Correctional Nursing: How to Improve the Practice Environment

Nursing background concept

The first examination of the qualities of professional practice in correctional nursing was done recently in Ontario, Canada. Conclusions from the surveys and interviews of 297 nurses and nurse managers were that the work environment was characterized as understaffed with significant role overload. These nurses also reported limited access to resources, significant autonomy but limited control over practice and experienced significantly higher levels of emotional abuse, conflict and bullying than nurses in other studies. The source of emotional abuse, conflict and bullying most often originated from custody staff followed by other nursing staff (Almost et.al. 2013a). These results support earlier publications about the practice challenges in correctional nursing including limited access to resources and education (Flanagan and Flanagan 2001, Maroney 2005, Smith 2005) , pressure to conform to the values of the custodial subculture (Holmes 2005), and challenges to clinical decision making authority (Smith 2005, Weiskopf 2005).

Reasons to improve the quality of the work environment include the ability to attract and retain nurses, increased productivity, improved organizational performance and better patient outcomes (Almost et.al 2013a, Sherman & Pross 2010, Dall et.al 2009, Needleman et.al 2006). Focusing on improving the professional work environment yields significant results even in the absence of increased staffing (Flynn et.al 2012, Aiken et.al. 2011, Friese et.al. 2008).

The following paragraphs discuss five factors in work environments that can be modified or enhanced to support professional nursing practice.

  1. Control over practice
    • Accurate interpretation and clarification of the state nurse practice act and its guidance in job descriptions, work assignments and policies and procedures (Knox, West, Pinney & Blair 2014, White & O’Sullivan 2012). Workplace directives should also incorporate or reference relevant aspects of the ANA standards of professional practice for correctional nurses (Knox & Schoenly 2014).
    • Work flow should be examined so that barriers to effective practice can be eliminated including system gaps that increase work complexity and work that is not related to patient care (Knox, West, Pinney & Blair 2014, Ebright 2010, Schoenly 2013). An example of the former is locating supplies used for nursing treatments in multiple locations. An example of the later is when nurses are expected to gather and report data on service volume or for quality assurance audits (number of sick call visits, number of clinic appointments, and number of incomplete MARs etc.).
    • Increase nursing participation on committees such as pharmacy and therapeutics, morbidity and mortality review, mental health, utilization review, and medical administration (Aiken et. al. 2011, Flynn et. al. 2012, Almost et.al. 2013a). Staff meetings also should be reviewed to see if meaningful two way dialogue can be increased to involve nurses in identification and early resolution of practice problems.
    • Consider assignment models that emphasize use of nursing process and clinical judgment rather than task completion; where registered nurses provide a greater proportion of direct care themselves while actively supervising care delegated to others (Corrazini et.al 2013a; MacMurdo, Thorpe & Morgan 2013). Staffing takes thoughtful preparation and legacy staffing practices may no longer work as complexity in health care delivery increases (Knox, West, Pinney & Blair 2013, Ebright 2010, MacMurdo, Thorpe & Morgan 2013).
  2. Autonomy in clinical practice
    • Considered one of the hallmarks of correctional nursing it is also an Achilles heel in the absence of appropriate clinical guidelines and support in their use (ANA 2013, Smith 2013, Smith 2005). Protocols should be based upon nursing process and coordination of care rather than reaching a medical diagnoses and rushing to treatment conclusions.
    • Nurses must be appropriately qualified and experienced in assessment and clinical reasoning as well as skilled in surveillance related to the variety of clinical situations encountered in the correctional setting to use protocols.
    • Provide access to information and tools that enhances recognition of clinical patterns and deviations necessary for good clinical judgment (Ebright 2010).
    • Assist nurses to prioritize and coordinate care with daily briefings, debriefings, huddles and work flow tracking to provide real time information about the availability and assignments of other members of the health care team (including primary care and mental health staff).
  3. Positive workplace relationships
    • Establish clear expectations for a respectful workplace in policy, procedure and other written directive. These instructions should define behaviors consistent and inconsistent with professional behavior in the workplace; describe what to do in the presence of unprofessional behavior and how to report these incidents (Almost et.al. 2013a).
    • Joint meetings and interdisciplinary training can be the vehicle to demonstrate support for the goals of both health care and custody (Almost et.al. 2013a, Weiskopf 2005).
    • Nurses may benefit from additional development in the area of conflict resolution because they have such a prominent role negotiating coordination of patient care with custody operations (Schoenly 2013, Weiskopf 2005).
    • Increase communication about patient care between registered nurses and LPN/LVNs (Corrazini et. al. 2013).
  4. Support education and certification
    • Orientation also needs to be tailored to the needs of each individual based upon education, licensure and an assessment of competency (Knox, West, Pinney & Blair 2014; Shelton, Weiskopf & Nicholson 2010). The ANA scope and standards of professional practice should also be incorporated into new employee orientation so that nurses develop institution specific skills consistent with the expectation of the professional discipline (Knox & Schoenly 2014).
    • Mentoring and coaching of new employees should be emphasized in development of expertise in clinical reasoning (Schoenly 2013, Ebright 2010).
    • Use creative, simple approaches to continuing education including self-study, reflective exercises, on-line web based seminars, facilitated case review and discussion, and a journal club (Almost et.al. 2013b, Schoenly 2013). Staff with superior knowledge and skill in a subject area can be asked to assist in developing relevant continuing education material (Knox, West, Pinney & Blair 2014).
    • Certification in correctional nursing is available through both the American Corrections Association and the National Commission on Correctional Health Care. These exams are offered regionally and can be administered at the place of employment if there are enough people taking the exam.
  5. Adequate resources
    • Includes staffing, equipment and supplies as well as access to leadership. Examining the work of first line managers may reveal sources of role overload (scheduling, meetings, payroll data gathering etc.) that impede their availability to line staff and can be reassigned to increase the availability of clinical leadership to line staff(Almost et.al. 2013a).
    • Review legacy staffing practices and work flow to identify opportunities to adjust assignments that result in more appropriate or effective use of existing resources (Knox, West, Pinney & Blair 2013, Ebright 2010).
    • Involve nurses in evaluation of equipment and technology decisions to prevent acquisition of products that complicate rather than improve delivery of patient care (Ebright 2010). For example decisions about how patient specific prescriptions were packaged have impacted timeliness and accuracy of medication administration in some correctional facilities because the packaging was cumbersome and time consuming for nurses to use.

