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Critical Thinking: Working Effectively with LPNs and Nursing Assistive Personnel

This course has been awarded six (6.0) contact hours. This course expires on December 19, 2014.

Copyright © 2007 by RN.com. All Rights Reserved. Reproduction and distribution

of these materials are prohibited without the express written authorization of RN.com.

First Published: February 16, 2007

Revised: September 27, 2011

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Acknowledgements RN.com acknowledges the valuable contributions of… …Bette Case, author of Critical Thinking: Working Effectively with LPNs and Nursing Assistive Personnel. Since 1993, Bette has practiced as an independent consultant to a broad spectrum of healthcare organizations including American Mobile Healthcare, Inc., professional schools, professional organizations, hospitals, disease management companies, managed care organizations, a public health department and providers of continuing nursing education. She works with her clients to assist them in achieving their goals by using educational, competency management and quality improvement strategies. She is also a partner in Clinical Care Solutions, Inc., which focuses its business on improving medication safety. She presents continuing education offerings at a variety of national and regional conferences. She has published on the topics of critical thinking, test construction, competency testing, precepting and career development. She has also written numerous continuing education self-study courses and prepared competence tests for a variety of nursing specialties. She serves on the editorial board of the Journal of Continuing Education in Nursing and on a regional advisory board for Advance Magazines. Prior to establishing her consulting practice, she held leadership positions in the school of nursing and the nursing department at Michael Reese Hospital and Medical Center in Chicago, IL. She has taught nursing students of all levels and college of education students. As a practicing nurse she enjoyed the roles of staff LPN, medical surgical staff nurse, school health nurse and camp nurse. She is an active member of the Nursing Staff Development Organization (NNSDO) and was among the first group of nurses to receive certification in Nursing Staff Development and Continuing Education from the American Nurses Association Credentialing Center (ANCC). She earned her BSN at Syracuse University and her MSN and PhD in educational psychology at Loyola University of Chicago.

Purpose & Objectives

The purpose of Critical Thinking: Working Effectively with LPNs and Nursing Assistive Personnel is to educate nurses about the roles and training of LPNs and Nursing Assistive Personnel (NAP) and to examine issues related to the delegation process. This course provides the nurse with critical thinking strategies that promote teamwork and improve patient care. After successful completion of this continuing education course, participants will:

1. Identify the important sources of information about the roles and responsibilities of Licensed Practical Nurses (LPNs) and Nursing Assistive Personnel (NAP)

2. Compare the preparation and roles of LPNs and NAP, identifying similarities and differences

3. Identify potential legal liability concerns for RNs when working with LPNs and NAP

4. List and apply The Five Rights of Delegation

5. Explain the steps of the delegation process

6. Describe effective techniques for supervising and communicating with LPNs and NAP


7. Describe approaches for building rapport and teamwork when working with LPNs and NAP

8. Identify ways for the RN to develop and mentor LPNs and NAP

9. Discuss ways to achieve job satisfaction for RNs, LPNs, and NAP in working together

Overview A Note about Terminology

In this course the term LPN - Licensed Practical Nurse – applies to both LPNs and Licensed Vocational Nurses (LVNs). LVN is the title used in California and Texas. The term unlicensed assistive personnel (UAP) has been widely used to designate Nursing Assistants, Patient Care Technicians and others who assist with patient care and are not licensed to practice nursing. In a joint statement concerning nursing delegation (2006), the American Nurses Association (ANA) and the National Council of State Boards of

Nursing use the term Nursing Assistive Personnel (NAP). The term NAP is used in this course. Introduction

“I’d rather do it myself!”

Many RNs feel frustrated when delivering care through other team members. But LPNs and NAP can capably provide many aspects of care, freeing the RN for those aspects that require nursing judgment. By thinking critically and delegating wisely, the RN can promote positive patient outcomes and a positive work environment. This course will assist you in applying critical thinking strategies to challenges and issues that arise when working with LPNs and NAP.

More Information

Issues and Challenges Critical Thinking Strategies

Recognizing and responding to the similarities and differences between LPNs and NAP

Distinguish among roles and individuals

Acquiring the facts and knowledge essential to manage LPNs and NAP, including legal implications

Build and elaborate on your knowledge base about roles, delegation, and legal implications Validate the credibility of your sources of information about roles and competencies

Mastering the delegation process Inquire about the individual’s competencies and analyze assignments to match competencies to patient needs Validate your assumptions about competencies and patient needs Evaluate care given by LPNs and NAP and give constructive feedback Assemble evidence to support your conclusions about appropriate assignments and safe care

Establishing rapport, achieving Explore multiple perspectives of all involved: LPNs,


teamwork, and developing LPNs and NAP

NAP, patients, and others Demonstrate open-mindedness to viewpoints of others

Improving your own job satisfaction and comfort level

Reframe situations by making adjustments that maximize your efficiency and effectiveness Reflect and gain confidence in your decision-making and delegation

Important Sources of Information about Roles LPN and NAP roles vary by state, within states, and by organization. Use credible resources to access information about the roles in your state and your organization. National Council of State Boards of Nursing (NSCBN) www.ncsbn.org

• Composed of Member State Boards of Nursing, including Boards of 50 states, the District of Columbia, and 4 US territories. Five states have 2 Boards – one for RNs and one for LPNs.

• Provides leadership to advance regulatory excellence for public protection.

• Develops definitions, position papers, and models related to nursing regulation.

• Develops and regulates all nursing licensing examinations.

• Collects information about practice issues, including updates of scope of practice.

Your State Board of Nursing https://www.ncsbn.org/2137.htm

• The State Board of Nursing licenses all RNs and LPNs.

• As mandated by federal law, each state has a process for regulating training and registration of NAP who work in long-term care (LTC). In many states, the Board of Health and not the Board of Nursing regulates LTC NAP.

• The State Board of Nursing defines the scope of practice for all individuals it licenses.

• The State Board of Nursing handles all allegations of misconduct of licensees.

• Some Boards of Nursing have developed position papers and guidelines regarding roles of LPNs, NAP, and the delegation process. For example, the California Board of Registered Nursing developed guidelines for working with UAP (California Board of Registered Nursing, 1994) and added further specifics after a 1999 change in the state’s Nurse Practice Act (California Board of Registered Nursing, 2000).

Your State’s Nurse Practice Act and Rules and Regulations

• Most State Board of Nursing Websites have links to the Nurse Practice Act and Rules and Regulations.

• Review of your state’s regulations is the FIRST step in learning roles and expectations of LPNs and NAP and your responsibilities for delegation. Your organization can allow individuals to perform only those activities permitted by these regulations.

Your state nurses association http://www.nysna.org/practice/positions/position1_04.htm


• Some state nurses associations have developed position papers and guidelines about delegation and working with LPNs and NAP, for example, Registered professional nursing’s utilization of unlicensed assistive personnel (NYSNA, 2004).

Your professional specialty organization

• Some nursing specialty organizations have developed position papers and specific guidelines about use of NAP. These include the American Association of Critical Care Nurses (AACN, http://www.aacn.org), the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN, http://www.awhonn.org) and the Infusion Nurses Society (INS http://www.ins1.org), and others.

Your organization’s job descriptions and policies and procedures

• Your organization’s job descriptions of the personnel to whom you delegate and the policies and procedures regarding delegation are the standards to which you are accountable – both to your employer and in a court of law. Read these yourself – do not rely on others’ interpretations. Organization job descriptions should reflect the limitations of the Nurse Practice Act and Rules and Regulations. However, any organization may restrict practice further and not permit certain activities to be performed by individuals in a particular role even though the state law allows it.

Your organization’s competency documentation system

• Your organization has a system for assessing, validating, and documenting competency of LPNs and NAP. Find out how to access this information so you are fully informed about the competency of those to whom you delegate.

The American Nurses Association (ANA) reaffirms its belief that the utilization of nursing assistive

personnel (NAP) in the provision of specific aspects of direct and indirect patient care, as the result of delegation and direction by a registered nurse (RN) in accordance with state nurse practice acts, is an

appropriate, safe, and resource-efficient method of providing nursing care (ANA, 2007). Validate Unit-Specific Information Validate feedback from other staff about specific LPNs or NAP. Do your own data gathering. When you are new to a unit, even within the same organization, proactively clarify the LPN and NAP role on that particular unit. You might assume the LPN will give all medications to her assigned patients because that was the way it was done on the unit where you worked previously. If you failed to check out that assumption, you could come to the end of the shift and realize none of the LPN’s patients received medications because this LPN has not yet passed the medication safety test required in this hospital.

LPNs

LPNs

• The state licenses the LPN.

• The state, through the Board of Nursing, approves educational programs that qualify graduates to take the licensing examination.

• The Board of Nursing disciplines licensees for infractions of the Nurse Practice Act.

• The LPN receives delegation from the RN and other health professionals including physicians,


dentists and others.

• In some jurisdictions, LPNs may delegate to NAP. Most states reserve initial patient assessment, initial care plan, and administration of IV push medication for the RN.

IMPORTANT POINT: Each state’s Board of Nursing clearly defines the role of the LPN in the state.

