nephrology nursing

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


    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!

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


    Continuing Education (CE)

    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?



    Task Is Not In Your Scope Of Practice

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

    Care For Nursing?



    Is The Skill/Task Listed In Your Hiring Agency Policy

    And Procedure Manual?


    Task/Skill Is Within Your Scope Of Practice


    Task Not Appropriate In This Setting




    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.

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


    Continuing Education (CE)

    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




    Nursing Assistive


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


    Continuing Education (CE)

    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