Conclusion: Attention to the work environment of nurses (control over nursing practice, autonomy without isolation, positive working relationships, support for education and specialty certification, and adequate resources) has a profound effect on nursing practice, the ability to recruit and retain nursing personnel and on patient outcomes. More resources about work environments that support professional nursing practice can be found at the sites listed in the resources section below.

What do you think can be done to improve the professional practice work environment for correctional nurses? Are there resources or solutions not discussed here that should be? Please share your opinions by responding in the comments section of this post.

For more on correctional nursing read our book, the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Resources

 

References

Aiken, L.H., Cimiotti, J.P., Sloane, D.M., Smith, H.L., Flynn, L., Neff, D.F. (2011) Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care 49(12): 1047-1053.

Almost, J., Doran, D., Ogilvie, L., Miller, C., Kennedy, S., Timmings, C., Rose, D.N., Squires, M., Lee, C., Bookey-Bassett, S. (2013a) Exploring work-life issues in provincial corrections settings. Journal of Forensic Nursing 9:1

Almost, J., Gifford, W.A., Doran, D., Ogilvie, L., Miller, C., Rose, D.N., Squires, M. (2013 b) Correctional nursing: a study protocol to develop an educational intervention to optimize nursing practice in a unique context. Implementation Science 8:71

American Nurses Association. (2013) Correctional Nursing: Scope and Standards of Practice. Silver Spring, MD: Nursebooks.org

Corrazzini, 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.

Dall, T.M., Chen, Y.J., Seifert, R.F., Maddox, P.J., Hogan, P.F. (2009). The economic value of professional nursing. Medical Care 47 (1):97-104.

Ebright, P.R. (2010). The complex work of RNs: Implications for a healthy work environment. Online Journal of Issues in Nursing. 15(1).

