Accountability of Registered Nurses in Delegating Care to Support Workers and Student Nurses - Essay Example

?Accountability of Registered Nurses in Delegating Care to Support Workers and Nurses Introduction Health care system has evolved and has been refined to accommodate and serve better to the needs of every individual seeking its nurture and care. From the topmost position to the bottom, every one in the health care system is given the opportunity to apply their knowledge and practice their skills in which when they assigned in the workplace, they are expected to be functional keeping in mind the accountability that comes with every decisions they have to undertake in their daily routine. Most of the times, the responsibility is given to those registered health practitioners in assigning tasks to their assistants or other support workers i.e. a registered nurse asks the health care assistant to collect the 24-hour urine output of a patient for monitoring. In this way, the burden of each and every activity in the hospital or any health care facility is not solely carried by few individuals but rather designated to many other individuals who have the appropriate knowledge and skill in performing hospital duties. Furthermore, errors committed in giving health care will be minimized if not avoided because of mastery of the skill to the tasks that has been designated to the assistants. In everything that has been done, it is the patient’s best interest that is taken into account. A patient has put the trust in our hands for us to deal and treat his disease, thus it is just necessary to return the trust and be their advocates in promoting their well-being. In this text, support workers are team members whom tasks are delegated to by the registered practitioners. Support workers may represent health care assistant, rehabilitation assistant or technician, therapy assistant, assistant practitioner or technical instructors. Registered practitioner on the other hand pertains to a registered professional who usually delegates the task i.e. the Health Professions Council (HPC) or the Nursing and Midwifery Council (NMC) (CSP, 2006). Discussion The health care practitioners are bound within the scope of both the criminal and civil courts so as to assure that what they are doing are within the limits of legal requirements especially since they are dealing with human life. Registered health care providers are responsible to their acts of health practice and patient care thus must conform to the conditions and terms set by the regulatory and professional bodies. Currently, heath support workers do not have professional registrations (Department of Health, 2004; Scottish Executive Health Department, 2004). When a registered health care provider has delegated tasks to a support worker, it is to note that the registered practitioner must understand the skill and knowledge needed to perform the delegated assignment. It is the registered health care provider’s responsibility to delegate a task and on the other hand, the support worker is responsible for taking the assigned job sand also for the actions he/she used for accomplishing the specific task. This principle applies when the support worker has sufficient knowledge, judgment, and skills in carrying out the delegated task given that the task is bounded within the standards and conduct set at the work place. Meanwhile, supervision and feedback regarding the task must be appropriately delivered by the registered professional (Mackey & Nancarrow, 2005). Delegation, Accountability and Responsibility Delegation is the process undertaken wherein a registered health practitioner distributes a task to a support worker who is believed to be capable in fulfilling the work. With delegation as basis, the support worker is trusted with the obligation for the task. In a stricter sense, delegation is different with assignment. In delegation of task, the support worker is responsible for the task and the registered health practitioner is held accountable to the support worker. In assignment, both the responsibility and accountability for a specific task passes from one person to the other (Barter & Furmidge, 1994). In other words, the delegator allocates or designates either clinical or non-clinical treatment or care to a competent person, the delegatee. The delegator remains responsible for the overall management of the service user, and also accountable for the decision to delegate tasks. However, he/she is not already held accountable for the decisions and actions of the delegate (NLIAH, 2010). Delegating or assigning a specific task is based on the judgment of the registered professional thus the physical, knowledge, and skill competence of a support worker must be taken into consideration for a satisfactory performance (CSP, et al., 2006). The principles of delegation have been identified to guide registered practitioners as well as the support workers in appropriate delegations of task. Generally, the registered practitioner assesses, plans, implements and evaluates a task that is to be delegated to a support worker who should be suitable to the specific role, possess experience and competence in accomplishing the task. To guarantee his/her competency, trainings are offered by the employer. Levels of supervision and feedback are based on the support worker’s knowledge and competence, the needs of the patient, the service setting and the delegated work. Consequently, the support worker must always bear in mind the scope of his/her expertise and ask for support when needed (Chartered Society of Physiotherapy, 2005). In delegation, it is necessary that the support worker, to whom an aspect of care is being delegated, takes into consideration their limitations and when not to go on with the task when there have been changes of instructions regarding the carrying out of the delegated tasks. No one should feel pressurized or forced into either delegating or accepting a delegated task (Delegation, 2008). In the aspect of nursing care to a patient, the person who is in charge of the overall care given to that patient is typically the registered nurse. However, with so many activities to be undertaken