Access your state’s Nurse Practice Act and Rules and Regulations. State Regulation of LPNs States regulate LPN education and revise the requirements to keep pace with changes in technology, practice, and the needs and expectations of healthcare facilities. Some states publish specific lists of permitted activities and restricted activities. Many states permit LPNs to administer IV medications. Some states require special training for IV therapy; others restrict IV therapy practice to hanging pre-mixed solutions and monitoring. Some states distinguish between the general LPN role and the role of the LPN in the dialysis setting. States differ in their definitions of LPN scope of practice (NCSBN, 2005), especially with respect to:

• Developing a plan of care independently

• Making changes in the plan of care

• Performing telephone triage

• Assessing patients

• Initiating and administering IV fluids and medications

• Patient and family teaching

• Delegation: 28 Boards of Nursing allow the LPN to delegate; 33 Boards allow the LPN to make assignments

States vary greatly in the restrictiveness and specificity of the LPN scope of practice and practice activities. Researchers rated U.S. states and territories on a 4-point scale for restrictiveness and specificity (Seago, et al., 2004).

Which 2 states were most restrictive? Iowa, the Virgin Islands

Which 5 states were least restrictive? Florida, Hawaii, Indiana, Louisiana, Massachusetts

Which 4 states were among the most specific? California, Kansas, Maine, New Jersey

Which 4 states were among the least specific? Arizona, Connecticut, Maryland, Michigan, Texas

Which 4 states did employers restrict LPNs from practicing some activities state law pemitted? California, Louisiana, Massachusetts, Iowa

LPN Scope of Practice

In your experience, do RNs and LPNs have the same role and perform the same work, with the exception of a few specific activities that the RN performs with the LPN’s patients, such as IV


medications and admission assessments?

YES – according to 39% of employers

52% of LPNs 62% of RNs

(Smith & Crawford, 2004 in NCSBN, 2005)

But State Nurse Practice Acts and Organization Policy and Procedure would not agree.

In addition to the disparity among states’ scopes of LPN practice, facilities differ in the descriptions and responsibilities of the LPN – even facilities within the same community. Some facilities define more than one level of LPN practice, such as: LPN I: the basic level of practice may be designated as LPN I or simply LPN. This basic level as defined by the organization may be more restrictive than the scope of practice defined by the state. LPN II: a level of practice expanded beyond the basic level. Facilities identify additional duties that may be performed by LPNs who hold this designation. Usually the additional duties are based upon additional education or training. Duties must be within the scope of practice defined by the state. Additional duties are often related to IV therapy. The organization may designate the higher level in various ways, such as MLPN (indicating medication administration) or LPN II. LPN Responsibilities The NCSBN develops licensing examinations based upon a systematic analysis of practice, a research process to identify the duties performed most frequently and considered most important by licensed individuals during their first six months of practice. Findings of the 2009 LPN practice analysis (NCSBN, 2010a) indicated that in addition to providing routine care, newly-licensed LPNs:

• Spent the greatest amount of time in medication-related activities (15%) and activities related to safety and infection control (13%)

• Acted as charge nurse (6% in hospital setting, 53% in LTC)

• Might have earned a certificate in intravenous therapy (26%) or phlebotomy (10%)

• Frequently:

• Assigned and supervised NAP or other LPNs

• Organized and prioritized care for a group of patients

• Monitored laboratory results

• Reinforced patient education

• Implemented measures and intervened to prevent complications

• Advocated for patients

• Measured oxygen levels

Case Study: The Mature, Experienced LPN Compare your thoughts about this situation with those of your supervisor and your RN colleagues. Make sure your response is in the best interest of the patient and you are giving both appropriate


respect and appropriate supervision to the LPN or NAP involved. There is more than one effective way to manage most situations.

You are new to a unit and need to assess the skills of a LPN who appears to be in her late 50s. When you ask her about her experience in catheterizing men, she is highly offended and says, “Look here, I was ‘cathing’ men on this unit long before you were even born!” Approaches to Consider

• Communicate to the LPN that you respect her experience and were asking simply because you do not know her or her skills.

• Is there another RN on the unit with whom you could validate the LPN’s skills?

Orientation Needs of the LPN Newly-licensed LPNs indicated their orientation process had not prepared them well for several tasks (Kenward & Zhong, 2006), including:

• Caring for large groups of patients

• Managing time and organizing tasks

• Recognizing changes in condition necessitating intervention

• Knowing when and how to call a patient’s provider

• Creating legally defensible documentation

• Teaching patients

• Supervising others

When working with a particular LPN for the first time, assess the individual’s competence and confidence with the activities you expect that individual to perform. NAP NCSBN has defined UAP as “any unlicensed personnel, regardless of title, to whom nursing tasks are delegated” (NCSBN, 1995). More recently, NCSBN and ANA have used the term “Nursing Assistive Personnel.” Some states, associations, and employers continue to use the term UAP. More frequently, employers refer to a job title, such as nursing assistant, patient care assistant or other such title. Federal law requires states to design and implement training and competency validation for LTC nursing assistants. Acute care facilities may choose to hire only nursing assistants who have completed the state requirements for LTC nursing assistants, but state registration of acute care nursing assistants is not a federal requirement. Each state determines its own registration process. States vary greatly in training and assessment requirements. In many states, the designation CNA is used, representing Certified Nursing Assistant in some states and Certified Nurse’s Aide in other states. More than 40 different titles for state-registered nursing assistants are in use throughout the U.S., including “Licensed Nurse Assistant” and “State Registered Nurse Aide” (Randolph & Sorrentino, 2010). In many states, it is the Department of Health and not the State Board of Nursing that regulates training and registration of LTC nursing assistants. State Guidelines for NAP Some individual states and state nursing associations refine the definition of NAP. For example, the California Board of Registered Nursing defined unlicensed assistive personnel as “those healthcare


workers who are not licensed to perform nursing tasks; it also refers to those healthcare workers who may be trained and certified, but are not licensed” (California Board of Registered Nursing, 1994, p. 2). Although most states do not license the practice of NAP, many states restrict NAP from performing specific duties. For example, consistent with a law passed in 1999, in California UAP under the direct clinical supervision of a registered nurse may not perform duties that require a substantial amount of scientific knowledge and technical skills, including but not limited to:

• Administering medications

• Performing venipuncture or administering IV therapy

• Administering parenteral or tube feedings

• Performing invasive procedures such as inserting NG tubes, catheters, or tracheal suctioning

• Educating patients and families regarding care and post-discharge care

• Performing moderately complex laboratory tests

(California Board of Registered Nursing, 2000)

Nurse Practice Acts, Rules and Regulations and positions of Boards of Nursing have the force of law. Definitions and positions authored by professional organizations serve as standards and guidelines, but do not have the force of law. States, through the Board of Nursing or Board of Health, may discipline NAP whom the state has registered. Many Boards of Nursing maintain a registry of NAP who have been disciplined for patient abuse. Some Boards of Nursing conduct competency evaluation of NAP. For acute care settings, such evaluations are conducted in 15% of states or jurisdictions: Guam, Kentucky, Maryland, Nevada, New Hampshire, New Jersey, Oklahoma, Vermont, Wyoming (NCSBN, 2009). Some Boards of Nursing (North Carolina and Oklahoma) designate an advanced level of NAP practice in acute care, “Advanced Unlicensed Assistive Personnel” (NCSBN, 2009). Organization Guidelines for NAP An organization defines NAP practice in policy and procedure and job descriptions. Facilities cannot legally permit NAP to perform duties that state law forbids. Facilities may restrict NAP practice further than state regulations do. Organization policies, job descriptions and guidelines apply ONLY within that particular organization. Some of the titles healthcare facilities use for their NAP include: Patient Care Assistant (PCA), Patient Care Partner, Technical Assistant, Hospital Assistant, Nursing Assistant, Certified Nursing Assistant, Nurse Technician, Critical Care Technician (or other unit-specific technician), and Environmental Assistant. Duties vary widely and might be limited to direct patient care, patient transport, specimen collection, housekeeping duties, or other limited responsibilities. Roles and responsibilities vary greatly from one organization to another. An organization may staff Patient Care Assistants and Environmental Assistants on general units and use other NAP titles and task lists for certain unit-specific jobs, such as Critical Care Assistant.


As part of your orientation at a new organization, find out whether there is more than one level or job description for LPNs and the various NAP on the unit(s) on which you will be working. Keep these differences clearly in mind when you plan your work, delegate, and set your expectations. NAP are accountable to the employing organization. If NAP are registered through the state’s registration program for NAP who work in LTC, the state has a role in disciplining inappropriate practice. Typical NAP Responsibilities In the NCSBN job analysis survey, nursing assistants reported caring most frequently for patients who had stable chronic conditions, patients with end-of-life conditions, and patients who had behavior/emotional conditions. The majority reported caring for older adults. In addition to performing basic care activities, all respondents reported they ask for help when needed, observe standard precautions, and respect patient confidentiality and privacy (NCSBN, 2010b). Facilities authorize NAP to perform many tasks. Most frequently performed tasks include (Bittner & Gravlin, 2009):

• Vital signs

• Blood glucose testing

• Weights

• Intake and output

• Feeding

• Ambulating

• Transport

• Bathing

• Activities of daily living

• Answering call lights

• Toileting

• Stocking rooms

Some facilities provide additional training and authorize NAP to perform more specialized tasks such as removing monitor leads, removing intravenous needles, and applying nasal oxygen. Working with NAP Clarify the NAP job description(s) specific to your organization and to your unit and individual NAP competency before assigning patient care tasks. Identify the staffing practices of your organization in the use of NAP. In some facilities, one NAP is teamed with only one RN. In others, a NAP may work with several RNs, performing various tasks with all of the patients assigned to those RNs. Research findings indicate that assigning one NAP with one RN is preferable (Potter & Grant, 2004). However, if you are sharing a NAP with another RN, you will need to coordinate your patient care assignments, ensuring that together you do not assign the NAP more tasks than can reasonably be accomplished during the shift. Case Study: The NAP Oversteps Practice Boundaries Compare your thoughts about this situation with those of your supervisor and your RN colleagues. Make sure your response is in the best interest of the patient and you are giving both appropriate


respect and appropriate supervision to the LPN or NAP involved. There is more than one effective way to manage most situations. You are working in the ED. The family of an 80-year-old female patient, who presented complaining of headache, tells you your new NAP has just told her to go home and take Tylenol® since the ED is so busy. You take vital signs and find that the woman has a temperature of 102° F (38.8° C) and a BP of 210/110 mmHg. Approaches to Consider

• Acknowledge to the NAP you understand the intentions were good, but only the nurse can make and communicate decisions about patient triage to patients.