Flanagan, N. & Flanagan, T. (2001) Correctional nurses’ perceptions of their role, training requirements and prisoner health care needs. The Journal of Correctional Health Care 8:67-85.

Flynn, L., Liang, Y., Dickson, G., Xie, M., Suh, D.C. (2012) Nurse’s practice environments, error interception practices, and inpatient medication errors. The Journal of Nursing Scholarship. 44(2):180-186.

Friese, C.R., Lake, E.T., Aiken, L.H., Silber, J.H., Sochalski, J. (2008) Hospital nurse practice environments and outcomes for surgical oncology patients. Health Services Research. 43(4): 1145-1162.

Holmes, D. (2005) Governing the captives: Forensic psychiatric nursing in corrections. Perspectives in Psychiatric Care 41(1):3-13.

Knox, C.M., Schoenly, L. (2014) Correctional nursing: A new scope and standards of practice. Correct Care, 28 (1) 12-14.

Knox, C.M., West, K., Pinney, B., Blair, P. (2014) Work environments that support professional nursing practice. Presentation at Spring Conference on Correctional Health Care, National Commission on Correctional Health Care. April 8, 2014. Nashville, TN.

MacMurdo, V., Thorpe, G., & Morgan, R. (2013) Partners in practice: Engaging front-line nursing staff as change agents. Presentation at Custody & Caring, 13th Biennial International Conference on the Nurse’s Role in the criminal Justice System. October 2-4, 2013. Saskatoon, SK.

Maroney, M.K. (2005) Caring and custody: Two faces of the same reality. Journal of Correctional Health Care. 11:157-169.

Needleman, J., Buerhaus, P.I., Stewart, M., Zelevinsky, K. Matke, S. (2006) Nurse staffing in hospitals: Is there a business case for quality? Health Affairs. 25(1):204-211.

Shelton, D., Weiskopf, C., Nicholson, M. (2010). Correctional Nursing Competency Development in the Connecticut Correctional Managed Health Care Program. Journal of Correctional Health Care. 16 (4). 38-47.

Sherman, R. & Pross, E. (2010) Growing future nurse leaders to build and sustain healthy work environments. Online Journal of Issues in Nursing. 15(1).

Schoenly, L. (2013) Management and Leadership. In Schoenly, L., & Knox, C. (Ed.) Essentials of Correctional Nursing. New York: Springer.

Smith, S. (2013) Nursing Sick Call. In Schoenly, L., & Knox, C. (Ed.) Essentials of Correctional Nursing. New York: Springer.

Smith, S. (2005) Stepping through the looking glass: Professional autonomy in correctional nursing. Corrections Today 67(1):54-56.

Weiskopf, C.S. (2005) Nurse’s experience of caring for inmate patients. Journal of Advanced Nursing 49(4):336-343.

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: Nursebooks.org.

Photo credit: © Kheng Guan Toh – Fotolia.com

 

Delegation and Collaborative Practice

????????????????????????????????????The development of more collaborative practice models is one solution to address the barriers to delegation of nursing care. These models have also been linked to better patient outcomes. Examining staffing patterns and assignment practices may identify changes that would improve nurses’ knowledge of staff capabilities, clarify staff roles and scope of practice, improve interpersonal relationships and support the registered nurse in leading the clinical care team.

Three weeks ago we asked how the charge nurse should delegate responsibility for nursing care in a case example from Chapter 17 of the Essentials of Correctional Nursing. Compare how you made those assignments to the three practice models described in the paragraphs below.  You might also consider how assignments in the case example might be made more consistent with the paired and partnered practice models which are more collaborative. This information is synthesized from several articles listed in the references below if you are interested in learning more about collaborative practice models.

Parallel practice: In this model staff use a list of tasks that are found in the job description or post order to organize and prioritize their work for the shift. This practice model requires almost no delegation and minimal direction or communication between staff because the duties are already spelled out. Registered nurses and practical or vocational nurses may be interchanged because the job descriptions overlap significantly. While task completion is emphasized it is not tied to patient outcomes. Accountability of staff for task completion may not be clear or it may be to someone not on shift, such as the nurse manager. Individuals work independently and may be unaware of other staffs’ roles or priorities creating potential for conflict and adverse patient outcomes. Because meaningful communication about patients does not take place in any regular or substantive way there is less opportunity to develop healthy working relationships between staff.

