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About We Care
• Founded in Brandon Manitoba in 1984 • 100% Canadian owned • Over 50 nursing lead offices across Canada serving over
800 communities • Provides professional and compassionate care that
allows seniors and others to live independently in their homes
About We Care
• We Care employs over 4,400 homecare staff - RN & RPN/LPN 475 - Personal Care Workers 3600
- Home Care Aides 325
Introduction
Increasingly, Support Workers are being required to assist with, or perform, certain aspects of care traditionally provided by regulated health care professionals.
The nurse is therefore expected to teach, supervise, or assign health care to the Support Worker.
Purpose
1. To define terms used in delegation of care in order to ensure consistent communication.
2. To identify the responsibilities of regulated and unregulated staff regarding the delegation of care.
3. To provide a process to follow when making decisions about delegation of care.
4. To provide a framework for delegation of tasks with standardized procedures and teaching materials.
Terms used in delegation of care to support communication
Delegation: Active process of transferring authority to a competent member of the health care team to perform a particular function or task in a specific situation
Delegator: person making the decision to delegate (RN or RPN/LPN)
Delegatee: health care staff receiving the delegation (support worker)
Terms used in delegation of care to support communication
Assigning: determining or allocating responsibility for particular aspects of care that may include both controlled and non-controlled procedures
Controlled Acts/ Restricted activities: activities that are considered potentially harmful if performed by unqualified persons. Each professional must therefore work within a scope of practice defined by a provincial governing body.
Terms used in delegation of care to support communication
• Teaching: providing instruction and determining if a person is competent to perform a procedure (not the same as delegation because it does not involve the transfer of authority to perform a controlled act procedure)
• Supervising: monitoring and directing specific activities of a Support Worker for a defined period of time. (can be direct of indirect)
Responsibilities
For example;
BC- delegable tasks are client-specific tasks Alberta- “Delegation” refers to the transfer of authority to perform nursing care in general Ontario- delegation is differentiated from “teaching”, “assigning”, or “supervising” and only refers to the controlled acts authorized to nursing.
Responsibilities
The Delegator Must:
- have the knowledge, skill, and judgment to perform and teach the procedure competently
- accept sole accountability for the decision that the Support Worker may perform the procedure considering all relevant factors
(ie. Risk and benefits to the client, predictability of the outcomes, safeguards and resources, and specific client or setting factors)
Responsibilities
The Delegator Must:
- personally evaluate or ensure that a process is in place to evaluate the continuing competence of the person to perform the procedure
- make decisions that are in the best interest of the client
Making Decisions
The process for delegating and teaching the tasks involved in ADLs for clients include five principles of delegation.
1. Right context/circumstances: consider the clients physical, emotional, social, intellectual, and spiritual needs. Do you have the necessary tools to delegate the care and the client’s participation?
Making Decisions
2. Right Task: can the task be delegated? Are you allowed to delegate it? Can you competently delegate it?
3. Right person: Do you have concerns about delegating the task to the Support Worker? Does the Support Worker have concerns?
4. Right communications: Provide clear directions and instructions. Can the Support Worker clearly report back and understand the task, risks, and expectations?
5. Right resources: Does the Support Worker know who to contact and how to contact you? After delegation, have you assessed the Support Worker’s performance?
Making Decisions
Decision Tree: Teaching or Delegating the Performance of a Procedure Nurse considers teaching/delega2ng procedure
Am I competent to perform the procedure?
Am I competent to teach/delegate the procedure?
Have I considered: risks and benefits of performing procedure, predictability of outcomes, safeguards and resources available, and other client specific factors
YES
YES
YES
NO
NO
Do not teach/delegate
Do not teach/delegate
Can I safely teach/delegate considering the factors?
YES
Is the Support Worker available with potenFal to perform procedure?
YES
Teach the Support Worker, determine competence, idenFfy condiFons for performing and indicators for seeking assistance
NO
NO
NO Do not teach/delegate
Do not teach/delegate
Is there a mechanism to determine ongoing competence?