• Tell the NAP under no circumstances is a NAP ever to recommend medical treatment, including over-the-counter medication.

Case Study: The NAP Gives Dietary Advice Compare your thoughts about this situation with those of your supervisor and your RN colleagues. Make sure your response is in the best interest of the patient and you are giving both appropriate respect and appropriate supervision to the LPN or NAP involved. There is more than one effective way to manage most situations.

Although you usually work 7P to 7A in the ICU, you are floated to a medical-surgical unit. When doing your initial patient rounds, you overhear a nurses’ aide talking with the family of a patient being treated for an exacerbation of insulin dependent diabetes and COPD. The nurses’ aide tells the family that it is OK for them to go to a nearby fast food restaurant specialized in fried chicken to buy some food for the patient, since he didn't like and wouldn't eat what was on his dinner tray.

Approaches to Consider

• Explain to the NAP diet is an important part of treatment, especially for this patient. Reinforce to the NAP that in a hospital, the doctor orders the patient’s diets and both patients and staff must work together to follow the diet orders strictly.

• Explain to the family that the NAP did not realize the patient had a dietary restriction and was inappropriate in her remarks.

• Explain to the family the physiologic and therapeutic rationale for the prescribed diet and emphasize they should not bring substitutes or supplements to the patient without checking with a RN. Inquire about the patient's food preferences to identify foods that are both preferred AND allowed.

• If indicated, obtain a nutritionist’s consult.

Selecting Tasks to Delegate After clarifying the job description and the competencies of those to whom you delegate, take the next important step of determining if a specific task is more appropriate for you as the RN, for the LPN, or for the NAP. The patient’s condition may make it necessary for you to perform certain tasks that normally an NAP or LPN could perform. For example:

• You may want to perform a certain sterile dressing so you can closely observe the wound, although the LPN with whom you are working is quite proficient in dressing changes.

• Organization policy may permit the NAP to draw blood. If a Nursing Assistant is working with you and there is a blood draw ordered on one of your patients, you will need to find out if this Nursing


Assistant is competent to perform this task and plans to do so. Legitimate questions to ask are:

• How many times have you drawn blood on this unit?

• What collection tubes are used for this draw?

• Does this test require any special techniques or treatment of the blood once drawn?

• How comfortable are you with doing this procedure?

• Have you drawn blood from this patient or from other patients in this condition before?

Use open-ended questions to assess competency. In an effort to please you or to appear skillful, an NAP may answer in the affirmative if you simply ask yes-or-no questions such as, “Have you been trained to do phlebotomy?” Always keep in mind that skills are lost when not practiced. An individual NAP may have been taught phlebotomy, but may have become rusty in assessing and finding good veins if the skill is not used frequently. NAP Previous Experience Some new NAP are long-term hospital employees who have worked in some version of nursing assistant roles for many years. Some nurses estimate that 40% - 50% of NAP are beginning nursing students who have little previous experience in giving personal care or in relating to hospital support services. Still others are medical students, emergency medical technicians (EMTs), or individuals who have formerly worked in other hospital departments such as patient transportation, dietary, housekeeping, lab, or respiratory therapy. With such variation in education, training, and prior experience there is a wide variation in language and computation skills. Regardless of previous roles and experiences, NAP are limited to perform ONLY the duties outlined in organization policy and procedure and job descriptions. Comparing LPNs and NAP In general, LPNs are a more homogeneous group than are NAP. Although there are some differences among states, LPNs receive education and training in similar settings - vocational schools, and community colleges. They may complete their training in as little as fifteen months. LPN students learn basic anatomy and physiology, but are not educated in the disease processes and rationales for actions to the same extent that RNs are. LPN training focuses on nursing skills.

The role differences between LPNs and NAP impact upon the way in which you plan your time. NAP require more supervision from you. LPNs give medications and take patient assignments, but NAP do not. Therefore, working with NAP means that as the RN you will probably have a larger patient assignment in addition to your supervisory responsibilities (Unruh, 2003). Only by delegating tasks to the maximum within the safe capabilities of NAP will you be able to give adequate attention to the patients’ needs which require RN capabilities and at the same time provide adequate supervision for the NAP.

Comparing LPNs and NAP


If a task is within the job description of the NAP, what 2 pieces of additional information do you need to consider before delegating the task?

1. The patient’s condition

2. The NAP’s competency with this task

Case Study: The NAP Recommends OTC Medication Compare your thoughts about this situation with those of your supervisor and your RN colleagues. Make sure your response is in the best interest of the patient and you are giving both appropriate respect and appropriate supervision to the LPN or NAP involved. There is more than one effective way to manage most situations.


You overhear a conversation between Shirley, a Patient Care Assistant, and Mr. Cooper who is hospitalized for treatment of COPD and BPH. He tells her “this all started with a ‘dang’ cold.” She responds, “Well, the next time you feel a cold coming on get some ‘Coldgone.’ My whole family swears by it. It’ll fix you right up in a day or two.” You recognize that the over-the-counter drug Shirley named has anti-cholinergic effects and taking that drug or many other OTC anti-histamines would present a risk to Mr. Cooper. Approaches to Consider

• Explain to the NAP only the doctor or other licensed prescriber can prescribe medications of any kind. Additionally, explain that nearly all over-the-counter cold remedies contain substances that would be particularly harmful for this patient.

• Explain to the patient the NAP did not understand the over-the-counter cold remedies might be harmful to him. Explain the rationale for him to avoid agents with anti-cholinergic effects.

Accountability and Responsibility

• ACCOUNTABILITY: “The nursing professional is legally responsible (liable) for his/her actions

as it relates to the overall nursing care of his/her patients”

• RESPONSIBILITY: “The nursing professional or competent individual has an obligation to perform tasks reliably, dependably and at an acceptable level”

(Barnes, 2006, slides 5, 6) Delegation and the Law The RN is accountable for:

• Appropriate delegation of tasks

• Appropriate supervision of team members

• The outcome of the delegated task

• Knowing and acting within the limitations of the scope of practice, job description, and competency of anyone to whom the RN delegates

The Consequences of Negligence

Negligent delegation or negligent supervision can lead to disciplinary procedures:

• The State Board of Nursing may suspend or revoke the license to practice nursing, or otherwise discipline the licensee.

• The employer may discipline the nurse according to the employer’s policy and procedure.

Nurse Practice Acts hold RNs accountable for the results of delegated tasks and for the supervision of those to whom they delegate.

Supervision includes:

• Assuring that the persons to whom you delegate are competent to perform the tasks

• Providing guidance, direction, evaluation, and follow-up to assure that they complete the tasks assigned

RNs may delegate only duties that are within the scope of their own practice and employment, and not excluded from the scope of practice of the person to whom they delegate.


The individual who receives delegation is responsible for performing tasks within his job description and competency and for seeking help if needed. The RN is accountable for the outcome and for applying sound judgment in choosing tasks and personnel for delegation, and for providing supervision. NAP may not delegate their assigned tasks to others. They may appropriately refer them back to the delegating nurse if they feel they do not have sufficient skills to perform the task at all, or are not comfortable with a specific patient. NAP are liable for performing tasks they have been trained to do and for NOT doing things they are NOT authorized to do by organization policy. • RNs practice independently; LPNs practice dependently, under supervision. • You are the only person practicing under your license. It does not cover anyone else. • LPNs are accountable for practicing within the scope of their licensure. Potential Legal Issues

Negligent hiring practices:

• In most states, NAP are not licensed. Certifications may be limited to long-term care settings and may not indicate competence in acute care. Reference checks are the responsibility of the employer.

Negligent training:

• The RN must delegate ONLY those tasks that are appropriate to the NAP’s training, credentials, experience, and job description. If a patient is harmed because the NAP job description includes tasks that NAP are not trained to perform, the employer may be liable for the negligent training.

Negligent delegation:

• Delegation can be negligent if the nurse delegates a task that is not within the job description or competency of the delegatee. Delegation can also be negligent if the circumstances such as patient condition create a risk, even though the task itself was within the job description and competency of the delegatee.

Negligent supervision:

• You can be found negligent if you breach the standards of care for supervision and consequently a patient is harmed.