Paired practice: This model is characterized by assignments that pair a registered nurse with a practical/vocational nurse or unlicensed assistive personnel (UAP) for a shift. The job descriptions differentiate the role of the registered nurse from other staff as responsible for directing patient care and they are expected to identify checkpoints for communication about patients’ status during the shift. Staff are also expected to participate in formal care planning conferences. Delegation is increased in this model because the pair discusses how care is to be prioritized, how it is to be done and identifies expected patient outcomes for the shift. Both formal and informal communication are increased because there is ongoing deliberation about patients to adjust plans and priorities for care. The members of each pair have more opportunity to understand roles, display mutual respect and communicate meaningfully. Additional steps that have supported the paired practice model are to provide training and discussion to clarify roles and development of behavioral norms that support healthy relationships.

Partnered practice: This model consists of staff partners who have the same schedule, days off and their leave time is planned to coincide.  It also is referred to as an “apprenticeship model” because the partners make a commitment to maintain a healthy work relationship, trust and advance each other’s knowledge by working together consistently. This model reflects a philosophy that values continuity and relationship-based care. The registered nurse has clear authority to delegate and direct care. As trust and knowledge about staff capabilities is enhanced, delegation potential increases. As information flow becomes more frequent and substantive subordinate staff anticipate what patient care is needed and care delivery becomes more timely and coordinated.  As the relationship between partners develops they are able to manage more complex situations and produce better patient outcomes.

Further thoughts and a challenge: Hospitals, nursing homes and ambulatory care settings are looking for new staffing models that support more effective and efficient patient-centered care. Nursing practice models that effectively utilize the diversity of providers to deliver quality patient care are being developed. Reflecting on my experience the majority of staffing patterns in correctional settings seem to be more consistent with the parallel practice model than either paired or partnered practice. In light of the evidence about better patient outcomes emerging from other health care settings perhaps it is time to examine the patterns of nursing practice and assignment in our setting to see if staff can be utilized more effectively in delegation and delivery of patient care? Do you think the paired and partner practice patterns have a place in correctional nursing? Let us know your opinion by responding in the comments section of this post.

For more on correctional nursing order your copy of the Essentials of Correctional Nursing directly from the publisher. Use promotional code AF1402 for $15 off and free shipping. 

References

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.

Corazzini, K.N.; Anderson, R.A.; Rapp, C.G.; Mueller, C.; McConnell, E.S.; Lekan D (2010). Delegation in long term care: scope of practice or job description? Online Journal of Issues in Nursing. 15 (2); 4.

Potter, P. & Mueller, J. R. (2007). How well do you know your patients? Nursing Management. 38 (2): 40-48.

Ray, J.D. & Overman, A.S. (2014) Hard facts about soft skills. The American Journal of Nursing. 114 (2): 64-68.

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

Photo credit: © venimo – Fotolia.com

Communication is at the Heart of Delegation

tonometer and heartOne of our colleagues, Gayle Burrow, commented last week that “Of the 5 Rights of Delegation the one that is most often missed is communication. Everyone gets busy during the shift and updating each other on the patients’ changes is left for the end of shift.”   This is so true and the result often is an adverse event, compromised patient safety or decreased quality of care.

Detailed and timely communication between registered nurses and delegated personnel has been linked to improved patient outcomes and higher quality measures. Negative patient outcomes (i.e. medication errors, patient falls and failure to rescue) were linked to brief, non-specific or infrequent communication (Corazzini et al. 2013, Bittner & Gravlin 2009).  In a review by the Joint Commission communication issues were the most common cause of deaths related to delays in treatment and the third highest root cause of all sentinel events (O’Keeffe & Saver 2013). Communication is the most influential of the five rights of delegation in shaping quality and patient safety outcomes (Anthony & Vidal 2010).

