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Leadership and Management: Unit 1

Lesson 1: Concepts of Delegation

Chapter 1: Delegation

Nurses
o Are responsible and accountable for individual nursing practice
o Determine the appropriate delegation of tasks to provide optimum patient care
o Are accountable under the scope of standards of nursing practice for patient care
delivered by both themselves and the personnel under their supervision
Delegation
o Transfer of responsibility for performance of a task from one individual to another
while retaining accountability for outcome
o Based upon the health, safety, and welfare of the public
Reasons for Delegation
o Cost containment
o Nursing shortage
o Increase in patient acuity
o Increase in elderly population
o Advancements of health care technology
Joint Statement on Delegation
o American Nurses Association (ANA)
Principles of Delegation
o National Council of State Boards of Nursing (NCSBN)
Decision Tree Delegation to Nursing Assistive Personnel (NAP)
Principles
o Nurse-related principles
Delegation of patient care
Monitor organizational policies, procedures, and position descriptions
o Organizational-related principles
Staff competence
Organizational policies on delegation
Allocation of resources to ensure safe staffing
Assignment
o Distribution of work that each staff member is responsible for in a given shift/work
period
o Determined by the staffs knowledge and skills
o Nurses are accountable for any task they delegate to others
o Inappropriate delegation and/or unauthorized performance of a task may lead to
legal action
Competence
o Ability of a nurse to integrate and apply knowledge, skills, judgement, and personal
attitudes required to practice safely and ethically in a designated role and setting
o Requires the application of knowledge and the interpersonal, decision-making, and
psychomotor skills expected for the practice role
Nurse Competence
o Theoretical knowledge
o Clinical knowledge
NAP Competence
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o Formal training
o Assessment
o Orientation to specific settings and patients
o Interpersonal skills
o Communication skills
o Experience in assisting the nurse to provide safe nursing care
Supervision
o Provision of guidance or direction, oversight, evaluation, and follow-up by the
licensed nurse for the accomplishment of a delegated nursing task by assistive
personnel
o Personally observing a function or activity, providing leadership in the process of
nursing care, delegating functions or activities while retaining accountability, and
evaluating or determining that nursing care being provided is adequate and
delivered appropriately
o Direct supervision
Nurse is present/available while task is performed
o Indirect supervision
Nurses provides direction through written and verbal communication
Accountability
o Being responsible and answerable for actions or inactions of self or others in the
context of delegation
o Nurse accountability involves compliance with legal requirements as set forth in the
jurisdictions laws and rules governing nursing
o Nurse is accountable for quality of nursing care provided; for recognizing limits,
knowledge, and experience; and for planning for situations beyond the nurses
expertise
Authority
o The right to act/command the action of others
o Provided to the nurse in the nurses job description
o Based on each individual states Nurse Practice Act
Nurse-Nurse Delegation
o To assess the situation and report back
o To collect data and make a recommendation
o To assess the situation, make a recommendation, report back, and then implement
final recommendation
o To complete the task as the nurse deems appropriate
Responsibility
o Obligation involved when one accepts an assignment
o Inappropriate to accept responsibility for an assignment if the individual does not
have knowledge, skill, experience, or willingness needed to complete assignment
o Once responsibility is accepted, responsibility is retained
Direct Patient Care
o Assisting patient with feeding, drinking, ambulating, grooming, toileting, dressing,
and socialization
o Data reported to the nurse, who uses the information to make clinical judgement
about patient care
Indirect Patient Care
o Assist in providing a clean, efficient, and safe patient care environment
o Necessary to support patient and environment
o Only incidentally involves direct patient contact
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Organizational Accountability for Delegation
o Provide appropriate resources
o Sufficient staffing with appropriate staff mix
o Document staff competencies of those providing direct patient care
o Ensure the nurses have access to competence information for the staff to whom
they delegate patient care
o Provide continued staff development
o Create an environment conducive to teamwork, collaboration, and patient-centered
care
o Develop organizational policies on delegation with active participation of all nurses
o Delegation is a nursing right and responsibility
Critical Thinking
o Use of thinking skills and abilities to make sound clinical judgements and safe
decisions
o Nurses must demonstrate critical thinking, reflection, and problem-solving skills in
order to thrive as effective practitioners in the 21 st century
o A critical thinker
Examines decisions from all sides
Takes varying points of view into account
Generates new ideas and alternatives
Asks Why? questions
Decision-Making Process
o 1. Identify the need for a decision
o 2. Determine the goal/outcome
o 3. Identify alternatives/actions and benefits/consequences of each
o 4. Choose an alternative
o 5. Evaluate the alternative chosen
Did you meet your goal?