YES
Ensure that a monitoring mechanism is in place
Do not teach/delegate
Adapted from CNO, working with Unregulated Care Providers, 2011
Framework, standard procedures, teaching materials
When delegation of task is required: 1) CCM/CCS will arrange visit for delegation with
client and Support Worker 2) CCM/CCS will provide Support Worker with “fact
sheet” (pre-reading materials) 3) CCM/CCS will delegate according to “procedure
checklist” 4) CCM/CCS will have client and Support Worker
sign documentation and keep copy of paperwork in chart
When teaching, remember to promote: D·I·P·P·S
D- Dignity I- Independence P- Preferences P- Privacy S- Safety
Fact Sheet
Example:
Fact Sheet for Delegations PERFORMING RANGE-OF-MOTION EXERCISES Range-of-motion (ROM) Exercises: range of motion is achieved by moving a joint to its full extent possible without causing pain and ROM exercises involve exercising the joints through their complete range of motion. ROM exercises can be: ►Active ROM: done by the client independently ►Passive ROM: exercises are done by another person who moves the joints of the client through their ROM ► Active-assistive ROM: exercises are done by the client with some help from another person Range-of-motion movement occurs naturally during activities of daily living such as bathing, eating, and walking. These all involve joint movements. Client who are ill or who are required to stay in bed get very little activity and therefore require ROM exercises. ROM exercises can cause injury such as muscle strain, joint injury, and pain if they are not done properly. It is therefore very important that you follow the following which will be reviewed during the delegation session with your Supervisor. ►Exercise only the joints you are instructed to exercise ►Expose only the body part being exercised ►Use good body mechanics ►The joint should be moved slowly, smoothly, and gently every time ►Never force a joint beyond its range of motion or to the point of pain
Delegation checklist PRE-‐PROCEDURE PROCEDURE POST-‐PROCEDURE
□ Iden2fy the client □ Explain the
procedure to the client □ Prac2ce hand hygiene
□ Collect: exercise instruc2ons as prepared by physiotherapist
□ If possible, raise bed to a comfortable height and/or consider body mechanics
□ Provide for privacy
□ Place/assist the client to the supine posiFon □ Expose the body part to be exercised by fan folding
top linens toward the client’s feet and cover the client with a blanket □ Perform rouFne ROM exercises as per instrucFons prepared and taught by a physiotherapist or delegated to you by your Supervisor
□ Provide for safety and comfort
□ cover the client and remove the blanket/towel □ Return bed to lowest posiFon and
remove privacy measures □ PracFce proper hand hygiene
□ Report and record your acFons and observaFons
_____________________________________________________________________________________
PERFORMING RANGE-OF-MOTION EXERCISES
Fact Sheet- example 2 Fact Sheet for DelegaFon ASSISTING WITH MEDICATIONS MedicaFons are drugs and other substances used to prevent or treat diseases or illnesses. As a PSW, you may be responsible for assisFng your clients with their medicaFons. Your role may involve one or more of the following as delegated by your Supervisor and outlined on the delegaFon form: Reminding the client to take a medicaFon Bringing medicaFon containers to the client Bringing pre-‐poured medicaFons, prefilled syringes, blister packs, or doseWes (pill boxes) to the client Reading the prescripFon label to the client Loosening or removing container lids or opening blister packs Checking the dosage against the medicaFon label Providing water or other fluids, as needed Supervising the client as he or she places the medicaFon into the hand, measuring spoon, or cup Steadying the client’s hand while he/she places medicaFons, administers eye drops, etc. DocumenFng that you assisted a client with his/her medicaFon You are not responsible for monitoring the outcome of the drug therapy but must report any changes in the client’s condiFon or behaviour to your Supervisor. The client’s medicaFon can be stored in a blister pack, doseWe or the client’s family may prepare the medicaFon by placing the medicaFon in a bowl/ cup/ or container. A blister pack is prepared by a pharmacy. A doseWe is prepared the client, the client’s family, or a nurse. It is not your responsibility to do this. The client’s medicaFons should be well established but drug allergies and anaphylaxis can occur at any Fme. Contact your Supervisor right away if your client develops a rash, appears puffy, has nasal drainage, complains of itchy eyes, presents with a fever, wheezing, extreme weakness, or nausea, and vomiFng. Anaphylaxis is the body’s way of fighFng or aWacking a drug and is life-‐threatening. In some cases, anaphylacFc shock can occur within seconds and signs and symptoms include: sweaFng, shortness of breath, low blood pressure, irregular pulse, respiratory congesFon, swelling of the larynx, hoarseness, dyspnea (difficulty breathing). In this event, you must call 911 immediately. If you believe that you have made a medicaFon error, you need to report this to your Supervisor right away. You should also report if you have found an error that your client or someone else has made. It is your Supervisor’s responsibility to assess the situaFon and to determine the next course of acFon. Deliberate failure to report a medica1on error is possible grounds for immediate dismissal (losing your job) or being charge in a court of law. You can be in more trouble if you fail to report the error than from making the error itself!