Vicarious liability:

• Supervisors are liable if they assign inappropriate tasks to anyone who lacks the skill or training to perform them. That is, you could be held liable for harm to the patient if you inappropriately delegated to NAP a task for which they have not been trained and which is not in their job description (Helm, 1998).

Patient abuse:

• A healthcare organization that receives a report of suspected abuse has legal and ethical duties to investigate the report. Law also requires the organization to inform the family of the suspected abuse. State law requires the physician to report suspected abuse within a specific timeframe. It is


important that all staff members are aware of the institution's policies related to abuse and neglect.

If you have concerns that patient safety is being jeopardized by any circumstances under which you are delegating, bring your concerns to the attention of your manager or the nursing administrator on duty. Case Study: The LPN Suspects the NAP of Abuse Compare your thoughts about this situation with those of your supervisor and your RN colleagues. Make sure your response is in the best interest of the patient and you are giving both appropriate respect and appropriate supervision to the LPN or NAP involved. There is more than one effective way to manage most situations. Mary, an experienced LPN on your unit, reports to you that Dan, a NAP, is “really rough with the patients.” She tells you that she found bruises on the upper arms of Mr. Sims, an elderly patient who is confused and agitated. Dan has been bathing and feeding Mr. Sims and making his bed for the past couple of days. Approaches to Consider

• Thank Mary for reporting this and tell her you will follow-up.

• Observe Dan frequently during patient care. Listen outside of his patients’ rooms.

• Report Mary’s concern to your manager and tell her what you did to follow-up and what you observed.

• If you note any evidence of abuse, remove Dan from the patient situation and notify the supervisor.

Protecting Yourself from Allegations of Negligence Delegation has been identified as one contributing factor in the increased number of malpractice payments made by nurses (Croke, 2003). Specifically, “delegation of some tasks may be considered negligence according to a given facility’s standards of care or a state’s nurse practice act.” (Croke, 2003, p. 55; italics added). Protect yourself from negligence by knowing and acting on your organization’s standards of care and your state’s nurse practice act. In addition to these standards, your actions may be compared with the actions that a reasonable, prudent nurse would have taken in the same situation – a standard supplied by the testimony of an RN comparable to you in training and experience. Court rulings in cases of alleged negligence in delegation emphasize the importance of communication, supervision, and NAP training (Anderson, et al., 2006). The RN’s liability has been determined based upon:

• How quickly the RN responded to information reported to the RN by NAP

• How quickly the RN reassessed a patient after the patient was burned during a bath given by NAP

• Whether the RN delegated and supervised appropriately

The RN, the NAP, and the organization may each, or all, be held liable when a patient is injured or dies and delegation was a factor in the situation. NAP have been found negligent for failing to report significant information. In one case in which a NAP failed to report repeated complaints of pain to the nurse and the patient died, the facility settled out of court for 3 million dollars.


Delegation Appropriate utilization of NAP can reduce some of the non-professional task burden of the RN and allow the RN to focus on the professional assessment, judgment, skills, and evaluation of outcomes required to maintain quality patient care. Integral to the delivery of safe, quality nursing care is the proper delegation. ANA outlines responsibilities for RNs and for facilities regarding delegation (ANA, 2007). If LPNs and NAP are in the unit’s staffing plan, then the unit manager expects you will make effective use of these personnel. Failing to do so may cause you to feel overwhelmed and dissatisfied. Your frustration may spread to other RNs on the unit as well as to the LPNs and NAP whose skills are not fully utilized. “Any nursing intervention that requires independent, specialized nursing knowledge, skill or judgment cannot be delegated” (ANA, 1997). You cannot delegate the nursing process. Likewise, specialized tasks, such as spinal drains on a neuro unit, are also reserved for licensed nurses. “The abilities to delegate, assign, and supervise are critical competencies for the 21st century registered nurse” (ANA & NCSBN, 2006, p.1). However, barely half of RNs surveyed indicated that their orientation prepared them adequately to delegate to and supervise LPNs or assistive personnel (Kenward & Zhong, 2006). Some nursing organizations, notably ANA, the American Association of Critical-Care Nurses (AACN), and the National Nursing Staff Development Organization (NNSDO), recognize the importance of training and continuing education for NAP as well as the importance of training for RNs in the effective use of NAP. Each has produced a number of tools, training plans and other materials intended to enhance effective use of NAP. Some of these tools are available for download and printing at the organizations’ websites.

Delegation across the USA

• 44 states define delegation

• For example, Arizona’s Nurse Practice Act states:

"’Delegation’ means transferring to a competent individual the authority to perform a selected nursing task in a designated situation in which the nurse making the delegation retains accountability for the delegation”

• 48 Boards of Nursing refer to delegation in the Nursing Practice Act or Rules and Regulations

• 39 states specifically include delegation in the RN scope of practice

• 32 states include grounds for discipline re: delegation

• 30 states include a specific delegation section

• 23 states authorize the LPN/LVN to delegate

Based on 2003 survey results (NCSBN, 2003)

Roles Definition Uncertainty about roles is a barrier to effective delegation (Bittner & Gavlin, 2009). “Unlicensed assistive personnel are equipped to assist – not replace – the nurse. Nursing is a knowledge-based discipline and cannot be reduced solely to a list of tasks. The nurse’s specialized education, professional judgment and discretion are essential for quality nursing care. While nursing


tasks may be delegated, the licensed nurse’s generalist knowledge of patient care indicates that the practice-pervasive functions of assessment, evaluation and nursing judgment must not be delegated.” (NCSBN, 1995) As a RN you might identify that for one patient, a small hourly urine output is expected and is normal, while for another that same number of milliliters per hour of urine output may indicate urinary retention with overflow. This type of analysis, based upon knowledge of pathophysiology and pharmacology is not included in the education of LPNs, and is not part of NAP training. Education and training for LPNs and NAP focuses on performing procedures and tasks, NOT on learning rationales or making judgments. Keeping Roles Clear NAP are responsible ONLY for performing tasks that they have been trained to complete. They are authorized ONLY to perform the tasks they have been trained to complete. Delegate to NAP only routine, repetitive tasks that are limited in scope. “The most experienced NAP cannot replace the least experienced professional nurse” (Boucher, 1998).

Issues Affecting the Decision to Delegate

• Task and patient assessment in terms of potential for harm • Complexity of task • Problem-solving and critical thinking required • Predictability of outcome • Caregiver-patient interaction • Practice setting, in terms of resources and patient acuity • Staff competency and scope of practice • Context of other patient needs

Adapted from (AWHONN, 2009; ANA & NCSBN, 2006; Snyder, et al., 2004)

You may use NAP effectively to extend your ability to collect assessment data. You do not need to teach the NAP all the rationale for the significance of findings, but be sure that you communicate to the NAP those observations that are important given the condition and treatment plan of each patient:

• Assure yourself that NAP correctly understand and interpret your intent. Be sure they do not assume the direction you give them for one specific patient applies to all patients.

• Collaborate with RNs on other shifts to make individualized checklists for NAP related to unique conditions of specific patients.

• Within organization policy and procedure, create checklists for patient conditions common on your unit.

• Facilitate good reporting from NAP through the use of a simple form on which NAP record their notes during the shift.

Case Study: The NAP Reverts to a Former Role Compare your thoughts about this situation with those of your supervisor and your RN colleagues. Make sure your response is in the best interest of the patient and you are giving both appropriate respect and appropriate supervision to the LPN or NAP involved. There is more than one effective way to manage most situations. You are working your regular shift as relief day charge RN on an orthopedic unit. You learn from


another RN that a NAP, who was formerly an EMT, has responded to a pre-operative patient’s complaint of headache by going to his locker to get some ibuprofen for the patient. Approaches to Consider

• Ask the NAP what he was thinking and listen to his thought process. Clarify the differences between his previous role and his NAP duties.

• Explain to the NAP that under no circumstances are NAP to administer any medications including over-the-counter medications. Remind the NAP that patients may only receive drugs that are ordered by a physician and supplied by the organization’s pharmacy.

Delegatee Responsibilities LPNs and NAP usually welcome supervision and structure. Their training has included orientation to their roles. LPNs are licensed and held accountable for practice as defined by the state Nurse Practice Act, just as RNs are. Any staff member who receives delegation within the scope of his or her license, job description, and competency is responsible for completing the delegated task correctly. Any staff member to whom you delegate also has the responsibility to demonstrate initiative in completing their assigned tasks and to communicate appropriately, including asking questions and reporting. Although the focus of this course is working with LPNs and NAP, remember that you also delegate to other RNs and other RNs may delegate to you. In RN to RN delegation, there is no difference in licensure and the RN delegating may not necessarily have more experience than the RN receiving delegation. However, the delegating RN retains accountability for the outcome of delegated patient care. Because both RNs are licensed, both are responsible for clinical judgment in the situation. Delegatee Responsibilities: 5 Rights of Delegation ANA and NCSBN highlight the importance of critical thinking and professional judgment in the delegation process. In the Joint Statement on Delegation (2006), these two professional organizations explain five rights of delegation:

5 Rights of Delegation: “The RIGHT task, under the RIGHT circumstances, to the RIGHT person, with the RIGHT direction and communication, under the RIGHT supervision and evaluation” (ANA & NCSBN, 2006, p.2).