especially if the facility is tertiary or offers specialized care, the registered nurse cannot execute all tasks thus comes into picture those individuals who can be considered to become part of the health care team to attend to attend to every needs of a patient. The health care team is composed of professionals and individuals who have been registered, trained or experienced in a specific aspect of health care services with their of possession of knowledge, skills, and competence and are thus capable of providing care within the scope of their practice. Thus, the registered nurse, being the leader in this aspect, designates certain tasks to his/her co-workers. Meanwhile, with doing or delegating such task, there should be someone who assumes accountability in order to legally protect the rights of patients (Royal College of Nursing, 2011). The law enforces a responsibility of care on all health practitioners such as physicians, registered nurses, health care assistants, assistant practitioners, or students because it is reasonably anticipated that being human, they could cause harm to patients through their actions or their failure to perform such acts (Cox, 2010). This duty of care that is applied to HCAs, APs, or students binds them to a legal obligation and responsibility as regards to the patient. Therefore, they must see to it that they perform their roles effectively and competently. Registered nurses are bounded to duty of care and legal liability with regard to the patient. They have to make sure that the task was appropriately designated and the support worker who accepts the specific task understands and has the knowledge how the task is done. He/she must possess skills and abilities in order to competently carry out the activity (Royal College of Nursing, 2011). Furthermore, a task may be delegated to a support worker whom by the judgment of the registered nurse is competent to carry out the instructions and achieve good outcome. If the individual to whom the phase of care is designated is employed, it is the employer’s responsibility to make sure that they have adequate education and training to competently carry out the aspects of care which a registered nurse is expected to delegate to them. Similarly, the registered nurse who had delegated a task has a continuing responsibility to monitor the appropriateness of the delegation by continuously reassessing the condition of the patient in the care of the nurse at intervals and determining that it remains stable and expected and monitoring the competence of the support workers and ensuring that they remain competent to safely carry out the delegated tasks to patients safely and effectively (Delegation, 2008). Delegation boosts the confidence and self-esteem of HCAs by letting them master their caring skills under supervision. Delegation has many positive outcomes for both patients and staff. Barker, Sullivan, and Emery (2006) have stated that delegation serves as trust-building process because it allows HCAs to prove that they can fulfill activities designated by the nurses. As a result, nurses become more confident in designating tasks to HCAs. Also, because of delegation, the patient is provided the right person having the right expertise for the right job. Keeney et al. (2004) have documented that HCAs were regarded positively by patients. Furthermore, The United Kingdom has established legal definitions regarding delegation which covers several elements such as leadership functions and delegation, management roles and delegation, information on tasks that can be delegated, involving legislation, guides, job descriptions, policies and procedures, and patient needs, and guidelines on how to delegate (Dimond, 2008). Despite the benefits that could be acquired from delegation of care to support workers there are factors that have been identified which may hinder the process of delegation. Such elements are include the delegator, the delegatee, and the situational context (Carr & Pearson, 2005: Swansburg & Swansburg, 2002). One or more of these elements can provide a barrier to the delegation process. Barriers involving the delegators are their predisposition to work alone, insufficiency of experience, insecurity, lack of self confidence in dealing with subordinates, desire for control, inadequacy of organizational or managerial skills, and unwillingness to develop subordinates and help them grow in their roles. Meanwhile, barriers that may bring about failure of delegation from the point view of the delegatee are inadequacy of experience, insufficiency of competence, turning away from responsibility, insufficiency of organizational skills, and excessive amounts of work. Furthermore, the barriers involved in the perspective of a situational context are the critical nature of decisions, the urgency of decisions, confusion relating to responsibility and authority, and understaffing (Mackenzie, 2009). Though barriers to effective delegation may hinder the main goal of delegation, fortunately, many of these barriers can be defeated via effective and appropriate education and training of both the delegator and the delegate (Gillen & Graffin, 2010). Role and accountability of support workers The role of health care assistants and assistant practitioners in care of patients have been increasing and progressing over the years. They are now taking a range of routine health care functions designated by registered nurses or other healthcare professionals i.e. phlebotomy, new patient health checks, health promotion and education, wound care, catheter care and intravenous cannulation. They are very helpful to the leaders of the health care team i.e. doctors, nurses by providing an extra hand for patient care. When HCAs and APs are appropriately and adequately trained, assessed, supervised and supported, they could play a significant role to patient care as member of the health team ensuring their patients or their co-workers standard provision of care and service. To attain a high-quality of care, careful consideration should be given to the education program for HCAs and APs. It is necessary that they know the principles of care before taking delegated roles. In addition