Characteristics of Information Communicated by Nurses

The type of information we communicate to other nurses and assistive personnel is complex and multifaceted. Some of this information is objective and discrete, like the results of recent blood work. It lends itself easily to written communication that can be easily retrieved from a chart or report. Other information is tacit or contextual and requires description or discussion; it is not so easily documented in a way that is meaningful to others.  The value of a specific bit of information (a change in vital signs for example) decays over time. If information is not conveyed timely it may be too late to intervene proactively or it may be inaccurate because the patient’s condition has changed. When the meaning or importance of information can be interpreted in more than one way miscommunication can occur. For example, a nurse seeing patients during sick call says to an assistant, “Please get a blood sugar on this inmate.”  The assistant, who does not know the patient’s condition the may interpret this request to mean right now or instead may schedule the inmate to return diabetic line which takes place in the next couple hours. Also each time information is handed off from one care provider to another some portion is lost, missing or forgotten. This can result in inadequate surveillance and failure to recognize a patient’s deteriorating condition (Anthony & Preuss 2002, Anthony & Vidal, 2010).

Standards of Professional Performance

The National Council of State Boards of Nursing (NCSBN) define the right communication as that which clearly and concisely describes the delegated task, how the task is to be done, the timing and nature of observations to be made (2005). According to the American Nurses Association (ANA), delegation communication should be respectful, timely and include a rationale that gives the task meaning. Good communicators demonstrate these behaviors:

  • Assesses the effectiveness of their communication
  • Actively works to improve communication skills
  • Desires to improve interpersonal relationship
  • Actions are consistent with words
  • Clear about the role of self and others
  • Candid, without partiality and unbiased (O’Keeffe & Saver 2013).   These behaviors are included in the competencies for the standard on communication in the ANA’s Correctional Nursing: Scope and Standards of Professional Practice (2013).

Strategies, Tools and Techniques to Improve Communication 

Various tools have been developed to support and improve communication in health care delivery. Among these are standardized communication formats such as SBAR and use of checklists which Lorry has written about on correctionalnurse.net. Use of these tools in combination with mindfulness have been shown to improve communication regarding patient care (O’Keeffe & Saver 2013). Mindful communication is characterized by authenticity, awareness, self-reflection and candidness. It involves more than just communicating the facts; it includes the rationale or how the facts pertain to the patient.When nursing personnel experience effective communication, the likelihood of sharing appropriate and timely information in the future increases (Anthony & Vidal 2010).

Clear, concise and complete communication is at the heart of delegation. The outcomes of improved communication are increased staff satisfaction and better clinical outcomes for patients. Some concrete communication suggestions are:

  • Conscientiously appreciate that we need the help of others to deliver safe, high quality nursing care.
  • Use kind words such as “please”, “thank you” and “good job”.
  • Be approachable and make eye contact; be aware of your body language and facial expressions.
  • Teach and don’t blame; give constructive feedback.
  • Speak the truth but speak it gently.
  • Identify checkpoints for communication that can occur throughout the shift.
  • Listen without interruption.
  • Allow time for the other to respond, ask questions or clarify (Ray & Overman 2014).

Do you have an example of an effort to improve communication among health care providers that contributed to better patient care outcomes? Let us know about the techniques or strategies you have used to improve communication when delegating care by responding in the comments section of this post.

For more on nursing delegation read Chapter 17 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1402 for $15 off and free shipping.

References:

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

Anthony, M.K. & Vidal, K. (2010) Mindful communication: a novel approach to improving delegation and increasing patient safety. Online Journal of Issues in Nursing. 15 (2) 2.

Anthony, M.K. & Preuss, G. (2002) Models of care: the influence of nurse communication on patient safety. Nursing Economic$. 20 (5): 209-215, 248.

Bittner, N.P. & Gravlin, G. (2009) Critical thinking, delegation, and missed care in nursing practice. Journal of Nursing Administration 39 (3): 142146.

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.

National Council of State Boards of Nursing. (2005). Working with others: a position paper. Accessed 2/11/2014 at https://www.ncsbn.org/Working_with_Others.pdf

O’Keeffe, M. & Saver, C. (2013) Communication, Collaboration, and You. American Nurses Association. Silver Spring, Maryland: Nursingbooks.org.

