The Business or Professional Practice of Transferring Responsibilities - Term Paper Example

Content Abstract page 2 Section 1 Introduction page 3 Section 1.2 Rationale of Choice page 3 Section 1.3 Search page 4 Section 2 Methods & Data Collection page 4 Section 2.1 Sampling page 6 Section 2 .2 Data Analysis page 7 Section 2.3 Findings page 9 Section 3 Dissemination page 10 Section 4 Ethical Consideration page 11 Section 5 Conclusions page 12 Section 6 Recommendations page 13 Improper Delegation in Nursing Abstract: Delegation is the term referring to the business or professional practice of transferring responsibilities to a subordinate or a person who does not have the license or authority to do the work (“4723-13-01 Definitions”, 2007). In nursing profession delegation is a common practice (Bjőrnsdottir, 2001) and the aim of the current paper is to compare the different studies made on delegation practice in nursing profession to get an insight of the entire system and to determine whether the practice can be considered as improper. The papers used have a number of shortcomings but still they can serve as a good source of information regarding the entire practice of delegation in nursing. The recommendations provided in the papers selected are quite significant regarding the delegation in nursing. 1 Introduction: In nursing practice delegation involves transfer of a selected nursing responsibility from an authorized and licensed nurse to an individual who is not otherwise authorized to perform the task. While delegating the task the nurse remains responsible for the task performed by the other individual. The nurse who delegates the task and adopts responsibility for the individual who receives the delegated care is known as “delegate nurse” (“4723-13-01 Definitions”, 2007). Delegation is increasing now-a-days as a result of increasing demand of services from healthcare professionals. The tasks previously performed by registered nurses only are now being delegated to the assistants. But care should be taken in this kind of delegation in terms of proper and serious handling of the jobs delegated as it is directly concerned with the life of the patient. It is a matter of concern that the nursing staff and managers suffer from severe lack of knowledge in the sector of task delegation leading to serious implications for the patients denying all the benefits offered by the process of delegation to the nurse and the patients. 1.2 Rationale of Choice: Three papers have been selected to be evaluated in the present work, namely “Why Workforce Development should be part of the Long-Term Care Quality Debate” by Stone, Dawson and Harahan published by Paraprofessional Healthcare Institute in 2003, “Delegation as Experienced by Nurse Manager” by Abedi, Eslamian, Salehi and Alame published in Iranian Journal of Nursing and Midwifery Research, Vol. 12 (2) in 2007, and “Nurse Delegation of Medication Administration for Elders in Assisted Living” by Reinhard, Young, Kane and Quinn in 2003 published by Rutgers Center for State Health Policy. These papers have been selected to study the practice for about a decade time and in different countries. Medication administration and professional skill development of the support staff, the two very important aspects of delegation practice by nurses are also considered in the present paper. 1.3 Search: The search has been conducted referring a number of Journals from different publishing. Library work formed a very important part in the research work. Primary research was given priority. The reference lists found from library helped to access a wide range of articles for the study. This list also helped in selecting the articles to be analyzed. Electronic sources played a very important role in the entire process. Keywords: Delegation in nursing, medication administration, nursing research, nursing management, legal and ethical issues in nursing Search limits between 2000 – 2008 Primary/ original research 2 Methods and Data Collection: Abedi, Eslamian, Salehi and Alame (2007) and Reinhard, Young, Kane and Quinn (2003) used qualitative methods for conducting their researches. Qualitative method is found to be the most effective method for conducting the studies on delegation of nursing tasks (Benzies & Allen, 2001). This is the most suitable method to describe life experiences and analyze them. But the main disadvantage with the qualitative method is that the findings can not be extended to wider populations with the same degree of certainty that quantitative analyses can as the findings of the research are not tested to discover whether they are statistically significant or due to chance. Stone, Dawson and Harahan (2003) used another qualitative method of case study and literature review approaches in their study establish a link between skill development and quality of long-term care by the direct care workers. The phenomenological method was used by Abedi, Eslamian, Salehi and Alame (2007) in their study as their research tried to understand the basic structure of delegation phenomenon through explanation of real life experiences. The interview technique was used as the primary method of data collection (Beech, 1999). The study conducted by Reinhard, Young, Kane and Quinn (2003) used interview as well as focus group discussion techniques. They also used participant observation method. The use