The obligation of registered nurses to provide quality and safe care creates challenges and induced concerns when they have to delegate duties to newly registered nurses or unlicensed assistive personnel. These concerns and challenges are exacerbated in the present health care setting marked by shrinking human resources and clients with complex conditions. Additionally, these concerns are magnified by the use of advanced technology. To delegate safely and effectively, registered nurses must understand the authority, accountability and responsibility attached to delegation. This paper explores various aspects of delegation with respect to unlicensed assistive personnel and preceptors.
Unlicensed Assistive Personnel
New York State Board of Nursing Viewpoint Regarding the Roles of Unlicensed Assistive Personnel (UAP) and Registered Nurses (RNs)
The position of the New York State Board for Nursing regarding RNs within the context of utilization of UAPs is that the experiences for UAPs are legal within the State with specific exceptions. Firstly, UAPs experience is legal if they are part of a credit-bearing course. Secondly, the experience is legal if the UAP id directly supervised by a registered nurses. In the same line, the New York State Nurses Association (NYSNA) holds that RNs bear the responsibility for the development, implementation and evaluation of nursing care as an integral part of the required interdisciplinary plan of care. Additionally, it is the role of RNs to verify the competence of UAPs. It is also the responsibility of RNs to identify tasks related to health and circumstances for cases assigned to UAPs. Most importantly, registered nurses bears the responsibility for recognizing that any form of inappropriate utilization of UAP in performing any professional nursing responsibilities is not only unethical but also illegal. In the same line, RNs should also recognize that such actions impedes quality of patient care and exposes practitioners and patients in risky positions.
Difference between ICU and General Medical Surgical Unit for Unlicensed Assistive Personnel
Characteristics distinguishing RNs and UAPs include and are not limited to critical thinking skills, depth of knowledge and amount of education. In that respect, the responsibilities of RNs include delegation, supervision and accountability. Therefore, when UAPs participate in direct care, RNs ensure that the UAPs job description and delegable activities comply with the States established statues, regulations and acts. Additionally, patients should be able to identify UAPs as non-licensed. All roles played by UAP should be delegated and supervised by registered nurses and in line with the clients formal plan of care and the UAPs evaluated level of competence. A client can be a community, group or individual receiving nursing services. Consistent with NYSNA, some of the health-related functions of UAPs include providing routine skin (intact skin) care, assisting RNs with routing bladder and bowel care and bathing patients. UAPs also make occupied or unoccupied beds. They also assist with mobility, including various motion exercise, transfers, positioning and ambulation. At the direction of registered nurses, UAP collect data and report it to the RN. Within the same context of health related functions, UAPs also measure vital signs, including respiration, pulse, temperature, and blood pressure. UAPs can apply oxygen to patients as per the direction of the registered nurse, including tubing.
Delegating interventions to UAPs is not always easy because one cannot always be certain how much can be delegated safely. It follows that lack of experience can result in under-delegation or improper delegation. In this context, the term intervention refers to a procedure, task, action or treatment with defined limits and can be delated or assigned to a UAP within a client cares context. Once of the reasons behind potential under-delegation relates to feedback. It is important to offer UAPs feedback on what they have done as means of either motivating them or as a corrective avenue. Giving feedback also demand ethics and professionalism whether or not objective have been attained. This can be challenging especially when one has to confront unresponsive UAP with a problem. Furthermore, it takes time to keep in touch with revised laws and to understand the UAPs strengths and weaknesses. Other obstacles to effective delegation including insecure delegator, inadequate resources, unwillingness to trust others, poor interpersonal or communication skills, and lack of training about delegation.
Safeguards to Reduce Delegation Errors
A number of factors should be considered when RNs are delegating to UAPs to minimize errors. Firstly, when delegating an intervention to UAPs, the delegation should only be to an UAP that has received further education. In the same line, the UAP should be competent enough to perform the intervention as supported by the employers policy. The second safeguard is ensuring that a delegation to UAP is only client-specific; thus, not delegation should be transferrable or performed by another UAP or the same UAP with another patient/client. The registered nurse must always assume delegation responsibility. RNs should also routinely perform inspection and evaluation of the UAPs competence, and then provide necessary corrective action. Registered nurses should also be aware of the UAPs job description or scope of work within the institution. In the same line, nurses should determine the kind and amount of supervision required. When status of the client changes, the RN must rely on professional judgement for situational assessment and ensure the patient receive effective and safe care linked to delegation. Most importantly, the five rights of delegation must be used by RNs when assigning care to others. These include the right person, circumstance, supervision and evaluation, communications and directions, and tasks.
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Consistent with delegation model by the National Council of State Boards of Nursing (NCSBN), the main issue in this case ineffective communication and lack of accountability from the preceptor. In this context, the term preceptor refers to a registered nursing practitioners with formal responsibility of supporting newly registered practitioner (NRP) Amy in this context through preceptorship. The predominant themes is ineffective delegation exhibited by deficiency in the understanding of authority, accountability and responsibility related to delegation.
Qualifications for a Preceptor
Typically, nurses designated are preceptors are experienced registered nurses who are passionate about the profession and desire to teach others. Preceptors should be well versed with the course and evaluative role. Academically, preceptors should have a minimum of BSN degree and preferably a masters degree in nursing. In simple words, preceptors must have active licensure, implying that they must either be a physician or a registered nurse practitioners. Good candidate are nursing department heads, advanced practice heads and unit-based nurse managers. Besides the passion and desire to teach newly registered practitioners, preceptors should have: good teaching skills, leadership skills, positive professional attitude, effective communication and interpersonal skills and sensitivity to the unique needs of each student nurse.
Including RNs in Preceptorship
The central aim of preceptorship is to improve the competence and enhance the confidence of NRPs as independent practitioners. This demands effective delegating good understanding of authority, responsibility and accountability. Second shift registered nurses can be included in the preceptorship by assigning them the preceptors work. Assignment refers to delegation of work to a group of competent individuals. This lateral transfer of responsibility from the preceptor to the RNs means that the Clinical Nurse Specialist for the Emergency Department retains the accountability for the outcome. Accountability means being answerable and responsible for actions of self and other within the delegation context. The Clinical Nurse Specialist should also ensure that the RNs supervise Amy provide guidance, oversight, direction and follow up for accomplishment of the delegated task.
How to Improve Orientation
The central goals of preceptorship to enable novice nurses to apply their theoretical knowledge in a clinical environment. This transition can be improved by demonstrating various nursing actions. In addition, preceptors should answer questions clearly and connect information to various concepts. Within the same line, the preceptor should be as open as possible with regards to conflicting opinions. Preceptors should also strive to explain the ground for decision and any corrective actions. In other words, feedback on performance is critical to the success of preceptorship. Preceptorship can be improved by ensuring that preceptors effectively communicate expectations and talk through actions to demonstrate their arguments. Lastly, preceptors should also assess the readiness of students before any assignments.
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From the analysis and discussion above, it is apparent that safe and effective delegation demands that RNs understand the authority, accountability and responsibility attached to delegation. The key responsibilities of RNs when involving UAPs include delegation, supervision and accountability. Challenges to effective delegation and preceptorship include insecurity, poor communication and interpersonal skills, inadequate resources, and lack of training about delegation and preceptorship. In concluding, the understanding of delegation and preceptorship is critical to safety and quality of care in the present demanding healthcare setting.