Ray, J.D. & Overman, A.S. (2014). Hard facts about soft skills. The American Journal of Nursing. 114 (2): 64-68.

Photo credit: © Alexander Raths – Fotolia.com

Barriers to Effective Delegation

Human Intelligence and CreativityIf 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

Principles for the Delegation of Nursing Care

Doctors having conversationThe post viewed most often this past year was on the Five Rights of Delegation.  Given the interest, we decided to return to this topic by starting with a case example from Chapter 17 of the Essentials of Correctional Nursing.  “The charge nurse during an evening shift at a large state penitentiary is making delegation assignments for the shift. He is working with another RN, an LPN and 2 nursing assistants certified to pass medications. There is a 2 hour medication pass on this shift and an evening sick call. In addition they have 4 patients in the 6 bed infirmary and 2 inmates on suicide watch” (page 333).

Recognizing how health care organizations have come to rely on many different types of nursing personnel to deliver patient care, the American Nurses Association provides up to date guidance for nurses making delegation decisions.  The following principles, developed by the ANA, form the basis for delegation decisions in nursing practice. 

Delegation Principles

  • Delegation is a fundamental aspect of nursing practice and therefore reflects the nurse’s primary commitment to the health, safety and welfare of the patient. In other words assignments should be responsive to the needs of the patient population.
  • Nurses use critical thinking skills when making clinical judgments about how patient care resources (staff) are allocated to deliver patient care. In addition to the patient’s condition and needs for care, the nurse considers the potential for harm, the stability of the patient’s condition, task complexity, predictability of the outcome and abilities of personnel to whom the task may be delegated and the degree of supervision that will be needed.
  • Nurses only delegate aspects of care that are consistent with the qualifications and allowable scope of practice of personnel to whom the task is delegated.  Nurses must be familiar with the scope of practice allowed by state law as well as the employer’s policies and procedures in order to make delegation decisions.
  • The nurse retains accountability for patient outcomes when making delegation decisions.  This is so that the plan of care can be modified, adapted or continued based upon the nurse’s evaluation of the patient’s condition. Personnel assigned delegated duties are responsible for completion of tasks and are accountable for safe performance of assigned tasks according to established regulations and standards.
  • Interpersonal relationships are the foundation on which delegation takes place. Two way communication, respectful behavior and trust are essential to effective delegation.

The charge nurse in this case example assesses the needs of the patient population during the shift change or handoff report. One infirmary patient was discharged from the hospital earlier in the day following cardiac catheterization and stent placement. The other three infirmary patients are stable and require convalescent care. One of the patients on suicide watch was admitted only an hour ago and is on constant watch, the other has been on the unit for a day and is on intermittent watch. Correctional officers conduct the watch. There are six patients who have not yet returned from off-site specialty care visits. There were no unusual events or other instances of care noted by the off going charge nurse.

Simulation is one of the ways nurses learn and strengthen their delegation skill (Weydt, 2010).  Using the principles above how should the charge nurse in our case example delegate responsibility during the shift? Let us know your thoughts on nursing delegation of duties by responding in the comments section of this post.

For more on nursing delegation read Chapter 17 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional 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

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

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The Five Rights of Delegation

Question listThe 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 

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Scope of practice, assignment and delegation of patient care in the correctional setting

Care teamIt is a weeknight shift at a 2000 bed male medium custody correctional facility. The health care staff on duty consists of a registered nurse (RN) who is “in charge” of the shift, three licensed practical nurses (LPN) and a clerk. The ten patients in the infirmary upstairs are cared for by a registered nurse, an LPN and a nursing aide.  A medical emergency is called following an altercation between two inmates and the assigned LPN responds to the housing unit. The LPN determines that the men involved are okay and each is taken to segregation. Later one of the men is found unresponsive in his segregation cell. The LPN calls the on-call physician who orders the inmate transported by emergency vehicle to the local hospital where he dies later of a head injury sustained during the alteration.

