Effective Delegation: Understanding Responsibility, Authority, and Accountability

Delegation of Work Within a Patient-Centered Medical Home

OBJECTIVE

The aim of this study was to analyze the perceptions of core team members implementing patient-centered medical home (PCMH) within the Veterans Health Administration regarding delegation of work.

BACKGROUND

Significant overlap exists in the performance of work tasks among PCMH team members (primary care providers, RNs, clinical associates, clerks), and scant literature exists on appropriate delegation within PCMH teams.

METHODS

This study conducted used a quantitative and qualitative analysis of 4254 respondents to a 2018 survey.

RESULTS

Primary care providers rely heavily on team members, and nurses report being relied upon at high levels. Lack of role clarity and a perceived need for a team leader were concerns voiced by participants.

CONCLUSIONS

Findings indicated a need for clear guidance on roles and responsibilities within the team. Patient-centered medical home team members need information about the scope of practice of each professional group to allow providers to function at the top of their scope of practice and ensure effective delegation.

Leadership competencies of first-line nurse managers: a quantitative study

PURPOSE

This paper aims to examine the leadership competencies of first-line nurse managers (FLNMs) at the unit level in the eastern region of Ghana.

DESIGN/METHODOLOGY/APPROACH

The paper is a quantitative cross-section design.

FINDINGS

Nurse managers exhibited a moderate level of knowledge and ability to apply leadership competencies. Gender, rank, qualification, professional experience, management experience and management training jointly predicted the leadership competencies of FLNMs [(R² = 0.158, p = 0.016]. However, only management training was a significant predictor in the model.

PRACTICAL IMPLICATIONS

Inappropriate leadership competencies have severe consequences for patients and staff outcomes. This situation necessitates a call for a well-structured program for the appointment of FLNMs based on competencies.

ORIGINALITY/VALUE

This study is the first in Ghana which we are aware of that examined the leadership competencies at the unit level that identifies predictors of leadership competencies.

Uncovering the Disconnect Between Nursing Workforce Policy Intentions, Implementation, and Outcomes: Lessons Learned From the Addition of a Nursing Assistant Role

The use of nursing assistants has increased across health systems in the past 20 years, to alleviate licensed nurses' workload and to meet rising health care demands at lower costs. Evidence suggests that, when used as a substitute for licensed nurses, assistants are associated with poorer patient and nurse outcomes. Our multimethods study evaluated the impact of a policy to add nursing assistants to existing nurse staffing in Western Australia's public hospitals, on a range of outcomes. In this article, we draw the metainferences from previously published quantitative data and unpublished qualitative interview data. A longitudinal analysis of patient records found significantly higher rates adverse patient outcomes on wards that introduced nursing assistants compared with wards that did not. These findings are explained with ward-level data that show nursing assistants were added to wards with preexisting workload and staffing problems and that those problems persisted despite the additional resources. There were also problems integrating assistants into the nursing team, due to ad hoc role assignments and variability in assistants' knowledge and skills. The disconnect between policy intention and outcomes reflects a top-down approach to role implementation where assistants were presented as a solution to nurses' workload problems, without an understanding of the causes of those problems. We conclude that policy makers and managers must better understand individual care environments to ensure any new roles are properly tailored to patient and staff needs. Further, standardized training and accreditation for nursing assistant roles would reduce the supervisory burden on licensed nurses.

Unregulated care providers' engagement in palliative care to older clients and their families in the home setting: a mixed methods study

Background

Unregulated care providers (UCPs) are at the forefront of direct client care in the community. Their services are required to meet the demand for home-based palliative care from a growing older population, yet understanding of UCPs involvement in care is limited. The study aimed to identify the types and frequencies of tasks performed by UCPs in home-based palliative care to older clients (> 65 years) and their families and to describe UCPs’ engagement in care, and barriers and facilitators to their work.

Methods

A mixed method approach was used comprising a quantitative retrospective chart review of UCPs’ tasks (n = 66), qualitative content analysis of progress notes from clients’ charts (n = 85), and thematic analyses of in-depth interviews with UCPs (n = 10).

Results

A thematic structure was derived from analyses and integration of data from the chart review and interviews. The themes reflect the physical, affective, and relational aspects of UCPs involvement in the care of clients and families at the end of life. The findings indicate that although a significant proportion (63%) of the 13, 558 UCP tasks identified were directed toward meeting clients’ physical care needs, their presence in the home, made UCPs an important source of information on the client’s condition; observing and appraising the situation. Further, the nature of their work and frequent interactions with clients and families also presented opportunities for UCPs to provide emotional support; a role UCPs felt was integral to their work.

Conclusions

The study highlights the challenging nature of palliative care to older clients and their families whose needs are often complicated, situated within the unique environment of home care where supervision of UCPs is at a distance. Challenges and facilitators to UCPs’ work in this context are discussed with recommendations to support UCPs in their roles.