to knowledge, clinical skill is as important. But these are not just the factors that could bring out a competent health care provider. Several characteristics or trainings are also assessed by the registered practitioner such as communication, personal and people development, health, safety and security, service improvement, quality, equality and diversity, and information technology skills. HCAs who have undergone training and who have been assessed as competent are allowed to perform patient observations such as temperature, pulse, respirations, and weight (NHS, 2009). If an HCA wanted to upgrade his/her level of responsibility, he/she has the chance to take the National Vocational Qualification (NVQ) programs wherein increasing NVQ levels means a higher responsibility and proficiency (Skills for Health, 2010). There are schools that offer trainings for health care assistants. The Scottish and National Vocational Qualifications (SNVQs/NVQs) are the most readily recognized vocational training for health care assistants. They provide a qualification that recognizes the transferable skills that HCAs acquire and develop during their stay in their work. Likewise, The Open University also provides a great deal of distant learning programs for HCAs. Meanwhile, For APs, majority have taken two-year foundation degree in college of further education or in a university. Such schools i.e. Primary Care Training Centre and Education for Health offer a wide range of courses for those individuals working in primary care. Nevetheless, merely having an HCA or AP qualification does not mean that they already have the right to perform the tasks that they have learned in training schools or universities. Their training background have given them the competence to practice but decision making on delegation of task to an appropriate support worker remains with the registered nurse or other healthcare professionals taking into consideration the needs of the patient. Furthermore, updates in training must be made available to ensure that all procedures practiced to the patient are up to date and based on good practice (Hopkins, et al., 2008). HCAs and APs are legally accountable to the patient for any errors they may make intentional or unintentional that brings harm to the patient through the civil law or indeed criminal law. Also, they are held accountable to their employer via the employment law through their contracts of employment. However, HCAs and APs are never professionally accountable because they are at present unregulated and thus are not within the scope of a profession. To make sure the HCAs and APs do not fall below the standard of care under which they function, there are guidelines produced for HCAs and APs. They have to know the limitations of their functions and must not take tasks to which they have no appropriate trainings. They also are not expected to enter into consultations with patients unless they have appropriate supervision from a registered professional. Health care assistants and assistant practitioners should always act within defined protocols and procedures, with supervision from a healthcare professional (Hopkins, et al., 2008). Competence refers to the general, overall ability of a person in effectively applying his/her knowledge, understanding, skills and values within the limits of an assigned scope of practice. It is assessed and evaluated according to one’s performance to fulfilling a specific task as well as the responsibilities associated with it. A competent individual provides an effective output based in his/her manner of operating and also at times may involve reflection and adjustment of their practice. Both delegation and competence is supported and enhanced by continuing professional development and growth (CSP, et al., 2006). In other literatures by Spilsbury and Meyer (2004), they have identified main areas of HCA work which are direct patient care, housekeeping duties, and clerical tasks. Direct patient care involves washing and dressing the patient, assisting with feeding, taking observations, and assisting with toileting. Housekeeping duties involve cleaning equipment and sorting laundry. Clerical tasks involve a range of duties, such as ordering supplies. The tasks which are commonly delegated by nurses to HCAs are those providing patient assistance with washing, dressing, feeding, mobilising, toileting, and bed making (NHS, 2009). Within the hospital setting, HCAs are engaged in medical and surgical wards, operating theatres, as well as accident or emergency, maternity, and outpatient departments. The activities that are designated to the HCA depend on the location of the care delivery. These sites do not only include the hospital or community setting, but may also involve in patients’ homes, day care centers, nursing and residential homes, and prisons (Gillen & Graffin, 2010). Due to absence of standardized function for HCAs, limits to roles of HCAs are vague. An individual HCA’s role depends upon a variety of factors such as the specific clinical area, the means by which delegation occurs, and the particular ideological thinking of the healthcare setting (Keeney et al. 2005). This lack of standardization is evidenced by differences in job descriptions for HCAs in different UK hospitals (Wakefield et al., 2009) which lead not just to confusion for the registered nurse but for the support worker as well who work together in a clinical area. It is expected that the three areas which are being considered in the HCA work responsibilities: direct patient care, housekeeping duties, and clerical tasks, will be designated and supervised by registered nurses. Nevertheless, in reality when HCAs are working in a clinical setting, there is a wide variation how their duties are performed which may be dependent on the hospital and ward. Generally, what was observed of HCAs are they oftentimes working solely and independently with least possible supervision and delegation (Spilsbury & Meyer, 2004). Role and accountability of registered nurses The function of registered nurses has been evolving in the past years. Nurses now carry out more highly technical care to the extent of doing the work of junior