Patient Safety: Four Easy Pieces

Could this happen in your work setting?

An inmate was evaluated for a heart condition and found to have several blocked coronary arteries. He was scheduled for cardiac stents at the local hospital where the prison had an agreement for services. He had the stents placed and returned to his cell block the following day. He returned with one discharge order sheet that included a note at the bottom to “see page 2”. No second page was included with the discharge order sheet. A nurse practitioner reviewed his one page of discharge orders, confirmed them, and wrote on the medical order sheet that there were no changes to be made. This was interpreted to mean no changes to the patient’s pre-procedure medications and he was returned to his prior medication regimen. Meanwhile the 2nd page of the discharge orders was faxed directly to the prison medical director. The medical director reviewed them during office hours the next day and placed the orders in his outbox for transcription and return to the chart. That order sheet never got to the chart. The patient told the medication technician who administered medications on his housing unit that he was supposed to be getting Plavix after his procedure. The med tech told the patient that there was no order for Plavix and he was mistaken. The patient continued to ask about the Plavix at subsequent medication lines with similar response. One staff member told him the medication was nonformulary and there might be a 3-5 day delay in obtaining it. Six days after the procedure the patient had crushing chest pain and returned to the hospital where it was found that two of his stents had occluded and required emergency treatment. Fortunately the patient survived the experience.

In a previous post I explained how, even though I am nervous about crashing when flying, there are more deaths each year from clinical errors than from airplane crashes. We would do well to focus in correctional health care on patient safety as there is such a significant return on our time investment. But, where do we start?

Patient safety experts developed a 3-part model for explaining components of a safety paradigm in the traditional health care setting. I adapted this model to the correctional setting and added a 4th element – the care environment to the original representation. As many of us practicing in the criminal justice system know, the environment in which we work has a significant effect on care delivery and outcomes.

Consider how each of these four patient safety elements might have affected the outcome of the case presented above.

Environment of Care

The environment is primarily the organizational culture of the workplace but can also include the physical environment such as the design of the care delivery setting and the available equipment and supplies. The secure environment of the criminal justice system adds intensity to the environment of care by also imparting a unique set of values and cultural norms. There can be a true culture clash or a struggle with dual loyalties among the care staff. We often talk about the impact of the security culture on health care delivery. The inmate culture also has an effect on patient safety. There develops a culture of mutual mistrust that can poison the patient-practitioner relationship. How might the organizational culture in the case presentation have affected the actions of the care team?

Systems for Therapeutic Action

Patient care is delivered through a complex system of intertwined processes. Patients and practitioners interact with these systems within the environment of care. Patient safety principles can increase the reliability of care systems; reducing error and improving outcomes. Do you think there were some real system failures in the case above?

Patient

The patient is also a vital part of the safety framework. Interacting with health care workers and the systems of therapeutic action within the environment of care, patients have opportunity to actively participate in and monitor care delivery. There are many barriers to engaging patients in the criminal justice system that must be considered and overcome. Was the patient a factor this critical incident?

Practitioner

The competence and judgment of health care staff is a major factor in patient safety. Staff interact with the patient and take therapeutic actions to deliver health care. Internal and external factors such as fatigue, work stress, impairment and shift rotation affect our abilities to deliver safe care. Emotional issues like burn out, vicarious trauma and compassion fatigue affect our clinical judgment. Could any of these be attributed to the actions taken in this case?

By using this model of patient safety in correctional health care, a full evaluation of the missing Plavix case can be undertaken and system improvements initiated.

Share your thoughts on what you would investigate further in the comments section of this post.

Of Airplanes and Patient Safety

Let me tell you a little secret. I’m not very fond of air travel. In fact, when I am preparing for a flight like the one that I took recently to speak in Sacramento, I had to distract myself from picturing all kinds of plane disasters. But, really, what were the chances that my plane would be hit by lightning or have engine malfunction and crash over the Rocky Mountains? Pretty slim, right? In fact, the most fatalities from air travel were clocked in the year 1972 when 2,429 people died in air crashes around the world. Most years are well below 1000; and this is worldwide. Much can be said for the safety mechanisms hardwired into high-risk airline industry.

