Download - Nephrology Nursing

2010 - 2012 DaVita Inc. All rights reserved Rev. August 2012

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Continuing Education (CE)

Nephrology Nursing: Scope of Practice Delegation Policy & Procedures

Objectives Define and explain the difference between independent nursing functions and delegated

medical functions

Recall how to identify tasks that are not in your states nursing scope of practice Explain the Standard of Care for nephrology nursing Recall delegation pathways and which tasks can be delegated by the nurse

Outline the four steps in nursing delegation

Recall how to identify tasks that cannot be delegated

Recall six strategies to achieve delegation success

Explain the difference between policies and procedures

State who sets the Standard of Care within DaVita and by what means Define the term negligence as it is applied to nursing practice Explain the importance of accurate and complete documentation

Introduction Nephrology nursing requires a broad scope of knowledge to provide quality care for renal patients and their multitude of special needs. Nephrology nurses are also charged with supervising nursing assistive personnel (NAP)

such as patient care and reuse technicians and delegating appropriate tasks

to these teammates. To assist nurses with these various duties, nursing practice is guided by individual State Board of Nursings (BON) Scope of Practice and Delegation Rules as well as DaVitas Policies and Procedures. This Continuing Education offering discusses how nurses decide whether a

task is within their scope of practice, what the rules are for supervision and

delegation of tasks, and why adherence to P&P is of utmost importance.

Scope of In general, the nursing scope of practice includes two tasks: independent Practice nursing functions and delegated medical functions. Independent nursing

functions are tasks or practices that are within the field of nursing and the nurse has the knowledge, judgment and skill to perform the task. These

functions do not require physician oversight. Delegated medical functions that require some degree of physician oversight include implementation of

a medical plan such as verbal, written or standing orders, and protocols.

BONs and the National Council of State Boards of Nursing (NCSBN) have developed Decision Trees to help nurses decide whether a specific

task is within the states nursing scope of practice. Following is such a generic decision tree.

Authors/Contributors Silvia German, RN, CNN, Education Manager Susan Juarez, MS, ARNP, CNN, Vice

President Clinical Education Greg Trulove, Assistant General Counsel,

Risk & Litigation

This free Continuing Education (CE) offering is provided by the DaVita University, School of Clinical Education.

To receive a CE certificate for 1.0 contact hours, complete the online post test (instructions given on final page of CE).

Thank you for your interest in learning!


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Is This Task Within

My States Nursing Scope Of Practice?

Was The Skill/Task Taught In

Your Basic Nursing Program?

Have You Completed A Comprehensive Training

Program, Including Clinical Experience?

Has This Task Become Routine In Nursing

Literature And In Nursing Practice?

Yes

No

Task Is Not In Your Scope Of Practice

No Does Carrying Out The Skill Pass The Reasonable And Prudent Standard of

Care For Nursing?

Yes

Yes

Is The Skill/Task Listed In Your Hiring Agency Policy

And Procedure Manual?

Yes

Task/Skill Is Within Your Scope Of Practice

No

Task Not Appropriate In This Setting

No

Yes

No

Task Is Not In Your Scope Of Practice

The Reasonable & Prudent Standard of Care for Nephrology Nursing - Key Concepts:

The Standard of Care is that care which a reasonable and prudent nephrology nurse would give under the same or similar circumstances.

The Standard of Care includes actions a reasonable and prudent nephrology nurse would do, as well as actions the nurse would avoid doing.

In general, the Standard of Care for nephrology nursing is keyed to this specialty and the skills and knowledge expected of a nephrology nurse.

Following the Standard of Care makes the care given defensible and avoids negligence.

When supervising non-licensed, assistive personnel, it is the responsibility of the licensed nurse to ensure these teammates also meet the Standard of Care.


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Delegation The NCSBN defines delegation as the act of transferring to a competent individual the authority to perform a selected nursing task in a selected situation, the process for doing the work.

Test Your Knowledge

Question: Charge RN Mike just received a verbal order from Mrs. Pales

nephrologist to initiate EPO therapy at 3,300 units per treatment. Mike asks RN Elvira to administer the medication.

