1. Discuss the importance of effective communication in the personal relationship, the therapeutic relationship, and the relationship within the interprofessional health-care team.
2. What similarities and differences can you identify among the above interactions?
3. Explain the concept of congruence between verbal and nonverbal communication.
4. There are many pitfalls to electronic communication. Identify a situation in which an electronic form of communication may result in a miscommunication. What other method of communication would have been more effective?
5. How have you seen ISBAR used during your clinical experiences?
6- Develop a hand-off report for yourself. Include items that you believe are pertinent for safe and effective nursing care. Refer to the information in the chapter for creating this report form. Using the information from the chapter, determine the effectiveness of the system currently in use on your unit for communicating shift-to-shift reports.
7-Dr. Roberts comes into the nurses’ station demanding, “Where are Mr. Adams’s lab reports? I ordered these stat, and they’re not here! Who’s responsible for this patient?” How would you, as the nurse, respond?
8-Explain the concept of accountability in delegation. What are the legal ramifications of accountability in delegation?
9. Dennie and Elias arrive in the unit for the 7:00 p.m. to 7:00 a.m. shift. Both nurses completed orientation 4 weeks ago. They find that they will be the only two RNs on the floor that night. There is a census of 48 clients. The remaining staff consists of two NAPs/UAPs and one LPN. What are the responsibilities of the RN, NAP/UAP, and LPN? Can Dennie and Elias effectively delegate client care tasks and care safely for all 48 clients? Use the Delegation Tree to make your decisions.
10. Discuss the differences between direct delegation and indirect delegation.
1. You have to observe delegation procedures in your assigned unit:
A-What considerations does the RN take into account when delegating patient care?
2-You have to look at the unit census and prioritize the patient care:
A- Give the rationale foryour choices.
3.Answer the following questions during your clinical experiences:
a. What specific tasks did your patients require that you might have been able to delegate?
b. How effective was your nurse/preceptor in delegating tasks to others?
c. How did your nurse/preceptor ensure that the tasks were completed safely and appropriately?
Chapter 6
Communicating With Others
and Working With the
Interprofessional Team
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Communication
• Giving information is only a small part of
communication.
• Occurs on several levels
• Involves different factors
• Requires active listening skills
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Factors Affecting Communication
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Emotional state of individuals
Outside distractions
Cultural background
Superficial listening
Individual attitudes regarding the content of the
communication
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Assertiveness in Communication
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Allows people to stand up for themselves
Respects the rights of others
Clearly states an individual’s position
Uses “I” statements
Assumes a greater importance in the
interprofessional environment
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Interpersonal Communication
• Most daily communication falls into this category.
• Interactions that occur on a personal level
• Process that gives individuals the opportunity to
construct personal knowledge
• Used to establish relationships
• Differs from general communication
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Interpersonal Communication (cont’d)
• Occurs on a more intimate level
• Systematic process
• Individuals hold a specific role within the
communication
• Dynamic and ongoing process
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Transactional Models of Communication
• Differ from earlier linear models
• Consider all individuals communicators
• Allow that communication among and between
individuals occurs simultaneously
• Acknowledge that “noise” occurs in all interactions
• Include the concept of time
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Barriers to Communication Among HealthCare Providers and Health-Care Recipients
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Challenges
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Low health literacy
Cultural diversity
Cultural competence of health-care providers
Lack of interprofessional communication
education among providers
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Electronic Forms of Communication
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Information Systems
• Communication through the use of health
documents
• The Health Information Technology for Economic
and Clinical Health (HITECH)
– Electronic Medical Records (EMRs)
– Electronic Health Records (EHRs)
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Advantages of EMR
• Track data over time
• Identify which patients need preventive screenings
or checkups
• Monitor patient status
• Evaluate and improve overall quality
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Advantages of EHR
• Documents are shared among varying
institutions/individuals
• Focus on the total health of a patient
• Provide a more inclusive view of a patient’s care
over time
• Designed to share information with other healthcare providers
• Assist in maintaining patient confidentiality
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E-mail
• Used both within and outside of organizations
• Same communication principles that apply to
traditional letter writing apply to e-mail
• Requires good writing skills
• Rules in the workplace different from personal email
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Text Messaging
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Evolved as a quick method of communication
Brief informal method
No “texting rules”
Business consultants predict that this
communication method will evolve
• Important to follow the same rules that apply to
e-mail
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Reporting Patient Information
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Hand Off Communications
• Previously referred to as “change of shift” report
in nursing
• Move toward an interprofessional team
philosophy has changed the way reports are
given
• Ensures continuity of care from one area to
another
• Part of the TJC “National Patient Safety Goals”
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Communicating With the Health-Care
Provider
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Communicate changes in patients’ conditions.
Share pertinent information.
Discuss modifications in the treatment plan.
Clarify orders.
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Before Calling the Health-Care
Provider
• Have all the information available.
• Be prepared to provide general assessment
information.
• Pertinent information
– Most recent vital signs and trends
– Laboratory values
– Medications and times the patient received the most
recent dose
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After Calling the Health-Care
Provider
• Document time of the call in the patient record.
• If the health-care provider needed to return the
call, document the time the call was returned in
a health-care provider call log.
• Follow the chain of command if a call is not
returned within an appropriate amount of time.
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ISBARR
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Introduction
Situation
Background
Assessment
Recommendation
Read-back
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Health-Care Provider Orders
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Written
Telephone
Fax
EMR orders
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Teams
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Purpose
• Bring professionals together
• Common goal: quality patient care
• Collaborative focus
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Teamwork
QSEN definition
• The ability to “perform effectively within nursing and
interprofessional teams, fostering open communication,
mutual respect, and shared decision making to achieve
quality patient care.”