doctors. As a consequence, the once nurse-centered patient care has been to health care assistants who are also called as support workers or care assistants. While there have always been nursing assistants before, the HCAs are formally designated as care workers (Spilsbury & Meyer, 2004). Registered nurses are those whose name is registered with the Nursing and Midwifery Council (NMC), the regulating body for Registered Nurses in the UK. In order to be registered as a nurse, an individual must have successfully completed an education program which binds to NMC standards for Preregistration Nurse Education (NMC, 2004). Health care assistants or support workers or care assistants are less clearly defined. They are generally those whose function is to work under the guidance and directives of a registered practitioner (NHS, 2009). It was clearly and precisely stated by the Nursing and Midwifery Council the standards as guidelines for conduct, performance, and ethics particularly of nurses and midwives. Aside from giving care and helping a patient in treatment, there are other several attitudes that are expected of a nurse especially in promoting the well being of a patient. A registered nurse who designates a task to others remains accountable for the appropriateness of that delegation and for furnishing the suitable level of supervision so as to ensure competence to performing the delegated aspects of care. The registered nurse remains accountable for the delivery of the care plan and for making sure that the overall goal for that particular patient is achieved (Delegation, 2008). Dimond (2008) has stated the legal responsibility of the nurse when undertaking delegation that it is the personal and professional responsibility of each professional practitioner who delegates aspect of care to make sure that the person to carry out that particular task is trained, competent, and experienced to accomplish the activity safely (p. 570). The Nursing & Midwifery Council (2008) defines the accountability of the delegator. When the registered nurse or midwife delegates care to another professional, health care support staff, carer or relative, he/she should designate a task effectively and holds then the accountability for the appropriateness of the process of delegation. The Code necessitates the delegators must establish that the delagatee has the ability to carry out the directions then must confirm that the result of the task satisfies the criteria of standards. Lastly, the delagatee are made sure that they are supervised and supported. Being responsible for making decisions on delegating work or tasks to another person, a registered nurse must make sure the person delegated with task fulfills some criteria for successful outcome of the activity i.e. knowledge, skills and competence. Additionally, continued supervision of HCAs and APs remains an essential part of the registered nurse. Though HCAs and APs are accountable for their actions in performing the delegated work, the RN is accountable for the general standard of nursing in the workplace. HCAs and APs functions are clearly stated in their job descriptions with a record of their assessed competences. Unless the task delegated clearly forms part of the HCAs’ or APs’ job description and he/she has been signed off as competent to do it, the RN remains professionally responsible for any form of care he/she delegates to the HCA or AP (NMC 2008b). Furthermore, if a registered nurse is supervising a HCA or AP who is performing a task that was given to him/her which is stated as part of his/her her job description and competences, then even though the RN is not directly responsible for the HCAs’ or APs’ actions, the RN is still responsible for making sure that the general care delivered given is safe and within the limits of competence (NMC, 2008b). Conclusion The worldwide insufficiency of qualified registered nurses and the ageing nursing population has consequently resulted in an increasing dependence on non-qualified personnel such as the support workers to carry out particular aspects of patient care within the care setting (Gillen & Graffin, 2010). Much hands-on care is now being carried out by support workers. And since they are not registered, it is important that they are trained and be qualified to a national standard. Also, patients must know who is taking care or treating them and they expect that these persons have understanding and knowledge and are competent in giving their service to patients (CSP, et al., 2006). The NMC’s Code of Professional Conduct defines steps to how to effectively delegate tasks (NMC 2008b). First, it is imperative that RN must ensure that whoever is delegated a task has the ability to perform the instructions given. Next, RN must make sure that everyone he/she is responsible for is supervised and supported. Lastly, the outcomes of the tasks must have undergone through standards of care. To avoid breach in delegations of tasks to support workers, registered nurses must always take into consideration some guidelines (NMC 2008a). They have to avoid delegating activities without giving sufficient instructions and have to have assurance that the support worker is able to do the activity competently. They can ask for assistance and advice to more experienced professionals when problems regarding delegation of work arise. They must also regularly review delegated tasks. They are expected not to delegate tasks which are outside the scope of their skills and experiences or are not competent to carrying out such tasks. Also, if the RN has been asked to delegate tasks to HCA/AP which she believes that it cannot be carried competently, she should refuse the instruction. It is stated in the Code of NMC that nurses are given the trust regarding a patient’s health and thus that trust can be justified by nurses through prioritizing care to a patient and respecting their dignity, working with other health team members for the benefit of the patient, providing a high standard of practice. Actions of the nurse must always be based on standards of nursing practice which is essentially under legal guidance. 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