of survey data from NASHP survey also helped them to reach their inference. The interview method was semi-structured to collect information about the nurses’ perception about the practice and the rules and regulations concerned with the same. The average time period given for each interview ranged from 30 to 90 minutes depending on the details provided. Stone, Dawson and Harahan (2003) used a wide range of published research papers as well as legal documents to collect information about the perception of the physicians, nurses, management staff, direct care staff and also the patients about capability of the direct care staff in relation to the quality of the care given. The paper was presented as an overview of the previous studies made in support of the skill improvement in direct care workers. They succeeded to collect exhaustive data on the past studies and compared them effectively to support their own view and was able to reach the finding properly. Thus this paper is a great literature review which is able to provide necessary information and recommendation about the entire practice. The researchers were not directly involved in any type of data collection techniques themselves; rather they depended on the data available in the existing literature. The other two papers, on the other hand are related to first hand data collection. Focus Group Discussion was conducted both with the nurses and the administrative staff in the study conducted by Reinhard, Young, Kane and Quinn (2003). The main focus was given on the issue of delegation of medication administration and the benefits and problems with the practice. The administrative staff was asked about their nature of quality supervision. According to the researchers in this study use of Focus Group Discussion in this study helped collecting spontaneous and rich data from the participants. The general perception can be understood with ease through this method, which was lacking in other studies. But this method has some difficulties like lack of control on respondents, irrelevant information, data may not be representative etc. and these may lead to data insufficiency (Walvis, 2003) 2.1 Sampling: The study by Abedi, Eslamian, Salehi and Alame (2007) considered all matrons as source of information. They used convenience sample type. They did not consider any of the nurses or Unlicensed Assistive Personnel (UAP) for their study. Thus they lacked in obtaining proper insight of the delegation issue from different point of view. No special formula was used in calculation of sample size. The size was determined based on the information obtained during primary interviews and data saturation was kept in mind. Generally a limited number of samples are selected in phenomenological studies as that limited number is able to provide sufficient information required (Brent, 1991; Koch, 1994). In this study the sample size reached 14, little more than usual 10. The different experience levels and rank of the individuals helped in collecting wide range of information though the information is from only one perspective. The data collection tool used in this method is open ended and axial questions at a calm environment. 9 women and 5 men have been selected as samples, which mean it was not been possible to maintain equality in male female ratio (Polit & Beck, 2005). All of the individuals were Bachelor’s degree holders except 3 men who had Master’s degree. Stone, Dawson and Harahan (2003) tried to use 8 different sample literatures through judgment sampling for the purpose of their research. They analyzed studies made with different view points and were able to reach the conclusion through balancing the data available. They analyzed different aspects of the issue through the consideration of job satisfaction, turn over rate, job skills, etc. among the direct care staff. But as the paper lacked direct researching techniques, it is limited in its approach. The researchers could not gather any first hand experience and had to depend on others’ thoughts completely. Reinhard, Young, Kane and Quinn (2003) conducted interviews with executive staff of state board of nursing. They used quota-sampling type for their study. There sample was quite exhaustive and capable of providing suitable data for the research. Interview was conducted on the proceedings they use while delegating medication administration. But the telephonic interview method used for this study was not a very good technique of data collection (Polit & Beck, 2005; Carolan, 2003). As the study was conducted with the executives from 42 states, there was no other option than telephonic interview. This might be a drawback for the study. The study included response from different stakeholders including a national representative for consultant pharmacists who studies medication administration in long-term care settings, a nurse leader in assisted living practice, three state licensing directors (two speak nationally on assisted living regulations), and four middle managers from the AL licensing department in two states. Focus Group Discussions were conducted with nineteen nurses and six administrators from 18 states. The sampling done here was quite exhaustive and was able to supply a wide range of data. Sampling is the most important and complicated aspect of research works and is always involved with some kind of bias or limitations that can not be avoided for that particular study (Crossan, 2003). Thus the studies being analyzed here also showed some limitations but overall the samples proved to be quite helpful towards the findings of the studies. 