Identifying the “RIGHT” in each case requires sufficient information and critical thinking. Bear in mind that as the number of steps in a procedure increases, possibility of error increases exponentially. Be especially vigilant when deciding whether to delegate multi-step tasks. When you delegate such tasks, make follow up a priority.

Organization's Responsibilities in Delegation In addition to accountabilities for the nurse who delegates and the person who receives delegation, the organization has accountabilities in relation to delegation: • Providing sufficient staffing with appropriate skill mix

• Documenting competence and giving delegating RNs access to competency documentation

• Establishing policies with the active participation of all nurses

• Acknowledging in policy that delegation is a right and responsibility

(ANA & NCSBN, 2006, p.3)


Case Study: “Too Many Patients” for the NAP Compare your thoughts about this situation with those of your supervisor and your RN colleagues. Make sure your response is in the best interest of the patient and you are giving both appropriate respect and appropriate supervision to the LPN or NAP involved. There is more than one effective way to manage most situations. For each of your last three shifts, the float pool has sent up a different NAP, each one less capable than the one before. Today, the NAP complains that you have assigned her too many baths. You are determined not to work another shift with help that is worse than no help at all. Approaches to Consider

• The NAP will begin the assignment and you will verify workload guidelines with your supervisor.

• Verify guidelines with your supervisor.

• Compare her workload with other team members. If workloads are similar, inform the NAP accordingly.

• Tell her to advise you of her progress in two hours.

Becoming a Skillful Delegator Whether you are interviewing for a position, or reporting for a float assignment; if you lack experience in delegation and in working with LPNs and NAP, make this limitation known to the manager who is interviewing you or the charge nurse to whom you report as a float. As an applicant for a position, during the interview process express your desire to develop this expertise. As a float, find out what is expected of you in relation to delegation. In today’s patient-care environment, supervision and delegation are critical skills for RNs to develop and master. If you encounter a puzzling delegation dilemma in your work, ask an experienced colleague or nurse manager for suggestions. Use the charge nurse as a resource and observe your more seasoned co-workers. Validate the capabilities of those to whom you delegate. Look for:

• Evidence of caring

• Response to call lights

• Willingness to help

• Interactions with the patients and staff

• Organizational skills

• How often they ask questions

• What kind of questions they ask

• Whether you ever have cause to suspect they might have falsified data

• Other activities of special importance on your unit

You will be more comfortable with delegation when you confirm the capabilities of those to whom you delegate.


Research findings suggest that RNs could improve their effectiveness in delegation by enhancing their competency in how to conduct reports, resolve conflicts, and how to convey their role in patient care management (Potter et al., 2010).

The RIGHT Task for NAP – All conditions must be met:

• Within the NAP range of function

• Frequently recurs in daily care of clients and groups of clients

• Little or no modification needed from one client to another

• Predictable outcome

• Does not require ongoing assessment, interpretation, or decision-making

• Does not endanger the client’s life or well-being

(ANA & NCSBN, 2006, p. 7)

The Delegation Process

Know:

• Your state’s Nurse Practice Act and Rules and Regulations.

• Your organization’s policies.

• Your unit’s practices.

• Your accountability.

• LPN and NAP responsibility.

• LPN and NAP training, experience, and competence.

• Your own competence in delegation and supervision. Determine:

• That the task you delegate is within your scope of practice.

• Which tasks are hands-on tasks and which are nursing process.

• Which tasks can be safely delegated.

• Your new NAP may be competent in performing bed baths, but maybe not for the CCU patient with an unstable arrhythmia.

• Your NAP may be competent in taking vital signs, but some of your neuro patients may require neuro checks along with vital signs. In these circumstances, it may be more efficient for you to do both.

• Your NAP may have drawn blood many times on the orthopedic unit where many of the patients are basically healthy, but you may need to do the draw on an elderly oncology patient with fragile veins so that potential sites are preserved.

• The patient’s status to be sure delegation is safe.

• Needs and risks for individual patients.

• Priorities.

Communicate


• Clear directions and expectations, including time element and priorities.

• Pertinent clinical cues for observation. During their interactions with patients, NAP may be the first to receive information that is important to patient care. Alert NAP to report specific observations immediately, such as:

• Noisy respirations in an elderly patient who is receiving IV fluids.

• A dramatic weight gain in a patient who has congestive heart failure.

• A diabetic patient whose breath has a fruity odor, or who mentions feeling light-headed this morning.

• Urgency of reporting specific observations.

• Ask the LPN or NAP to repeat back your instructions.

• One study found that RNs expected UAP to report significant findings and have higher level knowledge, including assessment and prioritizing skills. Successful delegation depended on the relationship between the RN and the UAP and good communication (Bittner & Gravlin, 2009).

Follow-up

• Make walking rounds.

• Give specific and timely feedback about performance to the LPN or NAP.

• Compare your actions as a delegator with your organization’s policies and the state’s Nurse Practice Act and Rules and Regulations as standards.

• Evaluate the impact of your delegation process upon patient safety and quality of care.

• If you identify needs for improvement, also identify ways to do it differently the next time. Ask for suggestions from colleagues, your charge nurse, and other resource persons to improve the effectiveness of your delegation.

• If your experience with delegation is not leading to a balanced workload, mutual trust, professional growth, and job satisfaction; consult with resource persons to identify ways to create outcomes that are more positive.

• One study found that RNs reported frequent instances of missed or omitted routine care by NAP (Bittner & Gavlin, 2009). Regular follow-up can prevent omitted care.

Supervision Where patient safety is concerned, adopt a zero-tolerance policy. If you observe your NAP performing a task in a manner that is placing the patient in a risk or potential-risk situation, intervene. Then later, outside of the patient’s hearing, give the NAP some kind, but firm corrective feedback. Obtain mini-reports at least three times during the shift. Keep apprised of changes in patient condition and gauge your team members’ progress and priorities. Maintain a pattern of walking-rounds and mini-reports throughout the shift, so that your NAP will expect you to be available to them frequently and in predictable timeframes. They will be less likely to interrupt you when you are performing other duties if your behavior is predictable.

Working Together

Researchers recommend:

• Assign one NAP with only one RN


• Adjust patient care assignments to permit one-to-one assignments – for example, lighter assignments for RNs who work alone

• Include NAP in change-of-shift report

• Make patient rounds with RN and NAP together and plan priorities during the course of rounds

Potter & Grant, 2004

When nurses experience disciplinary or legal problems related to delegation, it is most often related to failure to provide adequate monitoring and follow-up on delegated tasks, rather than the delegation itself (Trossman, 2006).

Adjust Your Leadership Style When leading a team which includes LPNs and NAP, vary your leadership/supervision style according to the competency, confidence, and willingness of the LPNs and NAP as individuals. Their competency and confidence may vary with different tasks. • When the LPN or NAP LACKS competence, confidence and willingness: You should: Take a directive approach. Tell the team member exactly what to do in detail, follow up to assure that the task is completed satisfactorily and give feedback accordingly.

• When the LPN or NAP LACKS competence, but SHOWS confidence and willingness: You should: Take a coaching approach. Give corrective feedback and encouragement about needs for improvement.

• When the LPN or NAP SHOWS competence, but LACKS confidence and willingness: You should: Take a supporting approach. Give specific positive feedback about performance. Emphasize positive contribution to patient care. Let them know they have every right to feel confident. Ask what would help them feel more confident and assist in creating a confidence-building atmosphere.

• When the LPN or NAP SHOWS competence, confidence, and willingness: You should: Take a true delegating approach. Purposefully avoid interfering or micromanaging performance. Perform assessments and other RN-only duties with their patients and verify completion of their assigned tasks, but communicate your respect for their competence, confidence, and willingness. [Adapted from Blanchard and Waghorn (1997)]. When you give direction and feedback, also consider the differences of education, life experience, and work experience. One size, or one style of supervision, does not fit all. Finding out about NAP's background and previous experience can help you anticipate potential threats to patient safety. Some have worked in other healthcare roles, such as EMTs who might have performed more skills than the NAP role permits. Older NAP who may have matriarchal roles in their families can unwittingly overstep their job descriptions by offering healthcare advice. Guard against HIPAA violations. Assure that NAP respect privacy and confidentiality. Some NAP may be unaware that conversations about patients within hearing of other patients, family members, other visitors, and staff not involved in the care of the patient violate Federal Law.


"... tailoring management styles to individual employees is so important...knowing when to delegate, support, or direct is critical; [And so is knowing] how to identify the leadership style suited to a particular person..." (Blanchard, Zigarmi & Zigarmi, inside cover, 1999). Case Study: The NAP Violates HIPAA Compare your thoughts about this situation with those of your supervisor and your RN colleagues. Make sure your response is in the best interest of the patient and you are giving both appropriate respect and appropriate supervision to the LPN or NAP involved. There is more than one effective way to manage most situations. You are just leaving a patient’s room after giving a medication. A NAP is assisting the patient out of bed. Family members are visiting. John, another NAP, enters the room and says in a loud voice to his NAP colleague, “Come help me clean up Mr. Jones – there’s stool everywhere in that room.” Approaches to Consider

• Say, “John, I need to speak with you for a minute.” and take the conversation outside of the room to a private location.

• Explain to John: • Making comments about patients, including stating their names and/or any information about

them or their conditions should not occur in the presence of any other patient, family member, visitor, or staff member who is not directly involved in the care of the patient.