How do you think that compares to deaths from medical errors? A 2013 study in published in the Journal of Patient Safety found there are as many as 440,000 deaths from hospital errors each year; and that is just in the United States! This is equivalent to 1000 jumbo jet crashes a year or wiping out the entire city of Colorado Spring…every year.

This calculation of deaths from clinical errors is based on traditional hospital care information. Unfortunately, we have no nation-wide data collection process for correctional health care. What do you think, though? Is our patient care likely to be safer than that provided in hospitals? Possibly. However, there are indications that our delivery systems may be even more risky given the nature of our patient population and environment.

Keeping our patients safe from clinical error, then, is an important part of our professional practice. Patient safety emerged as a concern in the early 1990’s. The Harvard Medical Practice Study published in 1991 is credited with starting the movement when it identified higher than expected rates of preventable medical errors. Over the last two decades, the patient safety movement has developed into a primary focus in traditional settings but is only now gaining interest in correctional health care. Yet organizing health care processes around patient safety can be particularly helpful in a setting such as correctional health care where the fragmented nature of care delivery, the transient nature of the patient population, and the added application of security structures can overwhelm and overshadow patient care.

As health care clinicians, focusing on the best for our patients through a patient safety perspective is a satisfying way to view our role, our values, and our professional goals. In addition, a patient safety perspective allows us as clinicians to fully address the ethical basis of our profession – beneficence (doing good) and nonmalfeasance (not harming).

I made it to Sacramento unharmed; in large part due to the many safety mechanisms in place to be sure the flight was safe. Regrettably, I review many an incident in correctional health care that indicate missing or omitted safety procedures.  How can we make correctional health care practice more like the airline industry? Any thoughts?

On Being Thankful

Be thankful for what you have; you’ll end up having more. If you concentrate on what you don’t have, you will never, ever have enough.” – Oprah Winfrey

Heart shape hands on the blue sky

As a reforming whiner, I often need reminding to be thankful. Yes, given the choice between appreciating a situation and complaining about it, I will regularly choose the later. That’s why I so appreciate having a holiday every year that focuses on gratitude and thankfulness. What better way to re-center our thoughts on the good in our lives and the contributions of others?

With that in mind, I’d like to offer my Thanksgiving gratitude list (not in any particular order):

  • Correctional Nurses: Frankly, I didn’t know correctional nurses existed 10 years ago. When I discovered this invisible nursing specialty, I know I found a home. It has been a blast getting to know so many nurses who work in difficult environments with often-difficult patients. Our patient population is marginalized and vulnerable, frequently forgotten by society and the traditional healthcare system. I am grateful for your work on behalf of our patients and delighted to have meet so many of you in my travels and through this blog.
  • Blog Readers: Speaking of blogs, Catherine and I are energized by the number of visits and comments on our posts over the years. You are our inspiration and the focus of our efforts.
  • Professional Associations: I am truly thankful for professional associations like National Commission on Correctional Health Care and the American Correctional Health Services Association. These organizations do great work in advancing correctional nursing practice and providing a wonderful venue for networking and communication. I enjoyed meeting many of you at NCCHC and ACHSA conferences this fall.
  • Correctional Officer Colleagues: This Thanksgiving season I have been pondering the great contribution of correctional officers to both public safety and the personal safety of correctional nurses throughout the criminal justice system. Our CO colleagues live with similar social stigma and feelings of invisibility. We are all in this together and need to support each other.
  • Family and Friends: Without the support of my husband, family, and friends I could not do what I do. Those I know who have much family stress and drama have no energy left to create new things. I often forget that I am free to write and speak and learn new things because I have a great support system.
  • A God Who Cares: Having a caring God who made me unique and expects me to use the gifts He gave me is also a cause to be thankful. Even when everything is ‘going wrong’ there is a comfort in knowing there is a plan in play and I don’t necessarily need to know what it is. I do need to do my part, though, by making a difference where I am with what I have been given.

Cultivating Gratitude in the Year Ahead                      

I am inspired to renew my efforts to reduce whining and increase appreciation this coming year. Are you with me on this? Here are two ways I’m going to increase my gratitude and decrease my whining:

  • Count My Blessings: Spend regular time meditating on the simple blessings of life such as a roof over my head and food on the table.
  • Say Thanks: Consciously sharing gratitude for friendship, support, assistance, and information provided by others in day-to-day living.