Did Mike delegate or assign this task? Answer: If you said assign you are correct. Because Elvira is also a

registered nurse, and administering a medication is within her

licensed scope of practice, Mike did not delegate but assign this task to her.

Question: Margaret is a competent PCT with 8 years of dialysis

experience and the team leader, nurse Wanda, trusts her

judgment completely. When Margaret reports that her patient Toni is short of breath, Margaret asks Wanda to give him oxygen at 2 L/min. Was

Wandas decision to delegate this task correct? Answer: The answer to this question is twofold. While Wanda can delegate the task

of administering oxygen to a PCT, the general nursing functions of

assessment, planning, evaluation, and nursing judgment cannot be delegated. Therefore, Wanda must assess Toni herself and determine the

need for appropriate treatment before delegating such a task to Margaret.

Question: Supervision is part of the delegation process and the nurse should consider the knowledge, skills and abilities of the unlicensed teammates that are

supervised. PCT Carl has been in training for six weeks and completed

DaVita Prep class. What tasks can the licensed nurse delegate to Carl? Answer: The DaVita training process is based on consistent education and the

completion of work books with skills check lists. Before delegating any task, the nurse should confirm that the trainee is able to perform the task

including the completion of the accompanying skills check list.

Question: PCT Beth is an advanced cannulator and has been asked by the charge

nurse to cannulate the new AV fistula of patient Myrna. But Myrna arrives 15 minutes late and it is now time for Beth to take her lunch break. She

therefore asks David, who is also an advanced cannulator, to put Myrna on the machine. Is this OK?

Answer: A task delegated by the licensed nurse to a non-licensed teammate cannot

be re-delegated by this teammate. Myrna should therefore go back to the nurse and ask that the task be delegated to another teammate.

Question: What is DaVitas accountability in the delegation process? Answer: The accountability of DaVita as an organization relates to providing

sufficient resources, adequate staffing ratios and an appropriate staffing mix. DaVita is also responsible for the implementation of policies &

procedures and job descriptions, creating an environment favorable to teamwork and patient centered care and providing opportunities for

teammate development.

Delegation Pathways

MD

RN

LPN/LVN

Nursing Assistive

Personnel


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Delegation Decision Tree for Nurses as outlined by the NCSBN Assessment & Planning

Are there laws and rules in place that support the delegation?

Is the task within your scope of practice?

Have you assessed the patients nursing care needs?

Are you competent that you can make delegation decisions?

Does the task meet all the criteria recommended for delegation to nursing assistive personnel (NAP)?

Is within the NAP range of function Frequently recurs in the daily care of one or more patients Is performed according to an established sequence of steps Involves little or no modification from one patient care

situation to another The outcome of the task is reasonably predictable Does not involve nursing assessment, interpretation or

decision making which cannot be logically separated from the procedure(s) itself

Does not endanger the patients life or well-being

Has the NAP been trained and is competent to perform the task?

Are there policies & procedures or protocols in place for this task

or activity?

Are you able to provide appropriate supervision?

Proceed with delegation.

Authority to delegate varies. For example, if regulated by the BON, tasks PCTs are allowed to perform vary. Licensed nurses must check the

jurisdictions statutes and regulations.

Tasks that are not in the licensed nurses scope of practice cannot be delegated to an NAP.

Assess the patients needs, then consider delegation

Do not delegate until evidence of appropriate education of the NAP is available, then reconsider

delegation; otherwise do not delegate.

Do not delegate.

Do not delegate until evidence of education and validation of competency is available, then

reconsider delegation; otherwise do not delegate.

Do not proceed without evaluation of need for policy, procedures and/or protocol

or determination that it is in the best interest of the patient to proceed with delegation.

Do not delegate

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No


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Delegation for Nurses Communication Nurse Responsibilities NAP Responsibilities

Explains the task to the NAP

Assesses the NAPs understanding of the task including expectations

Provides clarification as needed Assesses the NAPs knowledge how to accomplish the task Explains specific patient requirements Instructs the NAP when and what information to report to

the nurse Instructs the NAP which patient concerns/reactions must

be reported immediately Communicates availability to help and support the NAP Verifies that the NAP accepts the delegated task and

responsibility in carrying it out

Asks questions about the task Seeks clarification if needed Informs the nurse if he/she has not done this

task before or has done it only infrequently Asks for additional training or supervision if

needed Communicates understanding of expectations Establishes a plan of action for emergency

situations

Timely, complete and accurate documentation of the delegated task, assessment of the patient and the patients response if applicable are also part of the delegation communication process.