(http://qsen.org)
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Learning to Become a Team Player
• Recognize that every member brings value to the
team.
• Treat each team member with dignity and respect.
• Understand the role of each team member.
• Support each other in achieving the team’s goals.
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Building a Working Team
• Identify the team players.
• Make sure the team members understand the goals
and are committed to achieving the outcomes.
• Act as a role model and exhibit expected behaviors.
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Interprofessional Collaboration and the
Interprofessional Team
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Interprofessional Collaboration
“Occurs when multiple health workers from
different professional backgrounds work
together with patients, families, caregivers, and
communities to deliver the highest quality care.”
(WHO, 2010)
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Components of Collaboration
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Sharing
Partnership
Interdependency
Power
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Interprofessional Communication
• TJC attributes a high percentage of sentinel
events to breakdowns in communication among
health-care providers.
• Core competency for interprofessional
collaborative practice
• ISBARR
• Team STEPPS
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Team STEPPS
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Leadership
Situation
Monitoring
Mutual support
Communication
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Building an Interprofessional Team
• Communicate through conferences.
• Focus on the needs of the patients and/or clients.
• Each member has roles and functions that
contribute to patient care.
• Each member contributes and the contributions are
valued.
• Monitor and/or evaluate effectiveness of team
goals.
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Methods for the Hand-Off Report
• Traditional face-to-face
• Audiotape
• Computer reporting
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Conclusion
• Communication skills are needed to deliver safe,
quality, and effective patient care.
• TJC, IOM, QSEN, and MAGNET promote
interprofessional communication.
• Use of Team STEPPS and IBARR promote
interprofessional team work and communication.
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Chapter 7
Delegation, Prioritization, and
Decision Making
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Delegation of Client Care: Definition
The reassigning of responsibility for the performance
of a job from one person to another.
(ANA, 1996)
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Concepts of Delegation
• The responsibility of the task is transferred.
• Accountability remains with the delegator.
• Delegation may be direct or indirect.
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Direct Delegation
• Usually verbal direction
• RN decides which staff member is capable of
performing a specific task.
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Indirect Delegation
• Contained in an approved listing of tasks
established by an institution
• Permitted tasks may vary from institution
to institution
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Assigning Tasks
• The RN may assign a more skilled individual to
perform a task.
• The RN may not assign an individual to perform
an activity outside a job description or the
scope of practice.
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Delegation vs. Supervision
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Supervision
• Supervision is usually more direct than delegation.
• It requires directly overseeing the work or
performance of others.
• It includes checking with individuals during the day.
• It may entail delegation of tasks and activities.
– The nurse manager performs both.
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The Nursing Process and
Delegation
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Assessment
• Assess client needs.
• Set client-specific goals.
• Match the personnel with the appropriate skills
to care for the client.
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Planning
• Mentally identify who is best suited for the task
or activity.
• Planning prevents later problems.
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Implementation
• Assign the appropriate personnel who have the
level of expertise necessary to deliver the care
or carry out the activities.
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Evaluation
• Oversee the care or activities.
• Determine if client care needs have been met.
• Allow for feedback.
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Coordinating
Assignments
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Methods to Help Organize Care
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Critical pathways
Computerized information sheets
Personalized worksheets
Delegation tree
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Tips for Organizing Care
• Plan time around activities that must be performed
at a certain time.
• Perform high-priority activities first.
• Cluster activities that may be performed together.
• Consider your peak time when performing optional
activities.
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The Need for Delegation
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Changes in the Health-Care
Environment
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Nursing shortage
Health-care reform
Increased need for nursing services
Demographic trends
Use of unlicensed assistive personnel
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Unlicensed Assistive Personnel (UAPs)
• Individuals trained to function in an assistive role to
the nurse
• Perform delegated tasks
• Under direct supervision of the RN
• May or may not be certified
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Delegation to UAPs
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Examples of Tasks
• Vital signs
• Skills learned through special training
– Blood drawing
– ECGs
• Measuring intake and output
• Non-nursing duties
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Safe Delegation
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Criteria for Safe Delegation
• Potential for harm
• Complexity of the task
• Problem-solving and innovation necessary to
complete the task or activity
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Considerations for Safe Delegation
• Ability of the individual
• Fairness of the task
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Guidelines for Delegation
• https://www.ncsbn.org/delegation_grid_NEW.pdf
• https://www.ncsbn.org/contcaregrid.pdf
• https://www.ncsbn.org/Working_with_Others.pdf
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Task-Related Concerns
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Primary Concern
Does the individual assigned to the task have the
ability to perform the task?
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Other Task-Related Concerns
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Ability
Priorities
Efficiency
Appropriateness
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Relationship-Oriented Concerns
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Fairness
Learning opportunities
Health
Compatibility
Preferences
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Summary of Expectations of
Professionals
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Respect of others
A reasonable workload
Appropriate wages
Determining his/her own priorities
Ask for what he/she wants
Accountability
Give and receive information as a professional
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Barriers to Delegation
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Barriers
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Experience
Licensure
Quality of care
Assigning work to others
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The Five Rights of Delegation
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Right task
Right circumstances
Right person
Right direction/communication
Right supervision/evaluation
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Conclusion
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Points to Consider
• Delegation is not new.
• The role is essential for good working relationships.
• Organizational skills are a prerequisite for
delegation.
• Understanding client needs is essential for
appropriate delegation.
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The RN Needs to Understand
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The State Nurse Practice Act
The capabilities of each staff member
The tasks that may be delegated
The concept of accountability in delegation
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