Chapter 2: Prioritization of Care

Delegation Decision-Making Tree

o Assessment and planning
o Communication
o Surveillance and supervision
o Evaluation and feedback
5 Rights of Delegation
o 1. Right task
o 2. Right circumstances
o 3. Right person
o 4. Right directions and communication
o 5. Right supervision and evaluation
Regulation
o Nursing profession
Determines definition of delegation
o ANA and NCSBN
Define and guide education, training, and utilization
o State Boards of Nursing
Define legal parameters for nurses
o Nurse Practice Acts
Define tasks that may be delegated
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Delegation Requirements
o Discussion of knowledge and skills
o Clinical mentorship
o Practice delegation responsibilities
Power
o Having a basis in expertise, legitimacy, reference (charisma), reward, coercion, or
connection
o Power should be a means to accomplish a goal
o Effective nurses use sources of power when delegating care
o Sources of Power
Expert power
Knowledge and skills of the RN
Task proficiency=expert power
Most effective when acknowledged by others
Legitimate power
Derived from ones position within a group
Indicates degree of authority
Based upon
o Licensure
o Academic degrees
o Certification
o Experience in role
o Title/position at institution
Reference (charisma) power
Derived from the admiration, trust, and respect felt toward and
individual, group, or organization
Inspires confidence in others
Charismatic people of great vision
Reward/coercion power
Ability to reward/punish others
Creates fear in others, which influences behavior change
Connection power
Occurs in both personal and professional relationships
Enhanced
o Resources
o Learning and sharing information
Demonstrates broad influence over others
Examples
o Teamwork, collaboration, networking, and mentoring
Information power
Based upon any information one can provide to another or to the group
Provides a sense of stability
Synthesis of information
Subordinate power
Exerted upward in ones organization
Based upon legal and justice considerations
o Considerations Prior to Delegation
1. Potential for harm
2. Complexity of the task
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3. Amount of problem solving and innovation required
4. Unpredictability of outcome
5. Level of patient interaction
o Responsibility
Nurse Manager
Coordinates actions and allocated resources in an organization to
achieve organizational goals
Registered Nurse (RN)
Accountable for provision of patient care and outcomes
New Graduate Registered Nurse
Focus on direct duties
Licensed Practical/Vocational Nurse (LPN/LVN)
Responsible for their actions within their scope of practice
Work under the direction of the RN
Nursing Assistive Personnel (NAP)
Non-nursing duties
Ambiguous role due to lack of federal regulations