Delegation for Nurses Supervision Nurse Responsibilities

Determines the level of supervision needed and monitors the NAPs performance of the task accordingly Assures compliance with policies & procedures and standards of care Intervenes and follows up on problems and concerns in a timely manner Is aware if the NAP has difficulties completing the task, assists proactively and provides adequate follow up Responsible for the overall care provided to the patient

The Nurse Should Decline an Assignment to Supervise if the Nurse:

Does not have the authority to intervene and take corrective action if needed Has never performed the activity to be supervised Does not have the opportunity and/or proximity to provide effective monitoring Would not be able to intervene if there were a problem Does not meet the qualifications based on CMS Conditions for Coverage (CfC) and/or state regulations

DaVita Policy (per CfC): o RN in Charge of Nursing Services: Full time employed, has 12 months clinical nursing experience

and 6 months experience in providing care to patients on maintenance dialysis. Must play an active role in Quality Improvement programs and attend meetings. Provides oversight and direction to all direct patient care teammates in the facility. Has clinical supervisory responsibility. Responsible for assessing the charge nurses prior experience in demonstrating strong critical thinking skills before placing the nurse in the charge role.

o Charge Nurse Standards: RN or LPN/LVN, meets State practice requirements, has 12 months clinical nursing experience, including 3 months experience in providing care to patients on maintenance dialysis. LPN/LVN works under RN supervision in accordance with state nursing practice act provisions. Must be present whenever a patient is in the facility.

o Staff Nurse Standards: RN or LPN/LVN who meets the practice requirements in the State where he/she works. Cannot be left in charge without meeting requirements.

o Self-Care & Home Dialysis Training Nurse Standards: RN, has 12 months clinical nursing experience, and 3 months experience in the specific modality for which the nurse will provide self-care training.

Delegation for Nurses Evaluation & Feedback Nurse Evaluation of the Effectiveness of the Delegation

Did the NAP perform the task correctly following policy and procedure? Was the desired or expected outcome achieved? Was the communication effective and timely? What went well, what could be done better? If applicable, were concerns addressed in a constructive manner? Was appropriate feedback given to the NAP including praise for a task well done? Is the patient doing well or should the overall plan of care be adjusted?


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Delegation Pearls of Wisdom

The 5 Rights of Delegation:

Right Task Right Person Right Circumstances Right Directions & Communication Right Supervision & Evaluation

Tasks that can be delegated: Occur frequently Are technical in nature Are considered standard and unchanging Have predictable results Have minimal potential risk for patients

Achieving Delegation Success:

All teammates know delegation process Teammates have confidence in one another Teammates know their job descriptions Process for competency assessment is in place Teammates communicate well with one another Process is not used to delegate unpleasant tasks


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Policies, Procedures & Protocols

Policies, procedures and protocols play an important role when nurses decide

whether an activity or task is within their scope of practice and when delegating a task to nursing assistive personnel. Policies and procedures show that clinical

practices are planned and intended. They require that manufacturers specifications are followed and that activities are documented.

Policy & Policies are guidelines and principles and describe the purpose of what will be Procedure done. They are the overarching standard for handling activities, systems, and

problems.

Procedures are far more specific and provide a step by step series of actions, processes, or measures to be taken to implement or address a particular activity, system, or problem.

Protocols require a physician order for initiation. They are individualized to each patients clinical circumstance, e.g. current lab results or other objective data, and include explicit medication instructions which do not leave any discretion to DaVita

teammates in determining the dose and frequency. Protocols also include time

frames for the physician to review and sign medication dose changes, continuation of the protocol, and conditions under which the physician should be notified.