Were staff appropriately assigned and supervised on this shift? If the charge nurse asked your opinion about how the shift was managed what comments or advice would you offer? The nursing staff at the facility were so motivated by the experience that the “after action” review included consideration of the state nurse practice act. Nurse staffing and assignment practices at the institution were changed as a result.

Ambiguity in the scope of practice for practical or vocational nurses and unlicensed assistive personnel (UAP) as well as their supervision in patient care are among the most significant challenges of correctional nursing practice. This issue was first identified last spring when nurses discussed the draft revisions to the Corrections Nursing: Scope and Standards of Practice to be published by American Nurses Association in 2014. The problem was discussed more extensively at the National Conference on Correctional Health Care in October 2012. Correctional nurses are not alone in these concerns. The National Council of State Boards of Nursing, Inc. has documented wide variation among state practice acts and among employers in the scope of practice of vocational or practical nurses (2005).

A tragic patient outcome like the one described here can be avoided with attention to scope of practice, clear assignment and delegation and good communication between personnel.  The following are concrete steps that correctional nurses can take to begin to clarify and address concerns about patient safety related to the scope of practice of practical or vocational nurses as well as unlicensed assistive personnel.

1. Recognize that other personnel are necessary to achieve good patient outcomes. Correctional nurses are responsible for managing the health care of individuals who are incarcerated.  To do so nurses assign, direct and supervise others to ensure that appropriate, timely care is delivered as planned. These personnel may include other registered nurses, practical or vocational nurses, and unlicensed assistive personnel. The plan for delivery of care may also include emergency medical technicians and correctional staff. In hospice or palliative care programs inmate caregivers may be included as well. The support of these personnel enables the registered nurse to attend to more patients with complex care needs.  The registered nurse retains accountability for patient outcomes even when specific tasks of care delivery are the responsibility of others.

2. Be familiar with the scope of practice and regulations for registered nurses in the state where you are practicing. Correctional systems are not operated as health care organizations. Registered nurses must ensure that their practice is within the parameters allowed by state regulation because the correctional organization may be uninformed or naïve about the appropriate role or practice limitations of various health care personnel.  Also these regulations change so nurses should review the state practice act annually. Contact information for state boards is obtained at https://www.ncsbn.org/contactbon.htm.

3. Be familiar with the scope of practice and regulations of other personnel relied upon to deliver patient care in the setting.  In some states the nurse practice act also describes the scope of practice for practical or vocational nurses. It may also describe how and under what circumstances patient care can be provided by certified or unlicensed personnel. If not included in the nurse practice act, find and review other relevant information that defines the scope of practice for each of these types of health care providers allowed by state law or regulation.  The registered nurse needs this information to appropriately assign or delegate tasks to others.

4. Review the job description, policies, procedures and other written directives at your facility that delineate the roles and activities to be performed by health care personnel in the delivery of patient care.  This review is done to ensure that written directives of the agency are consistent with the state’s practice regulations and to identify more specifically how the nurse assigns, directs and supervises the delivery of patient care.  Any inconsistencies between the employer’s expectations and state law should be identified and clarified through the nursing chain of command.

Chapter 17 in the Essentials of Correctional Nursing describes the role of nurses in supervising and managing the delivery of patient care in the correctional setting and provides a case example for further discussion. Order your copy directly from the publisher. Use Promo Code AF1209 for $15 off and free shipping.

General guidelines published by the National Council of State Boards of Nursing (1997) for the types of activities that can be performed by LPN/LVNs or UAPs include those which:

  • frequently reoccur in the daily care of a patient or group of patients
  • do not require the exercise of nursing judgment
  • do not involve complex or multidimensional nursing process
  • the results are predictable or carry minimal risk
  • use a standardized and unchanging procedure.

Do you have concerns about scope of practice and the role of LPN/LVNs or UAP in your work setting? Share your thoughts in the comments section of this post.

References:

National Council of State Boards of Nursing. (2005) Practical Nurse Scope of Practice White Paper. Retrieved December 26, 2012 from  https://www.ncsbn.org/Final_11_05_Practical_Nurse_Scope_Practice_White_Paper.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

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