2.2 Data Analysis: In all the researches the data collected through interview or focus group discussions were recorded for analysis at a later stage. Abedi, Eslamian, Salehi and Alame (2007) used Colaizzi method for data analysis. This is a seven-step process used for data analysis in qualitative research. This is the most user friendly and exhaustive method for thematic analysis according to Aronson (1994). The data collected were transferred to paper and were used to codify the entire data, which were then turned to different categories (LE Roux, 1996). Measures were also taken to ensure validity and reliability of the data (Newell, 1996; Nolan & Behi, 1995). Stone, Dawson and Harahan (2003) analyzed their data using a case by case approach and evaluated the findings of each study individually. This individual attention to each study helped them reach the inference easily. Reinhard, Young, Kane and Quinn (2003) analyze the data collected from interview by categorizing the same based on nurses’ response on task delegation and knowledge of regulations, responses from Board of Nursing regarding task delegation, current practice and any additional observation. This method of categorization helped them analyze each and every aspect of the findings separately and minutely and impacted the validity (Polit & Beck, 2005). Data obtained from focus group discussion were analyzed using grounded theory methodology appropriate for studying complex, interrelated research problems and is particularly useful for examining situations where many perspectives exist and for exploring issues about which little is known (Bowers, 1988; Glaser, 1979; Kimichi, Polivka, & Stevenson, 1991; Lincoln & Guba, 1985; Sandelowski, 1986; Strauss, 1987; Strauss & Corbin, 1990; Ferguson, 2004). But grounded theory is not feasible to study long term processes. Ideas generated were categorized, organized and encoded and inferences were reported based on major themes evident. They also took care to assure credibility of the data (Chiovitti & Piran, 2003; Cutliffe & McKenna, 1999). All of the researches tried to conduct exhaustive data search and analysis but the major drawback they showed is the lack of review of current available literature (Polit & Beck, 2005). Literature review would have provided the researchers with more detailed idea and comparative analysis. 2.3 Findings: The results found from the study on Nurse Managers by Abedi, Eslamian, Salehi and Alame (2007) showed that the mangers did not actually have any experience regarding proper delegation and sense of privation. They did delegate minor matters but were not aware of the advantages of delegation in terms of nurses, assistants or patients and hospital. Consequently they knew nothing about the real obstacles they might have to face through improper delegation. The matrons studied had never been exposed to the issue of delegation, proper or improper, during their student life nor during their service (Behi & Nolan, 1995). The findings by Stone, Dawson and Harahan (2003) showed that inadequate development of skill has a direct impact on the quality of the care given to the patients. The support staffs are generally low income group with relatively lesser level of education. Thus delegation of nursing task to them without proper training could produce harmful impact on the patient. The staffs may also feel dissatisfied with their jobs and relative income level. Reinhard, Young, Kane and Quinn (2003) found that most of the American states have specific laws regarding delegation but the laws do not specify the tasks that can be delegated. Some states, such as California, Connecticut, and Delaware, specifically rule out the delegation of medication administration (“Delegation to unlicensed assisted personnel”, 2006). The training provided to the UAPs was not at all consistent. The nurses were taken to be responsible for the functioning of the UAP and this affected the entire system of delegation, as the nurses were afraid of delegating (Horsley, 1986). 3 Dissemination: The nursing tasks, previously done by the registered nurses only, are being delegated to the unauthorized assistants now-a-days (Bjőrnsdottir, 2001). These assistants called Unlicensed Assistive Personnel (UAP) might include nurse aides, nurse technicians, patient care technicians, personal care attendants, unit assistants, nursing assistants and others. (Kelly-Heidenthal, 2003) It is found from the above studies that very trivial matters are being delegated sometimes, as the delegate nurse does not have enough knowledge about the practice and the legalities attached. The registered nurses are often unprepared for proper delegation and place untrained persons for critical tasks. Important tasks like medication administration are also delegated with just minor information (Pepper, 1995). The legal issue arises mainly from accountability of the nurses to their patients regarding initiative and performance (Betts & Waddle, 1992). They are also accountable to follow the ethics-legal model of behavior, standards of professional practice and the policies of the health care organizations (Landreneau, 2002). Delegation of important