Standard In legal terms, Standard of Care means the level at which the average, prudent Of Care provider in a given community would practice. The standard of care is how

similarly qualified practitioners would have managed the patient's care under the same or similar circumstances. The Standard of Care is based on providing

ordinary care and the facts known at the time care is given. It is the practitioners duty to meet the Standard of Care.

A valuable Through its clinical policies and procedures, DaVita provides standard of care

Gift guidance for teammates working in the facilities. Developing new and revising existing P&Ps requires a systematic approach and the cooperation of many

teammates and departments:

Recognition of the need for a new policy or procedure, or revision to an existing policy or procedure (e.g. new products on the market, change in CMS

Conditions for Coverage, change in recommended practices by KDOQI, etc.) Review of current literature and manufacturer recommendations Drafting of new P&P or revision to existing P&P by committee members with

special knowledge of the subject matter

Editing by department leads specific to the P&Ps subject (e.g. medications, vascular access, BioMed, infection control, etc.)

Testing of the new or revised P&P in the field if applicable Formatting on DaVita template Review by designated member of OCMO (Office of the Chief Medical Officer) Approval by Clinical Oversight Committee Approval by Risk and Compliance Scheduled for release twice a year in March and September (in rare instances,

a new or revised P&P may be needed immediately and is then announced in and released through Village Communications)

Policy & Procedure Implementation consists of 4 steps: Governing Body approval Teammate Training (LMS based or hard copy handout) P&P Implementation Attestation of P&P Implementation


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Why Cant I Do It My Way?

Failure to practice within the standard of ordinary care can lead to civil liability in the

event of an adverse patient outcome.

Elements of Liability

Physical plant & dialysis equipment are integral to delivery of safe dialysis. Care can be questioned even if it is performed within the standard of care. Areas for legal attack include competence of care giver, procedure,

documentation, machines, water system and making a monetary profit.

Ive been a nurse for 30 years and some of these new policies just change the way we do things

Ive been doing this for ages and no one ever complained about the way Ive done it.

Its quicker the way I used to do it. This new policy just added more steps.

The answer to these questions and comments is the same:

Caregivers who are doing it their way without regard to P&P or Scope of Practice concerns may find themselves outside of the Standard of Ordinary Care in the event of an

adverse patient outcome!

NegligenceProximate

CauseDamages

Negligence:

Failure to exercise ordinary care which

results in an adverse event to a patient

Jury Verdicts 1994-2000 All States

#1: Medication Errors #2: Lack of Informed Consent #3: Treatment Errors #4: Negligent Supervision Source: Jury Verdict Research 2002


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Elements of Negligence

Importance of Documentation

Memorialize Monitoring & Observing: Reality Gather and document information

Recognize significance of certain information Keep patient safe Treatment:

Follow orders Implement interventions Respond to alarms Use equipment safely Medication Administration:

Administer medications correctly Check for allergies Note patient response Teaching: Rights, Responsibilities, Grievance Procedure Emergency procedure Other (renal disease, vascular access, infection control, adequacy,

complications, medications, etc.)

Did the nurse have a duty to the patient?

Yes

Breach of Duty Did the nurse fail to meet the Standard of Care?

Yes

Did this breach cause the plaintiffs injury or adverse event?

Yes

Are there damages as a result of this breach?

Yes

Plaintiff wins the medical malpractice suit!

A Point to Remember:

Lack of documentation will open an attack on your care!


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Communication:

Documentation & Notification Who was notified by name and title

Time you called / time you discussed

What you told them What they told you

Supervision:

Monitor performance Assign/delegate appropriately

Demonstrate DaVita P&P serves as Best Demonstrated Practice Compliance

Conform Acting according to P&P is prima facie evidence of compliance with the To P&P Standard of Care!

Conclusion Scope of practice, delegation rules, and policies and procedures are all

integral parts of nephrology nursing and assist nurses to practice within the

parameters of their license and according to the accepted standard of care. Good communication with other members of the interdisciplinary team, the

patients and their families is also very important. Communication includes

verbal interactions as well as accurate documentation in the medical record. In addition, nephrology nurses should be aware of changes within

their specialty. Certification, joining a professional organization and subscribing to nephrology related magazines will assist nurses in staying

up-to-date. Together, these measures will help nurses protect their license and deliver safe and effective care to our patients.

