having all delegations in this format in the future.

 

References

•  College of Nurses of Ontario (2011). Working With Unregulated Care Providers

•  Sorrentino, S.A, et al. (2009). Mosby’s Canadian Textbook for the Support Worker. Toronto: Elsevier Canada

•  We Care Policy # 4.25 •  What is a PSW’s Role in Medication (2009). Web.

<www.psno.ca>

Questions?

Video Links   •  https://vimeo.com/63609601    (French) •  https://vimeo.com/62906534    (English)

Questions?