• A patient may not necessarily have authorized members of his own family to be informed of aspects of his diagnosis and care.

• In addition to violating privacy, such action violates Federal Law (HIPAA). Substantial fines in the hundreds of thousands of dollars may be imposed upon facilities for HIPAA violations.

• Ask John how he could have approached his colleague for assistance without naming the patient and/or the situation.

• To assure that John recognizes the gravity of the situation, ask him to tell you in his own words what concerned you about his behavior and what he will do differently next time.

Feedback Giving specific direction and expectations are a vital part of supervision. Feedback on performance is also essential. Plan to give your team members feedback during rounds, mini-reports or other times as appropriate. Make it a habit to notice and comment positively on the things they do correctly.

Feedback to a Nursing Assistant-

Specific and Positive

"Dr. Smith just drew an INR on Mrs. Jones because he feels she may be getting too much warfarin based on her bruising. I told him you were the first to notice it as you were bathing her today. Would you please take the specimen to the lab now so they can run in STAT? Is there anything you need me to cover while you’re gone? Thanks, I really appreciate that." (Corbo, 2006)

• Focus on changeable things.

• Make descriptive statements. Describe what you observed, THEN compare what you saw with the standard for performance.

• Make specific statements. Give concrete details. Offer specific POSITIVE as well as corrective


statements.

• Be specific about not only what was done correctly, or what was unacceptable, but also, what the effect of the action was. For example, “That was good timing to ambulate your patient right after breakfast. It probably helped her to have a bowel movement.”

• Give immediate feedback. Immediate feedback is much more effective than delayed. If you must wait to give feedback, be sure to specifically identify the incident to which you are referring.

• Choose appropriate times. Give feedback in private. If you must intervene in front of patients or others, say as little as necessary to make the situation safe. Harsh words can damage rapport not only between you and the NAP, but also can also damage the trust that patients must be able to place in this person.

• Choose one issue to work on at a time. Do not overwhelm the NAP with information or counseling.

• When giving corrective feedback, identify exactly what needs to be improved. Demonstrate if indicated. Obtain a commitment to improve.

• Tell the NAP that you will give them prompt feedback when you see improvement.

• Congratulate your NAP on their efforts when they successfully improve their work. Recognize their efforts and recognize partial correction when you notice it, encouraging them to continue to improve.

Case Study: Inappropriate Feedback Compare your thoughts about this situation with those of your supervisor and your RN colleagues. Make sure your response is in the best interest of the patient and you are giving both appropriate respect and appropriate supervision to the LPN or NAP involved. There is more than one effective way to manage most situations. You are working with a young and inexperienced but willing and conscientious NAP. Upon your return from lunch, you witness a float pool RN in the hall, loudly criticizing the NAP about a mistake she has made. Approaches to Consider

• Approach the RN and NAP together and ask what the problem is. Listen to the description of the problem.

• State that the NAP has been working conscientiously and you would like to see them resolve this misunderstanding between the two of them.

• Check with each of them separately later in the shift to see how they resolved the situation.

• Inform the RN that the team really needs the contributions of the NAP. Give her a few suggestions about giving effective feedback. Stress the importance of giving any necessary criticism softly, and in private, not in any place where patients, families or other staff members can overhear.

Establishing Trust The effectiveness of delegation depends upon a trusting relationship among team members (Standing and Anthony, 2008). Identify for yourself what will improve your level of trust and actively seek to accomplish this by activities such as observing your co-workers performing tasks. Explain to them you need to validate their competencies for yourself at first, since you will be held accountable for the outcome of their actions. Ask about their training, comfort level, and experience with particular tasks. Approach them with respect and emphasize your concern for patient safety to earn their respect in return.


When you have satisfied yourself with the skills and competence of your co-workers on a task-by-task basis, delegate the more difficult, sophisticated tasks to them when appropriate. One of the factors that interferes significantly with rapport between NAP and some RNs is the failure of those RNs to call upon NAP to perform the skills they have been trained to do and can do well. Build others’ trust in you by displaying consistency, fairness, and respect for others. Overcoming Barriers to Rapport Differences in generation, gender, and cultural background can act as barriers to rapport. Lack of rapport complicates delegation and supervision. Perhaps one member of your team is an LPN who is 15 years older than you and differs from you in cultural background and gender. Another team member may be an NAP who is a nursing student at the school of nursing from which you graduated, whose gender is the same as yours and whose cultural background is similar to yours. Your relationship with each one will not be the same, but you can establish rapport with each by showing respect and consistently playing your professional role on the team. Take advantage of resources available to learn about generational, cultural, and gender differences in the workplace. But, most importantly avoid generalizations and assumptions based on stereotypes. Instead, explore with others as individuals to find the most effective ways to work with them. Ask your RN colleagues for tips based upon their experiences. Research findings support good working relationships between RNs and LPNs. However, some LPNs have expressed resentment that RNs receive higher pay for what the LPNs perceive to be similar work. Other LPNs identified more paperwork and supervisory responsibilities in the RN role and more direct patient care in the LPN role. Some RNs expressed dissatisfaction with their responsibilities for supervising LPNs (Seago, et al., 2004). Some studies have identified resentment of RNs by NAP (Standing and Anthony, 2008). Managing Conflict Conflict management strategies can strengthen working relationships (Potter, et al., 2010). Make the effort to express your needs clearly to your fellow team members and encourage and assist them to do the same. Work toward solutions for conflicts that satisfy the most important needs of both parties. Encouraging NAP to take initiative, collaborate, and participate as full members of the team enhances working relationships and avoids errors and dissatisfaction (Potter, et al., 2010). NAP may need guidance and support in developing initiative and a collaborative spirit. Showing Appreciation Show appreciation for the contributions of the LPN and the NAP. Give them specific feedback on how their performance has been especially helpful. In general, LPNs have a well-earned reputation for thoroughness. Those who have considerable experience on the unit can act as valuable resource persons. Make use of these potential contributions and show your appreciation with specific comments. Tell your co-workers that you are glad they are on the team, and thank them for their efforts at the end of a shift. You will reap the benefits of good rapport and cooperation.


Speaking the Same Language Effective two-way communication is essential for effective delegation (ANA & NCSBN, 2006). Give clear, specific, concise, and complete directions and encourage those to whom you delegate to ask questions, clarify directions and expectations, and raise any concerns they may have (Anthony & Vidal, 2010; Potter, et al., 2010). Reporting guidelines facilitate effective reporting. Staff development specialists have noted NAP often find it difficult to master medical terminology and names of supplies and equipment. Be sure you and your NAP share the same meaning for terms. Some NAP may be embarrassed to admit they do not know a particular word. If you are a newcomer to a unit, you may use a different term for a piece of equipment than is routinely used there. When NAP report data they have collected, you may interpret subtle patterns indicating a change in status or a risk. You may be able to take their observations at face value, but never permit NAP to turn their observations into assessments. With practice you will learn to refine the questions you ask NAP to best obtain the information that you need. Make continuous communication a priority. Communicate your availability to assist whenever needed. Case Study: The NAP Discounts Your Report Compare your thoughts about this situation with those of your supervisor and your RN colleagues. Make sure your response is in the best interest of the patient and you are giving both appropriate respect and appropriate supervision to the LPN or NAP involved. There is more than one effective way to manage most situations. You have been working on the telemetry unit for about a month. Today, Mildred, a Nursing Assistant, is back from a long vacation and you are working with her for the first time. You begin to give her some specific observations to report to you – ankle swelling with Mr. Foote, shortness of breath during Mrs. Hart’s walk. She interrupts you saying, “It’s okay, I’ve been here forever and I know these patients. Let’s just get to work.” Approaches to Consider Say, “OK, I just wanted you to know the information I will need about these patients throughout the shift and for report. I’ll follow up with you later to see what you’ve observed.” Keeping the Patient on the Team Remember to include the patient in the communication loop. In many settings, uniforms do not clearly identify roles. Even a clearly written name badge may not be meaningful to the patient, given the proliferation of roles and titles. Explain your role to the patient and the role of others involved in his or her care. This simple courteous act can keep communication clear Use your sensitivity to the patient’s perspective to address the subtle situations that can turn into public relations issues. Your male NAP may be very competent in assisting patients to the bathroom. However, some female patients may resist having a male NAP accompany them to the bathroom. In their enthusiasm for their work, sometimes NAP may become so preoccupied with completing their tasks that they do not notice this resistance. They may assume that certain actions are acceptable to the patient. If they receive feedback to the contrary, they may take it personally. Such misunderstandings distress patients and NAP as well. Building the Team