Will you join me in my efforts to ‘keep on the sunny side’ in the days ahead? Rather than concentrating on what is missing, as Oprah states, we can focus on what we have and end up having more!

Leave your suggestions and encouragement in the comments section of this post.

An earlier version of this post first appeared on CorrectionalNurse.Net

Best of the Blog #1: The Five Rights of Delegation

We searched through the stacks of almost 200 blog posts to pull out the most popular ones for this series. If you are new to the Essentials of Correctional Nursing Blog you may have missed some good reads. Enjoy!

This post, written by Catherine Knox, originally aired January 13, 2013.

The post last week included a case example about a licensed practical nurse (LPN) responding to a medical emergency after an altercation between two inmates. The LPN determined that neither inmate required further medical attention. Later in the shift one of the inmates was taken to the emergency room after being found unresponsive in the cell. The inmate subsequently died of the head injury that was sustained in the altercation. This example highlighted the registered nurse’s role in the assignment and supervision of patient care. Correctional nurses use their knowledge of state regulations defining the scope of practice for personnel assisting in the delivery of patient care as well as the employers’ expectations (job description, post orders, policy and procedure) to assign and supervise these personnel.

The American Nurses Association (ANA) describes correctional nurses as responsible for direction of patient care including the assignment and delegation of tasks to others (2007). These responsibilities are unchanged in the draft of the 2013 edition of the Correctional Nursing: Scope and Standards of Practice which was posted at http://www.nursingworld.org/Comment-Correctional-Nursing.html.aspx. Delegation has been described as an essential skill and yet is one of the most difficult responsibilities of a registered nurse. It is a complex process that requires sophisticated clinical judgment about the patient care situation, the competence of staff and the degree of supervision required (Weydt, 2010; NCSBN, 2005).

There are many resources available to help nurses build skill and competency in delegation of patient care tasks. The state board of nursing is an excellent first resource as well as the National Council of State Boards of Nursing (NCSBN) website which can be accessed at https://www.ncsbn.org. A resource suggested in the Essentials of Correctional Nursing is a framework for delegation from the NCSBN referred to as the Five Rights of Delegation (1997). These are discussed in relation to the case example from last week’s post.

1. Right Task: The nurse makes an assessment of the patient or a group of patients and determines that an activity can be delegated to a specific member of the health care team. Knowledge of state practice acts and agency directives are essential when making decisions about what patient care tasks can be delegated. In the case example the registered nurse’s decision to have the LPN respond to the medical emergency was problematic because the LPN was required to assess and make a complex clinical decision about the inmate’s need for medical care.

2. Right Circumstances: The nurse’s assessment of the patient or group of patients also identifies the health care need(s) to be addressed by the delegated task(s) and the goal or outcome to be achieved. The nurse’s decision about which task(s) to delegate matches the staff’s competency and level of supervision available. The registered nurse in the case example did not assess the patient’s needs or identify the outcome to be achieved by the task that was delegated to the LPN. The nurse also made no judgment about what level of supervision or monitoring would be appropriate in the circumstance.

3. Right Person: The registered nurse considers the skills and abilities of individual personnel in making decisions about delegation of tasks. The registered nurse works with each member of the team to improve performance and implements remedies when performance is below standard. In the case example the LPN had considerable experience responding to medical emergencies at the correctional facility and had worked in the emergency department at the local hospital. The registered nurse did not understand that monitoring or supervision of the LPN’s performance was required as part of the state practice act and expected by the employer.

4. Right Communication: The registered nurse communicates specifically what, how and by when delegated tasks are to be accomplished. Communication includes the purpose and goal of the task, limitations and expectations for reporting. In the case example there was no meaningful communication that took place between the RN and LPN. The LPN was not expected to communicate assessment data to the nurse and no limitations on the LPN’s actions were stipulated. The LPN reported the conclusion that both inmates were “okay” but was asked no follow up questions by the RN to amplify the basis for the decision. The LPN did not communicate with the registered nurse when the inmate was later found unresponsive even after the “on call” physician was called.