Lesson 2: Communication, Time Management, and Legal Aspects of Delegation

Chapter 3: Effective Communication

Societal Trends that Affect Communication

o Increasing cultural diversity
o Aging population
o Increasing electronic communication
Communication
o Interactive process
o Sender of message
o Receiver of message
o Verbal/nonverbal message
o Process is influenced by
Emotions, needs, perceptions, values, education, culture, goals, literacy,
cognitive ability, and mode of communication
4 Cs of Communication
o Clear
Did the receiver understand the message?
o Concise
Was unnecessary information provided?
o Correct
Is the direction given according to policy, procedure, job description, and the
law?
o Complete
Dose the receiver have all of the information necessary to complete the task
Interpersonal Communication
o Between individuals
o Person-to-person
o Small groups
o Verbal/nonverbal
o Goal: both parties understand the message and messages match
Communication Skills
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o Attending
Active listening for what is said and how it is said
Congruence of verbal and nonverbal messages
o Responding
Verbal and nonverbal acknowledgement of senders message
Verbal skills to increase level of responding
Questioning
o Clarify message by asking related questions
Restating
o Restate message to clarify the information
o Clarifying
Restating, questioning, and rephrasing to help message become clear
o Confronting
Identifying and explaining the problem
Knowledge and reason used to solve the problem
o Supporting
Siding with/backing up another
o Focusing
Centering on the main point
o Open-ended questioning
Allowing for receiver-directed answers
o Providing information
Supplying one with knowledge previously unknown
o Using silence
Allows for interpersonal communication
o Reassuring
Restoring confidence/removing fear
o Expressing appreciation
Showing gratitude
o Using humor
Provides relief
Gains perspective
o Conveying acceptance
Making known that receiver is capable/worthy
o Asking related questions
Expanding the listeners understanding
Cultural Phenomena
o Communication
Volume, dialect, use of touch, context of speech, and kinesics (gestures,
stance, eye contact)
o Space
Physical closeness
o Social organization
Varying amount of close social supports
o Time
Past
Focus on tradition and its maintenance
Present
Focus on day-to-day activity
Future
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Focus on future happenings and prepare for any potential problems
o Environmental control
Internal locus
Plan and take action
External locus
Luck/fate guides action
o Biological variations
Physiological strength, stamina, and disease susceptibility
Common Communication Barriers
o Culture
o Gender
o Anger
o Status differences
o Thought distortions
All/nothing thinking
Overgeneralization
Dwelling on negatives
Jumping to conclusions
Pessimism
Reasoning from feeling
Obligations
o Incongruent responses
Blaming
Placating
Being super reasonable
Using irrelevant information for decision making
o Conflict
Interpersonal and organizational
Resolved through conflict resolution
Conflict Resolution
o Accommodating
o Avoiding
o Collaborating
o Competing
o Compromising
o Confronting
o Negotiating
Additional Communication Barriers
o Offering false reassurance
o Being defensive
o Stereotyping
o Interrupting
o Inattention
o Stress
o Unclear expectations
o Incongruent responses
o Giving advice
Overcoming Communication Barriers
o Understand the receiver
o Communicate assertively
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o Use two-way communication
o Unite with a common vocabulary
o Elicit verbal and nonverbal feedback
o Enhance listening skills
o Sensitivity to cultural and gender differences
o Engage in meta-communication
Groupthink Symptoms
o Illusion of invulnerability
o Collective rationalization
o Belief in inherent morality of team
o Stereotyping others
o Pressures to conform
o Use of mind guards
o Self-censorship
o Illusion of unanimity
Member Roles of Communication
o Group task roles
Initiator-contributor
Information seeker
Information giver
Coordinator
Orienteer
Energizer
o Group maintenance roles
Encourager
Harmonizer
Gatekeeper
Standard setting
Group observer
Follower
o Self-oriented roles
Aggressor
Blocker
Recognition seeker
Dominator
Myers-Briggs Personality Types
o Psychological testing instrument that identifies personality types
o Four category pairs
Extrovert/introvert
Sensing/intuitive
Thinking/feeling
Judging/perceiving
o Various possible personality combinations
o No right/wrong personality type
Communicating with Supervisors
o Observe professional curtesises
o Demonstrate respect
o Communicate at an appropriate time and place
o Utilize the chain of command, if required
o State concern clearly and accurately
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o Provide support evidence
o Cooperate to find a solution
Communicating with Co-Workers
o do unto others as you would have them do unto you
o Goal:
Provide quality patient care
o Positive feedback
Increases team building
Improves ones sense of worth
o Learn from each other
Communicating with Health Care Practitioners
o Collaboration
o Seek creative/integrative solutions
o Work through emotions
o Present information clearly and accurately
o Explain the problem
o Support with pertinent evidence
o Give due respect and expect same
o Document, document, document
Building a Successful Team
o Value the contributions of all team members
o Encourage interaction among group members
o Discourage we versus they thinking
o Involve others in shaping plans and decisions
o Acknowledge and celebrate team accomplishments
o Evaluate your effectiveness as a team member