References

DaVita Inc. Policies, Procedures & Guidelines DaVita Inc. Educational Materials

Working with Others National Council of State Boards of Nursing (2005)

Prima facie: On its first appearance

or At first sight

A Latin expression


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Instructions for completing the Post Test and printing your CE Certificate 1st Read the CE article 2nd Log onto DaVitas Star Learning

Type starlearning.davita.com in the address box. Then click go. Type in your login ID and password (same as you use with intranet). Then click login

3rd Select the course Click on Main Menu (located in horizontal blue menu bar) Click on Self-Service Click on Learning Click on Search Catalog In the Search the Catalog box, type in Nephrology Nursing: Scope of

Practice Delegation Policy & Procedures and click Search Activities Click on the title Nephrology Nursing: Scope of Practice Delegation Policy

& Procedures

4th Complete the online post test and evaluation Select Enroll (or if you previously enrolled, select launch) In the Review Information page select Submit Enrollment In the Enrollment Confirmation page select Launch In the Table of Contents page select Launch Read instructions. Then scroll to bottom of page and select next Complete test (the questions will be the same as listed below)

Complete evaluation. Please note, entries must be made in all boxes or program will not proceed

Click Mark Complete to ensure your score is recorded

5th Print CE certificate Click on Main Menu (located in horizontal blue menu bar). Click on Self-Service. Click on Learning Click on All Learning On All Learning page click on All Learning, Any Status, Date, Type in the Filter

Name drop down box

Click on View Certificate in the course you just completed and print


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Post Test Questions (to be completed on Star Learning)

1. An independent nursing function is defined as

a. Implementing a physician ordered protocol b. Outlining the patients plan of care c. Performing a task that is within the field of nursing

d. Adjusting a patients dry weight

2. A skill/task that was taught in your basic nursing program, but has not yet become routine in nursing literature and practice

a. Is within your scope of practice b. Is only within your scope of practice if you have completed an additional

comprehensive training program

c. Is within your scope of practice if policies and procedures are available to perform the skill/task

d. Is not within your scope of practice

3. The nurse acting within the standard of ordinary care for nephrology nursing is

a. A nurse of ordinary prudence b. A nurse who is extraordinary careful

c. A nurse who is exceptionally skillful d. A medical law professor

4. Tasks that can be delegated by the nurse a. Require a patient assessment and have predictable results

b. Occur frequently and are considered standard and unchanging c. Require planning and are technical in nature

d. Have minimal potential risk for and require an evaluation of the patient

5. When delegating a task, it is the nurses responsibility to a. Verify the delegatees training and competence to perform the task and that the

delegatee accepts the delegated task and the responsibility in carrying it out

b. Ensure that the jurisdictions statutes and regulations allow the delegatee to perform the task

c. Determine the level of supervision needed and monitor the delegatees performance of the task accordingly

d. All of the above

6. Which is not a strategy for delegation success?

a. Teammates know their job description b. Unpleasant tasks are rotated

c. A process for competency assessment is in place

d. All teammates know the delegation process

7. Within DaVita, the Standard of Care is defined by a. The teammates experience in completing a task correctly b. DaVitas clinical policies and procedures c. The physician ordering a procedure d. A general understanding of what constitutes quality patient care


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8. In nursing practice, the term negligence means

a. Failure to exercise ordinary care which results in an adverse event to a patient b. Failure to exercise ordinary care which does not result in a personal injury to a

patient c. All of the above

d. None of the above

9. Within the United States, Negligent Supervision was the number ___ cause for jury

verdicts during the years of 1994 2000 a. One

b. Two c. Three

d. Four

10. Poor or incomplete documentation

a. Can be excused during times of working short staffed b. Can be amended in a court of law through a verbal recollection of what happened

c. Will open an attack on your care

d. Has no impact on quality patient care

DaVita is accredited as a continuing education provider by the California Board of Nursing. This

educational activity is approved by most states and specialty organizations that recognize the California

Board of Nursing accreditation process.

Download - Nephrology Nursing

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