5. Right Supervision: The registered nurse monitors and evaluates both the patient and the staff’s performance of delegated tasks.  The registered nurse is prepared to intervene on behalf of the patient as necessary and provides staff feedback to increase competency in task performance. In the case example the RN had several opportunities to monitor the patient’s care and to intervene but failed to do so. The nurse was unaware of the responsibility to monitor and supervise the LPN in the performance of the delegated task. The nurse said that the LPN always provided the response to medical emergencies and did not think the RN could alter this “assignment”.

Conclusion of the Case Example: The agency policies, procedures and the description of job duties were consistent with state practice guidelines but were too general. The nurses were not familiar with the nurse practice act and had simply continued practices on the evening shift that had been in place at the time, including staff defining the duties that they were most comfortable performing. The “after action” review resulted in increased staff knowledge of the nurse practice act, coaching of the nurses on delegation of tasks, and increased communication between staff on shift about the goals and process of patient care.

Your thoughts about this subject are important to us. Have you had experience clarifying nursing scope of practice in correctional health care?  What tools or resources did you find most helpful? Please share your experience and advice in the comments section of this post. For more information and discussion about correctional nursing order your copy of the Essentials of Correctional Nursing directly from the publisher. Use Promo Code AF1209 for $15 off and free shipping.

References:

American Nurses Association. (2007). Corrections Nursing: Scope and Standards of Practice. Silver Spring, MD: Author

National Council of State Boards of Nursing and the American Nurses Association. (2006). Joint Statement on Delegation. Retrieved December 31, 2013 at https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf

National Council of State Boards of Nursing. (1997) The Five Rights of Delegation. Retrieved December 26, 2012 from https://www.ncsbn.org/fiverights.pdf

Weydt, A. (May 31, 2010). Developing delegation skills. OJIN: The Online Journal of Issues in Nursing. Vol. 15, No. 2, Manuscript 1 

Photo Credit:   © igor– Fotolia.com

 

Best of the Blog #2: Correctional Nurse Certification Options

We searched through the stacks of almost 200 blog posts to pull out the most popular ones for this series. If you are new to the Essentials of Correctional Nursing Blog you may have missed some good reads. Enjoy!

This post, written by Lorry Schoenly, originally aired July 19, 2012.

Blank award ribbon rosetteHave you considered certifying in the correctional nursing specialty? Most established specialties have a certification process. Correctional nursing has several options for your consideration. Is certification for you?  According to the American Nurses Association, certification validates nursing skills, knowledge, and abilities. In addition, they contend that certification contributes to better patient outcomes. Certified nurses are role models of professional accountability. Certification empowers nurses and validates their understanding of the unique nature of their specialty. It can lead to increased self-esteem, job satisfaction and respect. Certified nurses distinguish themselves through a commitment to lifelong learning and career advancement, according to the American Association of Critical Care Nurses.

In Chapter 3: Legal Considerations in Correctional Nursing of the Essentials of Correctional Nursing, Jacqueline Moore, PhD, RN, CCHP-A, CCHP-RN suggests that another benefit of certification may be decreased liability. Since certification is fairly new in correctional nursing, the jury is still out on that aspect.

Certification is not only important for the individual nurse, it is also important to the correctional nursing profession. The development of specialty certification for correctional nursing is an important milestone. It helps to legitimize the specialty of correctional nursing and validates that professionals possess a unique body of knowledge and skills. It inspires other correctional nurses to seek certification and stimulates interest in correctional nursing research. Correctional nursing certification is another action toward enhancing and fostering professionalism in this specialty.

There are two main certifications available to correctional nurses.  The National Commission on Correctional Health Care (NCCHC) awards the CCHP-RN (Certified Correctional Health Professional – Registered Nurse) to registered nurses working in the correctional setting. The American Correctional Association offers two certifications:  CCN (Certified Corrections Nurse) is a generalist certification and CCN/M (Certified Corrections Nurse/Manager) is a manager certification. Certification requirements and exam content areas are listed below.