Intentions of Kentucky School Nurses to Delegate Diabetes-Related Tasks to Unlicensed Assistive Personnel

Many children have diagnosed diabetes that must be safely managed at school. New laws have created the potential for school systems to rely more heavily on unlicensed assistive personnel (UAP) than on nurses to deliver health services, including administration of insulin injections. Using the theory of planned behavior as a framework, aims were to (1) determine the nature and extent to which health services related to diabetes were being delegated to UAP in Kentucky schools, (2) describe the attitudes of Kentucky school nurses regarding the delegation of diabetes health services to UAP, and (3) examine the relationship of selected variables to school nurses’ intentions to delegate diabetes health services. Survey results revealed that school nurses in Kentucky intended to delegate some diabetes-related tasks despite their lack of support for delegation of those tasks.

Barriers of Nurse Collaboration for the Care of Acute Coronary Syndrome Patients in Emergency Departments: A Pilot Study

Introduction:

Acute Coronary Syndrome (ACS) is a cardiovascular disease that is one of the main causes of death worldwide. Nurse collaboration in Indonesia is still very complex and inadequate. Positive collaboration in providing care for patients with ACS is essential in the practice of nursing services.

Objective:

This study aims to explore the barriers in the implementation of nurses-physicians collaboration for the care of patient with ACS in Emergency Departments (EDs).

Method:

This research is a qualitative survey using purposive sampling. It was conducted on 16 nurses who worked in emergency departments from four general hospitals in East Java, Indonesia. Research data were collected using open-ended questions in semi-structured interviews.

Results:

There were three themes obtained from the data analysis, which include the difference of confidence between senior and junior nurses in ACS actions, limitations in performing professional nursing, and unclear job responsibilities.

Conclusions:

Collaboration of nurses and physicians in emergency departments still faces many problems. It is important to carry out interprofessional education initiations for nursing and medical students, apply peer-mentoring to increase the self-confidence of junior nurse, develop and train the clinical pathway of collaboration between physicians and nurses for the care of ACS patients in EDs.

Staffing and Service Availability in Assisted Living: The Importance of Nurse Delegation Policies

OBJECTIVES

To examine the health services provided in residential care and assisted living (RC/AL), the staff providing these services, and the degree to which the services relate to state-level nurse delegation policies and other correlates of service provision.

DESIGN

This cross-sectional study descriptively examined the relationships among RC/AL characteristics, services, staffing, and nurse delegation regulations/policies.

SETTING

RC/AL settings (N=245) in 8 U.S. states (CA, FL, IL, KS, NC, NH, NJ, OR).

PARTICIPANTS

Administrators and healthcare supervisors (individuals overseeing health care and services provided to residents).

MEASUREMENTS

Using a telephone survey, we examined how delegation policies related to staffing and the availability of 26 health services.

RESULTS

Significantly more services were available in RC/AL settings that permit delegation (delegation states) than states that do not permit delegation (nondelegation states) (19.7 vs 18.1, p < .001). Delegation states also had more medication technicians administering, assisting with, or observing self-administration of prescribed and as-needed medications (p < .001), whereas nondelegation states had staff with fewer qualifications handling medications (p < .001). In 2-way comparisons of categories of nurse staffing (none, licensed practical nurses (LPNs) and licensed vocational nurses (LVNs) only, registered nurses (RNs) only, LPN/LVNs and RNs), RC/AL communities with no nurse staffing offered significantly fewer services than all other categories. Those with RNs only also offered a significantly fewer services than those with LPN/LVNs only.

CONCLUSION

This study is a first step in identifying how staffing and availability of services in RC/AL are related to statewide nurse delegation practices, forming the basis for further exploration of how these characteristics may relate to quality of care. J Am Geriatr Soc 66:2158-2166, 2018.

The Role of School Nurses, Challenges, and Reactions to Delegation Legislation: A Qualitative Approach

Passage of new laws, national standards regarding delegation, and the recommendation for at least one full-time nurse in every school have provided more visibility to the role of school nurses. Recent legislative amendments in Kentucky presented an opportunity to examine how the role of the school nurse is changing. Aims were to describe the (1) role of school nurses in Kentucky, (2) impact of school nurses, (3) challenges faced by school nurses, and (4) impact of budget cuts and legislation. Three focus groups were conducted. School nurses faced challenges of limited time and resources, communication barriers, and multiple documentation requirements. Nurses’ greatest impacts were their availability, recognition of psychosocial problems and health concerns, and connection with resources. Nurses had not yet encountered many changes due to new legislation that expanded delegation of diabetes-related tasks to unlicensed school personnel, but some had concerns about possible negative effects while others expressed support.