functions like assessment, analysis, diagnosis, planning and evaluating the different stages in the nursing process to the UAPs may be avoided. Ideally the delegation takes place during the implementation of the nursing process (Barter and Furmidge, 1994). The Nursing and Midwifery Council (NMC), UK issued ten principles related to delegation practices: Assessment of patient condition should be of primary importance in delegation The delegate nurse should retain the responsibility for the delegation The delegatee should be a competent person to perform the task The registrant is responsible and can interfere in improper delegation practice by any other authority. The registrant can solely decide about the necessity of delegation. The registrant can also refuse delegation. The delegation should be within a robust local employment policy framework to protect the public and support safe practice. The person deciding to delegate is accountable for the delegation. The delegatee should be aware of her/his limitation related to the task. No one should feel pressurised into either delegating, or accepting a delegated task. (Medical News Today, 2007) Studies showed that registered nurses at health care centers are increasingly misusing UAPs, by making them perform duties outside their scope of work (Spital, 1999). 4 Ethical Consideration: Delegation of nursing and caring tasks could be very helpful for the entire medical profession and quite risky at the same time. Careful delegation is very important and needs to take care of several issues and questions. Delegation in nursing was observed and practiced during the 1800s (Ulrich, 1992). Proper delegation will ensure the reduction in health care costs through the efficient use of time and the resources. But the intelligence of the delegate nurse is very much counted upon in judging the capability of the delegatee (Spital, 1999). Delegation makes the doctors and nurses to be able to cover different serious activities that would otherwise be impossible (Kreplick, 1995; Bower, 2000). Without delegation nurses might feel exhausted and the patient will suffer consequently. Only delegation skills can help them achieve the required objective otherwise (Hansten & Washburn, 1996). Improper delegation on the other hand might lead to loss of reputation and legal cases as well because the nurses are responsible for their actions as well as those of the delegatees (Aiken, & Catalano, 1994). Thus, the use of unlicensed people might increase the responsibility of the nurses instead of relieving them. Further newer nurses might not be right in their judgments since they lack in experience (Guba & Lincoln, 1985). Proper nursing requires a focus on the patients’ responses and not simply on the technical parts of the job of nursing (Hesook, 1993). They need to learn the art of studying the patient closely for all health aspects (Shea, 1993). Otherwise the judgment will be regarding delegation (Hardin & Kaplow (ed)., 2005). Using UAPs to perform critical nursing tasks outside the scope of their practice is a violation of the state nursing practice Act. 1996 and also pose a threat to the safety of the patient. Delegation is not an ethically bad concept at all, but is conditioned by the efficiency of the people involved (Norman, 1998). The nurse manager sometimes also looks into the choice of personnel mix within a nursing unit. The manager would need a wide range of skills for delegation (Dogloss, 1996; Loveridge & Cumming, 1996; Fadaie, 2000). Ethical behavior comes from humanitarianism and realization of the fact that the life of the patient is totally in the hand of the nurse concerned. Besides the law, some turnaround needs to be brought at individual level and an overall concern and supervision of the patient should always be in the background of all delegation activities (Winters & Ballou, 2004). 5 Conclusions: With proper cares taken the delegation in nursing tasks can be exercised properly within the legal and ethical limits without posing any harm for the patients and the entire pool of nursing staff including assistants can be able to improve their knowledge and service effectively (Francis & Souza, 2000). 6 Recommendations: The nurse managers or registered nurses should be trained properly about delegation system since their student life (Al Ma'aitah. & Momani., 1999). The UAPs should be properly trained about the concerned task before delegation. The entire task delegated should always be supervised properly by the registered nurse or nurse managers (Barter & Furmidge, 1994; Ellis & Hartley, 2000). The delegate nurse or doctor must always be responsible for the task delegated. The nurse must have accurate legal knowledge about the specification of tasks that have been allowed to delegate (Harris, 1991; Hesook, 1986; 1999). The interrelationship between the superiors and subordinates needs to be improved to prevent misuse of subordinates. A task should be delegated in writing to the subordinate after judging her/his capabilities for that task and after required training (“Nursing Agenda – Section 3 – Work Design”, 2007). A collaborative staffing methodology can be set up to provide appropriate input to both the delegate nurses and their delegatees. Flexibility and redesigning of work requirements need always be exercised (Eby, 1993). 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