Eligibility Requirements

CCN-Licensed RN, LPN, LVN; One (1) year work experience in correctional nursing in present position

CCN/M – Registered Nurse (RN) in good standing with State Nursing Board;  Associate, Bachelor of Science, Master of Science in Nursing, or a three (3) year Nursing Diploma;  One (1) year of Correctional Nursing Management experience; individual supervises other medical personnel and administrative staff

CCHP-RN – Current CCHP certification;  Current, active RN license within a U.S. state or territory or the professional, legally recognized equivalent in another country, not restricted to corrections only;  Equivalent of 2 years full-time practice as a registered nurse (2,000 hours of practice in a correctional setting within the last 3 years);  54 hours of continuing education in nursing, with 18 specific to correctional health care, within the last 3 years

Certification Exam Content Areas

CCN & CCN/M

CCHP-RN

Health care in corrections Clinical management of patients
Legal issues in corrections Promotion of a safe & secure health care environment
Mental health Health promotion & maintenance
Nursing practice & standards Professional role & responsibilities
Managing security & environment
General & offender management
Conflict management
Human resource management

Have you taken one of the certification exams described above? How has it benefited you?

Photo Credit: © valdis torms – Fotolia.com

Best of the Blog #3 – New Scope and Standards of Practice for Correctional Nursing

We searched through the stacks of almost 200 blog posts to pull out the most popular ones for this series. If you are new to the Essentials of Correctional Nursing Blog you may have missed some good reads. Enjoy!

This post, written by Catherine Knox, originally aired June 14, 2013.

On May 27, 2013 the American Nurses Association (ANA) published the new edition of Correctional Nursing: Scope and Standards of Practice (2013).  These are broad parameters defining our specialty area of practice that transcend geographic location (south, east, west, midwest), type of employer (public/private, jail, prison, detention center), and the various populations served in correctional health care (sentenced, unsentenced, juvenile, female etc.).  The standards define who, what, where, when, why and how of nursing practice (ANA, 2010, p.2). The ANA standards are used to:

  • inform nurses and others about correctional nursing practice
  • guide nurse’s day- to- day practice and resolve conflicts
  • develop policy and procedure and other governance of  professional practice
  • reflect on professional practice and plan improvement

Correctional nursing was first acknowledged as a specialty practice by the ANA in 1985. At that time, the first standards for the specialty were published as: Standards of Nursing Practice in Correctional Facilities. Since 1985 the standards for correctional nursing have been revised four times.  This revision was the result of collaboration among seventeen correctional nursing leaders representing various settings and organizations. Input from correctional nurses was sought at various conferences, by survey, and during a public comment period over a period of eighteen months. The input from practicing nurses was incorporated into the description of the scope of correctional nursing practice.

Patricia Voermans MS, RN, APN, CCHP-RN, chairperson of the task force described this edition as “expanding the description of the patient population and addressing the challenges of delivering evidenced based care in the correctional setting.  It also discusses the evolving role of nurses in coordinating care, developing policy and continuing leadership in correctional health care” (April 22, 2013).

Correctional nursing is defined as… “the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, advocacy, and delivery of health care to individuals, families, communities, and populations under the jurisdiction of the criminal justice system” (ANA, 2013).  It is the location of nursing care, with its unique population demographics, environmental constraints and ethical dilemmas that defines our specialty practice (Voermans, Schoenly & Knox, April 22, 2013).

There are sixteen standards of correctional nursing practice in the new edition. The first six standards delineate the steps used in the nursing process. The next ten standards define the professional role of nurses in the correctional setting. This edition emphasizes the importance of communication and collaboration in the delivery of safe and effective patient care. The areas covered by the standards are listed in the table below.

Table 1: Scope & Standards of Practice for Correctional Nurses
     Practice      Professional   Performance
1. Assessment 7. Ethics
2. Diagnosis 8. Education
3. Outcomes Identification 9. Evidence-Based Practice and Research
4. Planning 10. Quality of Practice
5. Implementation 11. Communication
6. Evaluation 12. Leadership
13. Collaboration
14. Professional Practice Evaluation
15. Resource Utilization
16. Environmental Health

Correctional nursing: Scope and standards of practice. (2013). 2nd Edition. Silver Spring, MD: American Nurses Association.

Each standard is further defined by the competencies registered nurses and graduate-level prepared or advanced practice registered nurses (APRN) are expected to demonstrate in meeting the standard. Competency is defined as the integration of knowledge, skills, abilities and judgment needed to achieve an expected level of performance (White & O’Sullivan 2012). The registered nurse is responsible for maintaining professional competence and accountable for each of the decisions made in their nursing practice.