When making the patient care assignments, think about each patient care assignment from multiple perspectives, including your own, your LPN’s, your NAP’s, and the patient’s to anticipate and prevent problem situations. When such situations do arise, do what you can to facilitate delegation, keeping the patient’s rights foremost. If you must rearrange tasks among LPNs and NAP, or take on a task yourself, distribute the workload fairly for all – including yourself. Teamwork The goal of the team is to help the patients. Each team member helps the patient by making his or her own particular contribution. The football team composed of eleven quarterbacks, or the baseball team with nine pitchers could not expect a winning season. Your role on the team includes delegating and supervising. The education and training process for LPNs and NAP usually emphasizes their roles as ones in which they should expect and accept delegation. Competent LPNs and NAP will seek your help, ask questions and validate their observations when necessary. Clarify your expectations of your co-workers with them. Let them know what to expect of you. Clarify how the team works at the outset. When you are new to a unit, ask your RN colleagues how the team works. Clarifying Team Roles Clarify how the team works Does each NAP work with only one nurse or two or more nurses? Do all nurses delegate to NAP on an ongoing basis throughout the shift, or does the NAP proceed to perform selected tasks with all of your patients unless you tell the NAP otherwise? If you are sharing a NAP with another nurse or nurses, how will you avoid conflict or giving confusing, conflicting directions? When you begin the shift, communicate with the NAP and the other nurses involved so you can prevent difficulties. Research findings suggest that when “a NAP is assigned to work with multiple RNs during a given shift, the RNs and NAP do not partner and do not work together in ways that build trust and familiarity with one another’s work habits.” One-on-one assignments promote collaboration in working together (Potter & Grant, 2004, p. 20). Case Study: Sharing the NAP with another RN You and Fred, another RN, are both working with Mary Lou, a Nursing Assistant. It is 10:30 AM and you ask Mary Lou about the urinary output of one of your patients, Mr. O’Leary. You had advised her at the beginning of the shift that she needed to report his urinary output to you and notify you if he had not voided by 10:00 AM. When you ask her about Mr. O’Leary’s output, she says, “I haven’t gotten to him yet, Fred had me getting all his beds done while his patients were off the unit for tests.” Compare your thoughts about this situation with those of your supervisor and your RN colleagues. Make sure your response is in the best interest of the patient and you are giving both appropriate respect and appropriate supervision to the LPN or NAP involved. There is more than one effective way to manage most situations.


Approaches to Consider

• Tell the NAP to go now and check on the urine output of the patient. Tell her to report the information to you immediately.

• Ask her to see you or Fred for help if she does not know how to set her priorities for the shift.

• Tell her you will talk with Fred about how you and he can avoid giving her conflicting directions.

• Meet with Fred for a few minutes to establish an equitable workload for both of you and for Mary Lou.

• Talk with Fred about how you can both give Mary Lou direction more effectively for the rest of the shift.

Leading the Team Overall staffing levels, including RNs, LPNs and NAP, relate positively to reduced patient distress, fewer problems with symptom management, fewer falls, and increased likelihood that patients manage self-care effectively (Potter, et al., 2003). In addition, researchers have found an association between increased RN workload and adverse events (Kane, et al., 2007; Aiken, et al., 2010). Several literature syntheses and meta-analyses have demonstrated the association between increased RN staffing and patient outcomes, including reduced mortality, complications, adverse events, and length of stay (Kane et al., 2007; Lankshear, Sheldon, & Maynard, 2005; Lang, Hodge, & Olsen, 2004). An increase in RN staffing has been associated with prevention of four Never Events: pressure ulcers, falls with injury, bloodstream infections, and urinary tract infections (Buerhaus, 2010). There can be no question RN care contributes significantly to patient well-being. Yet, these findings also have significance for working with LPNs and NAP. These findings signal risk areas – aspects of care in which patients are particularly vulnerable when RN attention to their needs is reduced. Using Team Members Effectively Let these findings alert you to risk and stimulate you to think of ways to use team members more effectively:

• What signs and symptoms can you insist LPNs and NAP report promptly to reduce failure-to-rescue?

• What precautions can you direct team members to take to prevent patient falls?

• How can you work most effectively with LPNs and NAP to prevent pressure ulcers and nosocomial infections?

• What can you delegate to increase your undivided attention to interpreting assessment findings and identifying early signs of complications?

Building Skills and Confidence As a staff RN, you play a role in developing and mentoring NAP by providing the supervision and corrective feedback they need to enhance their confidence and competence. Supervision and feedback may look very different for each individual NAP, depending upon the NAP’s experience and other factors. In the words of one staff development specialist, many NAP enter their new world of bedside care simply “petrified of patients” (Biemolt, 2000). Working with inexperienced NAP and getting to know


experienced NAP can prove time-consuming for the RN. Some NAP need close supervision and corrective feedback on tasks, even though their competency documentation would lead you to believe otherwise. Although it may be frustrating, time spent in developing NAP is usually a wise investment. You may reap rewards later, not only in confidence that the NAP can safely take a fair share of the workload, but also in rapport, team spirit, and the willingness to go the extra mile for you when necessary. Developing co-workers is a professional nursing responsibility - an opportunity to refine skills in feedback and delegation as well as an opportunity for professional growth. Research findings suggest that NAP would benefit from developing competency in using effective communication skills for giving feedback, clarifying tasks and patient status, and resolving conflict (Potter et al., 2010). Developing Team Members Guide your LPNs to appropriate resources for professional development. More than half of the U.S. jurisdictions require LPNs to complete continuing education courses in order to renew their licenses. Suggest courses to them based on your own experience. The increased knowledge and skill that LPNs gain will build your trust and confidence in working with them. The guidance you offer respectfully can build rapport and teamwork. When developing LPNs and NAP feels like more work than meeting all the needs of your patients by yourself, it probably is! Nevertheless, there will be a return on your investment in more productivity from them, better rapport and teamwork, and a positive work environment. Focus on these positive outcomes. You may need to rethink the way you manage your assignment in order to devote needed time to developing a new NAP. You may find deficits you cannot reasonably remedy or patterns of knowledge and skills deficiencies common to many NAP. When this occurs, consult your manager and/or staff development resource person. Your input may have an impact on the selecting and training of NAP in the future.

Un-Common Sense What is common sense to you may well be far beyond the grasp of NAP with whom you work. Translate, fill in the blanks and interpret your common sense to those to whom you delegate. Case Study: the NAP is Puzzled Compare your thoughts about this situation with those of your supervisor and your RN colleagues. Make sure your response is in the best interest of the patient and you are giving both appropriate respect and appropriate supervision to the LPN or NAP involved. There is more than one effective way to manage most situations. You have reviewed the competencies of Paula, an NAP. According to her checklist, she is competent to do glucose testing. You ask her to obtain the AM blood sugar results for two diabetic patients. Fifteen minutes later, you find her standing in the hallway with the glucometer looking puzzled and uncertain. Approaches to Consider

• Say, “You look puzzled.” Ask how long it has been since she last obtained a blood glucose with the glucometer.

• Say, “Let’s review how to do this.”

• Supervise her on performance of one or two readings.


• Inform your manager and any other NAP trainer/supervisor of this incident.

Nurturing Job Satisfaction “Good outcomes can be achieved with a combination of professional and non-professional staff. An organization must attend to …the working relationships of professional and unlicensed personnel.” (Potter, et al., 2003, p. 166). Job satisfaction for yourself and your team members requires constant nurturance. Continuous communication, clarification, and respect for one another create an atmosphere for high quality patient care and positive working relationships. To create positive relationships, set yourself up for success. RNs have expressed dissatisfaction with the inability of NAP to complete delegated tasks (Bittner & Gravlin, 2009). Can you prevent this type of dissatisfaction by careful assessment of competencies, careful selection of tasks, and vigilant supervision? Higher patient-to-nurse ratios have been associated with substantially increased nurse burnout and job dissatisfaction (Aiken, et al., 2002a). There is no acceptable substitute for a safe workload. But, within the guidelines of safe staffing, you may improve your job satisfaction by developing confidence in the competence of LPNs and NAP and delegating within legal and organization guidelines to the fullest extent of their capabilities. Set yourself up for job satisfaction and comfort with delegation by planning ways to build your trust in your LPN and NAP co-workers. Building Your Confidence in Delegation As with most nursing activities, experience counts when it comes to effective delegation (Anthony, et al., 2000). Researchers found that experienced RNs obtained more positive patient outcomes through delegation than RNs with less experience. More positive outcomes were also observed when NAP had more experience on the particular unit, but not more overall NAP experience. The researchers raised the question of whether RNs might sometimes expect too much too soon from NAP. More positive outcomes were also observed when RNs employed close, planned, intentional supervision. Brief or non-specific communication was associated with more negative patient outcomes. The researchers found that RNs frequently consulted with their nurse managers and their peers concerning delegation. They also found that RNs experienced increased confidence in their delegation when they used a system or grid such as the NCSBN Delegation Decision-Making Grid (Anthony, et al., 2000). Patient outcomes and nurse retention are best in hospitals in which nurses have greater autonomy and authority to act on behalf of their patients (Aiken, et al., 2002b). One means of exercising your autonomy and authority is through careful, effective delegation to and supervision of others. Working effectively with LPNs and NAP offers you opportunities to use your clinical expertise to the fullest extent and to experience the satisfaction of doing so. Reflect on your successes in effective work with LPNs and NAP. Repeat those best practices. Let them contribute to your confidence in your expertise in leading your team. Addressing Problems Promptly


When you encounter problems in working effectively with LPNs and NAP, identify the etiology of the problem, specifically:

• Lack of knowledge?

• Lack of understanding of priorities?

• Confusion in the work assignments?