Chapter 4: Time Management

Time Management
o A set of related common-sense skills that helps people use their time in the most
effective and productive way possible
o Achieve more with available time
o Self-examination of pursuits
o Current time analysis
o Distraction assessment
Pareto Principle
o 20% of focused effort = 80% of desired outcomes
o 80% of unfocused efforts = 20% of desired outcomes
o Strategy for balancing life and work through prioritization of effort
Outcome Orientation
o Determine long-term goals
o Break down long-term goals into achievable outcomes
o Flexible goals
Analysis of Nursing Time
o Value of nursing time
Nurses often undervalue their time
o Use of time
Direct patient care (34%)
Indirect patient care (38%)
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Unit activities (8%)
Personal (13%)
Other (7%)
o Activity log
Determine personal and/or professional time use
Illuminate good and wasted time use
o Creating more time
Prioritize/delegate work
Eliminate worthless tasks
Wake up one hour earlier every day
Time Wasters
o Casual visitors
o Unplanned phone calls
o Unwanted/low priority jobs
o Requests for assistance
o Clutter
o Interruptions
o Procrastination
o Perfectionism
Perfectionists
o Hate criticism
o Are devastated failure
o Get depressed and give up
o Strive for impossible goals
o Value themselves for what they do
o Have to win to maintain high self-esteem
o Must be number one
o Remember and dwell upon mistakes
Pursuers of Excellence
o Welcome criticism
o Learn from failure
o Experience disappointment and keep going
o Enjoy meeting realistic high standards
o Value themselves for who they are
o Do not have to win to maintain high self-esteem
o Are pleased with knowing they did their best
o Correct and learn from mistakes
Effective Use of Available Time
o Teamwork
o Know
Available resources
Co-worker expectation
What is happening on other shifts, in the organization, and in the community
o Consider the big picture
Identifying Priority Patients
o 1. Problems with ABCs
Assess physiological needs first
o 2. Activities essential to safety/security
Are there any urgent threats?
o 3. Comfort, healing, and teaching
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Prioritize other needs
Prioritizing Traps to Avoid
o Doing whatever hits first
o Taking the path of least resistance
o Responding to squeaky wheel
o Completing tasks by default
o Relying on misguided inspiration
Face-to-Face Reports
o Advantages
Live audience
Pertinent information addressed
Clarification
Time for questions
o Disadvantages
Time consuming
Incoming and outgoing nurses involved in report
No patient input
Walking Rounds Report
o Advantages
Examine patient during report
Address assessment/treatment questions
Patient involvement
Increased accountability
Continuity of care
o Disadvantages
Time consuming
HIPAA/privacy violation
Making Patient Assignments
o Patient prioritization
o Unit geography
o Complexity of patient needs
o Other responsibilities
o Attitude and dependability
o Continuity of care
o Fair work distribution
o Isolation/protection requirements
o Staff skill, education, and competency
o Protecting patient and staff from injury
o Patient care standards
o Environmental concerns
o Insurance education programs
o Lunch/break times
o Unit routines
o Accreditation regulations
o Agency organizational system
o State laws
Patient Rounds
o Initial rounds on high-risk patients
o Rapid assessments
o Assess
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IVs, drains, and/or treatments
o Patient concerns and desires
o Maintain flexibility
o Evaluate and reassess