Standard 16 on Environmental Health is a new standard and requires the correctional registered nurse to practice in an environmentally safe and healthy manner. Environmental health is the assessment and control of factors in the environment that can potentially affect health.  Two of the competencies of the correctional registered nurse in this area of practice are:

  • Knowledge of environmental health concepts, with implementation of environmental health strategies.
  • Reducing environmental health risks for workers, patients, and others in the correctional setting.

To experience how the ANA standards are applied in day to day practice they have been interwoven into every chapter of the Essentials of Correctional Nursing which can be ordered directly from the publisher. If you use Promo Code AF1209 the price is discounted by $15 off and shipping is free.

Copies of Correctional Nursing: Scope and Standards of Practice, 2nd Edition (2013) can be ordered from the ANA at http://nursesbooks.org/Homepage/Hot-off-the-Press/Correctional-Nursing-2nd.aspx. When you receive your copy of the new edition of the ANA standards one suggestion is to assess your competency to practice in conformance with each of the standards.  Select one or more areas that you would like to improve and develop a plan to do so.

We will share more about how to use the standards in correctional nursing practice in future posts.  In the meantime what experiences have you had applying the ANA Correctional Nursing: Scope and standards in your daily practice?  What tools or resources did you find most helpful? Please share your experience and advice in the comments section of this post.

References:

American Nurses Association. (1985). Standards of nursing practice in correctional facilities. Washington, DC: American Nurses Association.

American Nurses Association. (2013). Correctional nursing scope and standards of practice. Silver Spring, MD: American Nurses Association.

Schoenly, L. (2013). Overview of Correctional Nursing. In Schoenly, L. & Knox, C. Essentials of Correctional Nursing. New York: Springer.

Voermans, P., Knox, C., Schoenly, L. (April 22, 2013). Correctional Nursing: Applying the New Scope and Standards of Practice. NCCHC Spring Conference 2013, Denver, Co. Accessed May 8, 2013 at http://ncchc.sclivelearningcenter.com/index.aspx?PID=4622&SID=172421

White, K., O’Sullivan, A. (2012). The Essential Guide to Nursing Practice: Applying ANAs Scope and Standards in Practice and Education. American Nurses Association. Silver Springs, MD.

Photo Credit:  American Nurses Association NSPS’10_Fig 4  Nursing Process  Stds

Best of the Blog #4 – Barriers to Effective Delegation

Human Intelligence and CreativityWe searched through the stacks of almost 200 blog posts to pull out the most popular ones for this series. If you are new to the Essentials of Correctional Nursing Blog you may have missed some good reads. Enjoy!

This post, written by Catherine Knox, originally aired February 11, 2014.

If delegation is a fundamental aspect of nursing practice why do nurses find it difficult? Part of the reason is that as the resources to provide care shrink and the environment for care becomes more complex the importance of delegation has become more apparent. Nursing care today is delivered in correctional settings by a wide variety of personnel (registered nurses, practical or vocational nurses, unlicensed assistive personnel, etc.) each with different educational preparation and scope of allowable practice. Correctional nurses also work in a very restrictive and challenging environment with a very diverse patient population which has complicated health care needs. The National Council of State Boards of Nursing (NCSBN) identifies delegation as a “complex process of professional practice requiring sophisticated clinical judgment” (2005) and yet many nurses received little formal training in delegation during their education and employers rarely evaluate and develop nurses’ delegation skills as they do other clinical competencies (Weydt, 2010). Well no wonder nurses find delegation challenging!

The American Nurses Association (ANA) recently asked nurses what barriers to delegation they were experiencing as part of the process of updating the Principles for Delegation (2012). Three major barriers were identified and each is discussed below:

Poor partnerships: It is difficult to delegate when the nurse does not know the staff or their capabilities. It is also not practical to assess each of the staffs’ skills in all areas before making a delegation decision. Participating in the orientation of new staff is one way to get to know what skills are evaluated and to become familiar with the capabilities of individual staff.  Nurses should also periodically review staff competency records. Working together is an opportunity to build partnerships with each of the staff.  Good quality partnerships are correlated with improved patient safety (McCoy & Duffy, 2013).