Challenge yourself to think of and investigate all the possible causes of the difficulty. Try different supervisory and reinforcement techniques. Seek assistance from RN colleagues, supervisors, staff development resources, and other resource persons. Conclusion Achieving quality patient outcomes through the work of others is a required professional competency for RNs in today’s healthcare environment. In facilities in which NAP and LPNs participate in patient care, the success of the NAP and LPNs you supervise is an important ingredient of your patients’ care and a component of your own performance. Critical thinking strategies are essential tools that can assist you to develop and to refine your expertise in achieving quality patient outcomes through the work of LPNs and NAP. Your effective development and use of your critical thinking skills can empower you to maximize the use of all human resources available to you, making your job as a professional nurse in a team situation, doable and enjoyable! References Aiken, L., Clarke, S., Sloane, D., Sochalski, J. & Silber, J. (2002a). Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. Journal of the American Medical Association, 288: 1987-1993. Aiken, L., Clarke, S., Sloane, D. (2002b). Hospital staffing, organization and quality of care: Cross national findings. International Journal of Quality in Health Care, 14:5-13. Aiken, L.H., Sloane, D.M., Cimiotti, J.P., Clarke, S.P., Flynn, L., Seago, J.A., Spetz, J., & Smith, H.L. (2010). Implications of the California nurse staffing mandate for other states, Retrieved August 2010 from http://www.nationalnursesunited.org/assets/pdf/hsr_ratios_study_042010.pdf American Nurses Association. (1997). Unlicensed assistive personnel legislation. Washington, DC: Author. American Nurses Association (ANA) (July 13, 2007). Registered nurses utilization of nursing assistive personnel in all settings. Revised Position Statement. Silver Spring, MD: Author. Retrieved October 2010 from http://www.ana.org American Nurses Association & National Council of State Boards of Nursing (2006). Joint statement on delegation. Chicago, IL: NCSBN. Retrieved October 2010 from https://www.ncsbn.org/Joint_statement.pdf Anderson, P., Twibell, R., & Siela, D. (2006). Delegating without doubts, American Nurse Today, 1(2), 54 – 57.


Anthony, M., Standing, T. & Hertz, J. (2000) Factors influencing outcomes after delegation to unlicensed assistive personnel. The Journal of Nursing Administration, 30(10): 474-481. 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. Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN). (2009). The role of unlicensed assistive personnel (nursing assistive personnel) in the care of women and newborns. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 38(6), 745 – 747. Barnes, J. N. (2006). Legal aspects of delegation. Center for American Nurses. Audioconference April 26, 2006 PowerPoint® presentation. Biemolt, P. (2000). Personal communication. Bittner, N.P. & Gravlin, G. (2009). Critical thinking, delegation, and missed care in nursing practice. The Journal of Nursing Administration, 39(3), 142 – 146. Blanchard, Ken, Zigarmi, Patricia, & Zigarmi, Drea. (1999) Leadership and the one-minute manager. William Morrow & co.: New York. Blanchard, K. & Waghorn, T. (1997). Mission impossible. New York: McGraw-Hill. Buerhaus, P.I. (2010). Health care payment reform: Implications for nurses. Nursing Economic$,28(1), 50 – 52. California Board of Registered Nursing. (1994) Unlicensed assistive personnel. Sacramento, CA: Author. Retrieved October 2010 from http://www.rn.ca.gov/pdfs/regulations/npr-b-16.pdf California Board of Registered Nursing. (2000) Unlicensed assistive personnel acute care. Sacramento, CA: Author. Retrieved October 2010 from http://www.rn.ca.gov/pdfs/regulations/npr-b-29.pdf Corbo, S.A. (2006). Delegation defined. Advance for Nurses, Greater Chicago/Wisconsin/ Indiana, 4(16), 17 – 19. Croke, E. (2003). Nurses, negligence and malpractice. American Journal of Nursing, 103 (9): 54-64. Helm, A. (1998) Liability, NAPs, and you, Nursing 98, 11, 52-53. Infusion Nurses Society (INS). (2009). The use of nursing assistive personnel in the provision of infusion therapy. INS Position Paper. Journal of Infusion Nursing, 32(1), 21 – 22. Journal of Continuing Education in Nursing Editorial Staff. (2010). Annual CE survey, Journal of Continuing Education in Nursing, 41 (1), 3 – 11. Kane, R.L., Shamliyan, T., Mueller, C., Duval, S., & Wilt, T. (2007). Nurse staffing and quality of patient care. Evidence Report/Technology Assessment # 151. (Prepared by the Minnesota Evidencebased Practice Center under Contract No. 290-02-0009.) Rockville, MD: AHRQ. AHRQ publication No. 07-E005. Retrieved August 2010 from www.ahrq.gov/downloads/pub/evidence/pdf/nursestaff/nursestaff.pdf


Kenward, K. & Zhong, E. (2006). Practice and Professional Survey Fall 2004. Chicago, IL National Council of State Boards of Nursing (NCSBN). Retrieved October 2010 from https://www.ncsbn.org/Vol_22_web.pdf Lang, T.A., Hodge, M., & Olsen, V. (2004). Nurse:patient ratios: A systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. Journal of Nursing Administration, 34, 326–337. Lankshear, A.J., Sheldon, T.A., & Maynard, A. (2005). Nurse staffing and healthcare outcomes: A systematic review of the international research evidence. Advances in Nursing Science, 28, 163–174. National Council of State Boards of Nursing (NCSBN). (1995). Delegation: Concept and decision-making process, National Council position paper, 1995. Chicago, IL: Author. National Council of State Boards of Nursing (NCSBN). (2003). Working with others. Chicago, IL: author. Retrieved October 2010 from https://www.ncsbn.org/Working_with_Others.pdf. National Council of State Boards of Nursing (NCSBN). (2005). Practical nurse scope of practice white paper. Spector, N., Ed. Chicago. IL: Author. Retrieved October 2010 from https://www.ncsbn.org/Final_11_05_Practical_Nurse_Scope_Practice_White_Paper.pdf National Council of State Boards of Nursing (NCSBN). (2009). Member boards profile 2009 – Assistive personnel. Chicago, IL: Author. Retrieved October 2010 from https://www.ncsbn.org/2009_Member_Board_Profiles_updated.pdf National Council of State Boards of Nursing (NCSBN). (2010a). 2009 LPN/VN Practice analysis: Linking the NCLEX-PN® examination to practice. Research Brief, volume 44. Retrieved October 2010 from https://www.ncsbn.org/10_LPN_VN_PracticeAnalysis_Vol44_web.pdf National Council of State Boards of Nursing (NCSBN). (2010b). Report of findings from the 2009 job analysis of nurse aides employed in nursing homes/long-term care, hospitals/acute care and community/home health care settings. Chicago, IL: Author. New York State Nurses Association. (2004). Registered professional nursing’s utilization of unlicensed assistive personnel. Retrieved October 2010 from http://www.nysna.org/practice/positions/position1_04.htm Potter, P., Barr, N., McSweeney, M. & Sledge, J. (2003). Identifying nurse staffing and patient outcome relationships: A guide for change in care delivery. Nursing Economics, 21(4): 158-166. Potter, P. & Grant, E. (2004). Understanding RN and unlicensed assistive personnel working relationships in designing care delivery strategies. Journal of Nursing Administration, 34 (1), 19 – 25. Potter, P., Deshields, T., Kuhruk, M. (2010). Delegation practices between registered nurses and nursing assistive personnel. Journal of Nursing Management, 18(2), 157 – 165.


Randolph, P. & Sorrentino, S. (June 29 – 30, 2010). Workshop on the regulation of the nursing assistant. Presented by NCSBN, Chicago, IL. Seago, J., Spetz, J. Chapman,S., Dyer, W., & Grumbach, K. (2004). National center for health workforce analysis: Supply, demand, and use of Licensed Practical Nurses. Washington, DC: USDHHS HRSA. Retrieved October 2010 from http://bhpr.hrsa.gov/healthworkforce/reports/lpn/LPN1_5.htm#exec. Snyder, D., Medina, J., Bell, L. & Wavra, T. (2004). AACN delegation handbook, 2nd edition. Retrieved October 2010 from http://www.aacn.org/AACN/practice.nsf/Files/DBEd2/$file/1editedrevisedAACNDelegationHandbook%207-1-2004.pdf Standing, T.S. & Anthony, M.K. (2008). Delegation: What it means to acute care nurses. Applied Nursing Research, 21(1), 8 – 14. Trossman, S. (2006). Getting a clearer picture on delegation, American Nurse Today, 1(1), 54, 56. Unruh, L. (2003). The effect of LPN reduction on RN patient load. The Journal of Nursing Administration, 33(4), 201-208. At the time this course was constructed all URL's in the reference list were current and accessible. rn.com. is committed to

providing healthcare professionals with the most up to date information available. IMPORTANT INFORMATION: This publication is intended solely for the educational use of healthcare professionals taking this course from RN.com in accordance with RN.com terms of use. The guidance provided in this publication is general in nature, and is not designed to address any specific situation. As always, in assessing and responding to specific patient care situations, healthcare professionals must use their judgment, as well as follow the policies of their organization and any applicable law. Organizations using this publication as a part of their own educational program should review the contents of this publication to ensure accuracy and consistency with their own standards and protocols. The contents of this publication are the copyrighted property of RN.com and may not be reproduced or distributed without written permission from RN.com. Healthcare providers, hospitals and healthcare organizations that use this publication agree to hold harmless and fully indemnify RN.com, including its parents, subsidiaries, affiliates, officers, directors, and employees, from any and all liability allegedly arising from or relating in any way to the use of the information or products discussed in this publication.

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