Delegation checklist- example 2
ASSISTING WITH ORAL MEDICATIONS
PRE-‐PROCEDURE PROCEDURE POST-‐PROCEDURE
□ Iden2fy the client □ Explain the procedure to the
client □ Prac2ce hand hygiene and assist client with hand hygiene □ Collect medica2on(s), standard
measuring spoon or device, and glass of water or liquid □ Provide for privacy if required
For MedicaFons from a PrescripFon Container: □ Check and read label on each container for the client if assistance required
□ Loosen lids on container(s) if the client cannot do so.
□ Place the container where the client can reach it or hand the container to the client. With the client
wearing his/her eyeglasses if needed, have him/her read the medicaFon name to you. For MedicaFons from a Blister Pack:
□ Check blister pack label and ensure you have the correct blister pack, right day, and right Fme of day
□ Instruct the client to open the blister pack by pushing the soa plasFc “bubble”. Have the client do this over a dish or bowl.
□ *If the client cannot manually push open the “bubble”, you can do this for the client.
For all MedicaFons: □ Help the client pour the correct amount of liquid medicaFon or count the correct number of pills.
□ Give a sip of water to moisten the mouth
□ Support the client’s hand, if needed, to pour the medicaFon
□ Encourage the client to drink a full glass of water aaer he/she has taken the medicaFon. Lowering the chin can ease the swallowing process.
□ * If the medicaFon is to be dissolved under the tongue, have the client place the medicaFon under his/her tongue and remind him/her not to chew or swallow it. Do not give fluids while it is dissolving.
□ Securely close the containers aaer use
□ Have the client record the medicaFon(s) taken when applicable □ Store materials in their proper locaFons □ PracFse hand hygiene □ Report and record you acFons and observaFons
Procedures to date:
• Assisting with medications a) Oral b) Suppository/ Enema c) Eye drops and ointments d) Ear drops e) Transdermal patches f) Inhalers
Procedures to date:
• ROM Exercises • Stocking Application • Applying dry non-sterile dressings • Assisting with Urinary Elimination a) Assisting with urinary catheters b) Changing leg bag to night bag c) Providing catheter care d) Condom catheter care
Testimonial
• Hi Melissa : Just a quick e-mail to say how helpful I have found the delegation tool kit. It is user friendly and provides a quick reminder of all the steps that we should be following without having to think about it. It is fast and concise with all of the steps listed. Previously I would have to try and search out materials but you have made my task of teaching and delegating a lot easier. Will look forward to having all delegations in this format in the future.
References
• College of Nurses of Ontario (2011). Working With Unregulated Care Providers
• Sorrentino, S.A, et al. (2009). Mosby’s Canadian Textbook for the Support Worker. Toronto: Elsevier Canada
• We Care Policy # 4.25 • What is a PSW’s Role in Medication (2009). Web.
<www.psno.ca>
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