Attitudes: Nurses express concern that delegation results in loss of control over patient outcomes. Another way of saying this is …“If I am held accountable for the patient, why should I delegate?”  This was discussed in last week’s post on the principles of delegation. The staff person accepting delegation is responsible for performing the assignment and accountable for accomplishing it safely and correctly. Therefore the nurse’s accountability is for the patient, not the staff’s performance. This is because the nurse retains authority to direct the patient’s ongoing care. Knowing how to identify and evaluate patient outcomes are critical aspects of accountability and delegation of patient care. These competencies are described in Standard 3 of the ANA’s publication Correctional Nursing:  Scope and Standards of Professional Practice and can be used by nurses as a resource in developing delegation skill (2013).

Sometimes the nurse goes on to say “…especially someone I either don’t know or don’t trust?” Trust comes from concentrating on building good interpersonal relationships while working together.  Delegation is an invitation to participate in the delivery of care and when delivered in a respectful and conscientious manner it promotes communication. When meaningful two-way communication is increased the quality of patient care improves (Corazini et al. 2013).

RN Leadership: The third barrier identified was lack of sufficient registered nurses to support effective delegation. Contributing factors were nurses’ lack of experience with delegation, insufficient ratio of registered nurses in the staff mix, and administrative work that supersedes clinical care.    Many correctional facilities do not have a strong structure to support professional nursing practice with policies, procedures, job descriptions and other directives or guidelines that are consistent with state laws and regulations. Uninformed or ill-advised managers may not fully support a healthy workplace that includes developing the delegation potential of registered nurses. Traditionally, little focus has been placed on developing the leadership responsibilities of nurses to ensure delivery of patient care by delegating and supervising care provided by other members of the nursing staff (Weydt 2010).

The ANA articulates the expectation that correctional registered nurses are competent to delegate care in Standard 15: Resource Utilization (2013).  Nurses can develop delegation skills by, first, becoming familiar with the laws and regulations concerning scope of practice, reviewing job descriptions and other workplace guidance that defines the roles and responsibilities of staff. The next step is to understand how the principles of delegation can be applied to patient care in the correctional setting. The use of a decision tool such the one included in the Joint Statement on Delegation (2006) helps guide nurses through the critical thinking that results in a delegation decision. As experience using structured critical thinking  increases delegation decisions are accomplished with speed and confidence. Using simulation or case review and reflection are also effective ways to build delegation skill (Weydt, 2010). Nurses can do this on their own or with a proctor or mentor at the worksite.

Your thoughts about this subject are important to us. Do these three barriers resonate with your experience as a correctional nurse?  Does your communication contribute to good interpersonal relationships? Are registered nurses sufficiently involved in clinical care to effectively delegate? Please share your experience and advice in the comments section of this post. For more information and discussion about correctional nursing order your copy of the Essentials of Correctional Nursing directly from the publisher. Use Promo Code AF1209 for $15 off and free shipping.

References

American Nurses Association (2012) Principles for Delegation by Registered Nurses to Unlicensed Assistive Personnel (UAP). Silver Spring, Maryland. Accessed on 1/29/2013 at http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/NursingStandards/ANAPrinciples/PrinciplesofDelegation.pdf.aspx 

American Nurses Association (2005) Principles for Delegation. Silver Spring, Maryland. Accessed on 1/29/2013 at http://www.indiananurses.org/education/principles_for_delegation.pdf

Corazzini, K.N.; Anderson, R.A.; Mueller, C.; Hunt-McKinney, S.; Day, L.; Porter, K. (2013). Understanding RN and LPN Patterns of Practice in Nursing Homes. Journal of Nursing Regulation. 4(1); 14-18.

Correctional Nursing: Scope and Standards of Professional Practice (2013). American Nurses Association. Silver Spring, Maryland: Nursingbooks.org

McCoy, S.F. & Duffy, M. (2013, March 20). Navigating the Complex World of Delegation [Audio podcast]. Retrieved from http://www.nursingworld.org/MainMenuCategories/CertificationandAccreditation/Continuing-Professional-Development/NavigateNursing/Webinars/Nav-deleg.html

National Council of State Boards of Nursing and the American Nurses Association. (2006). Joint Statement on Delegation. Retrieved December 31, 2013 at https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf

Weydt, A. (2010). Developing delegation skills. Online Journal of Issues in Nursing 2 (1)

Photo Credit:   © freshidea – Fotolia.com