Chapter 05: Legal Aspects of Patient Care and Delegation

Sources of Law
o Constitution
Basic laws that specify the powers of the various segments of the
government and connection of each segment
o Legislative Bodies
Enact laws on both federal and state levels
o Administrative Branch
Implementation of laws
o Judicial branch
Interpretation of laws
o Common Law
Precedential judicial decisions of previous cases that hold the force of the law
o Public Law
Governs the relationship between citizens and the state
Constitutional, criminal, and administrative law
Constitutional Law
o Constitutional Rights
Right to practice ones religion
Right of a woman to undergo an abortion
Right to die
o Nurses may:
Not interfere with patients constitutional rights
Refuse to work in areas where certain controversial constitutional rights of
the patient may conflict with their own
Administrative Law
o Govern and protect citizens rights
o Code of Federal Regulations
Administrative rules of the federal government
o HIPAA, Social Security, and Medicare
o Violations may result in lack of federal funding and/or criminal penalties
o Nurse Practice Acts
State administrative laws
Nursing State Boards
Define nursing practice
Nursing Licensure Compact
Agreement among 23 states which allows nurses licensed in any state
participating in the agreement to practice nursing without applying for
a new license in each separate state
Criminal Law
o Governs the actions of individuals that intentional do harm to others
o Victims of abusive action are often the very young/old
o Mandatory state laws require nurses to report unexplained/suspicious injuries
o Failure to report problems could result in criminal penalties
o Criminal background checks required for anyone who may work with children/elderly
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o Substance abuse prohibition
o Off-duty behavior may affect employment status
Civil Law
o Governs relationships between individuals
o Contract Law
Regulates transactions between individuals and/or legal entities
Governs transactions between businesses
o Tort Law
Negligent/intentional civil wrong not associated with a contract/statute that
results in juries for which the injured may sure the wrongdoer for damages
Unintentional/intentional
Legal Contract Elements
o Agreement of two or more legally competent individuals/parties stating what each
must/must not do
o Mutual understanding of the terms and obligations imposed upon each party
o Payment/consideration given for actions taken/not taken pursuant to the agreement
o Written/oral contract
Employment Contract
o Nurses agree to:
Adhere to organizational policies and procedure
Execute job duties
Respect rights and responsibilities of healthcare providers in the organization
o Employers agree to provide nurses with:
Payment for services rendered
Assistance, supplies, and equipment
A safe environment
Reasonable treatment and behaviors from coworkers
Tort Law
o Denial of ones legal rights
o Failure to comply with public duty
o Failure to perform private duty that results in harm to another
o Unintentional
Negligence/malpractice
o Intentional
Assault/battery
Unintentional Torts
o Negligence
Failure to provide care
o Malpractice
Failure to meet professions standard of care
Wrongful conduct of professional duties
Selected Torts
o Assault
Threat to touch another individual in an offensive manner without consent
o Battery
Touching another individuals without consent
o Invasion of privacy
Everyone has a right to privacy and may bring charges against anyone who
violates that privacy
o False Imprisonment
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Restriction of an individuals freedoms
Inappropriate use of physical/chemical restraints
Allowing one to believe they cannot leave
o Defamation
Intentional false communication, publication, and/or remarks that may cause
loss of ones reputation
Libel (written)
Slander (verbal)
Proof of Liability/Fault
o Duty/obligation created by law, contract, or standard practice owed to the
complainant by the professional
o Breach of duty, either by omission or commission
o Complainant harm (physical, emotional, financial)
o Proof that breach of duty caused complainant harm
Patient Advocates
o Communicate patients needs/desires
o Protect patients safety
o Preserve patients legal rights
Informed consent laws
o Protect patients right to practice self-determination
Power of Attorney
o Legal document voluntarily executed by an individual (principal) that grants another
person (agent) the right to perform certain activities on the principals behalf
o Does not eliminate principals choices
o Principals (patients) wishes prevail over agents wishes in disagreements
o Medical Power of Attorney
Authority to make principals medical decisions only
Living Will
o Written advance directive voluntarily signed
o Specified desired type of care if/when a terminal state occurs
o Enacted when one cannot sign a consent form/convey ones wishes verbally
Do Not Attempt to Resuscitate (DNAR)
o Written by an attending physician
o Considered a medical decision
o Instructs medical staff NOT to perform cardiopulmonary resuscitation (CPR) should
sudden cardiopulmonary arrest occur
o May be enacted in absence of advance directives
State Nurse Practice Acts
o Define the legal parameters of nursing practice per state
o Nurses responsibility to know state practice acts as needed
Good Samaritan Laws
o Care rendered in an emergency
o Health care professional rendering care without pay
o Care provided did no recklessly or intentional cause harm/injury to the injured
individual
Documentation Reasons
o Professional responsibility
o Accountability
o Communication
o Education
o Research
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o Compliance with legal and practice standards
o Reimbursement
Accurate Documentation
o Ensures continuity of patient care
o Communication among health care team members
o Written evidence of patient care provided, patients response to care, and plan of
care revisions
o Compliance with professional standards
o Fulfillment of accreditation criteria
o Resource for review, quality, improvement, reimbursement, education, and research
o Legal record protects the patient, organization, and healthcare team members
FLAT Charting
o F Factual
Objective and not subjective
o L Legible
No erasures
Draw a single line through error and initial
o A Accurate and complete
o T Timely
Completed as soon after occurrence as possible
Keep late entries to a minimum
Ethical Principles and Rules
o Beneficence
Duty to do good to others and maintain balance between beliefs and harms
o Nonmaleficence
Doing no harm
o Justice
Fairness that is served when no one is given that which one if due, owed,
deserves, or can legitimately claim
o Autonomy
Respect for ones right to self-determination and individual liberties
o Fidelity
Duty to keep ones promise/word
o Respect for others
Right to make ones own decisions
o Veracity
Obligation to tell the truth
o Advocacy
Responsibility to promote others rights
Strategies to Enhance Ethical Responsibility
o Formal mechanism for monitoring ethics
o Written organization codes of conduct
o Communication that reinforces ethical and socially responsible behavior
o Leadership by example
o Encouraging confrontation about ethical deviations
o Ethics and social responsibility training
o Ethics committees
o American Nurses Association of Ethics for Nurses
Risk Management
o Identify and correct system problems that contribute to errors in patient care and/or
employee injury
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o Emphasize quality improvement and organizational protection from financial liability
Malpractice Insurance
o Organizations policy may/may not cover an employee
o Intentional injury voids malpractice coverage
o Failure to comply with organizational policies and procedure may result in defense
denial
o Employee may be named individually as a defendant
Professional Liability Insurance
o Provides defense independent of ones employer
o Cover unaffiliated employees
Respondent Superior
o A master is subject to liability for the torts of his servants committed while acting in
the scope of employment (Restatement of the Law of Agency, 1958).
Monetary awards
o Compensatory damages
Awarded to compensate plaintiff for his/her damages
o Punitive Damages
Compensate plaintiff for any loss
Intended to punish defendant for acting with recklessness, malice, deceit
(Blacks Law Dictionary, 2005).
o 30 states have legislation capping plaintiffs monetary damages
Nurse-Attorney Relationship
o Retain a legal specialist
o Be attentive
o Notify ones insurance carries of potential liability issues
o Keep costs sensible
o Keep informed
o Examine all writing
o Set ones own course