DECIDING TO DELEGATE: A DECISION SUPPORT FRAMEWORK … · responsibility and accountability on...

Northern Ireland Practice and Education Council for Nursing and Midwifery

DECIDING TO DELEGATE:A DECISION SUPPORT FRAMEWORK

FOR NURSING AND MIDWIFERY

Leading and inspiring nurses and midwivesto achieve and uphold excellence

in professional practice.

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Foreword ................................................................................2

Introduction and Context ....................................................3

Scope .......................................................................................4

Framework Overview ............................................................4

Definitionandpurpose ........................................................5

RequirementstoSupportDecisionstoDelegate NursingandMidwiferyTasksandDuties .........................5

NursingandMidwiferyDecisionSupport FrameworkforDelegation ....................................................7

DecisionSupportMatrix .................................................... 12

Appendix 1:UsingtheDecisionSupportMatrix: ScenariosinPractice ........................................................... 13

Addendum 1:ProductionoftheFramework ................ 16

Addendum 2:MembershipofTaskandFinish GroupSub-Group ............................................................... 19

Glossary............................................................................. 20

Leading and inspiring nurses and midwivesto achieve and uphold excellence

in professional practice.

| CONTENTS

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| FOREWORD

Wearedelightedtoprovidetoyou:Deciding to Delegate: A Decision Support Framework for Nursing and Midwifery. Thisframeworkhasbeenco-producedthroughahighlevelofengagementwithnurses,midwivesandotherprofessionalsacrossNorthernIreland.

Theworktoproducethisnewresourcehasbenefitedfromtheexperienceofawiderangeofindividualswhoaredelegatingtasksanddutieseverydaytoenableperson-centredcareandservicestobedeliveredinNorthernIreland.Inrecognitionoftheincreasingcomplexityofservicedeliveryandresponsibilityforthedeliveryofcarecrossingprofessionalboundaries,particularlybetweennursingandsocialwork/socialcare,wewereaskedtojointlyChairtheTaskandFinishGroupconvenedtocompletethisinitiative.Thisapproachaffordedanopportunitytounderstandtherolesandresponsibilitiesofeachoftheprofessionsandthechallengesandissuesfacedinthedelegationoftasksandduties.

TheconstructionoftheframeworkacknowledgedtheworkthattheCentralNursingandMidwiferyAdvisoryCommittee(CNMAC)hadcompletedinthepast,andtherevisionoftheNursingandMidwiferyCouncil(NMC)Codein2015,whichincludesclearmessagesabouttheresponsibilitiesofnursesandmidwiveswhendelegatingtasksandduties.

Thefocusofthisframeworkiscentredonthepersonbeingcaredforandtheneedforsafeandeffectivedelegationthatsupportsservicestoenableandpromotehealth,independenceandwellbeingintheplaceoftheperson’schoice,asfarasispossible.

Wecommenditsuseandlookforwardtoadvancingthenextstagesofthisimportantworkwhichwillconsideraframeworktosupportdelegationacrossprofessions.

Kathy FodeyDirectorofRegulationandNursing,RegulationandQualityImprovementAuthority(RQIA)(untilApril2018)

Colum ConwayChiefExecutiveofNorthernIrelandSocialCareCouncil(NISCC)(untilSeptember2018)

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Introduction and Context Section11oftheNursingandMidwiferyCouncilCode(NMC)1statesclearlythatregistrantsareaccountablefordecisionstodelegatetasksanddutiestootherpeople.Thatincludestheresponsibilitytoconfirm that the outcome of any task2 delegated meets the required standard3forthetask.

Theabilitytodelegatesafelyisacriticalrequirementandcompetenceforthe21stcenturyhealthcareworker.StakeholderfeedbackinNorthernIreland(NI)onthecurrentdecisionmakingprocessfordelegatingnursingandmidwiferytasksanddutiesidentifiedthatthedevelopmentofadecisionsupporttoolwouldpromoteconsistencyacrossallcareandservicecontexts.Consequently,thereisthepotentialforpatientsafetyandthequalityofcareandservicesprovidedtobeimproved.

ThepublicinNIarelivinglonger,oftenwithlong-termhealthconditionsandarehavingfewerchildren.Estimatedfiguresindicatethatby2026,forthefirsttimetherewillbemoreover65sthanthereareunder16yearolds4,whichwillpotentiallyhaveanimpactonthesupplyofaworkforceforthefuture.WhilstlongevityisameasureofthesuccessofourservicesinNI,italsobringschallengesintermsofthedemandsandpressureson

HealthandSocialCare(HSC)services.EfficientuseofHSCresources,thepaceofinnovation,existingworkforcerecruitmentchallengesandinefficientdeliverymodelsinformthecaseforchange,outlinedinthestrategicdirectionoftheministerialstatementwithinHealth and Wellbeing 2026: Delivering Together5.

TheadventofanewoutcomesbasedapproachinthedraftProgrammeforGovernment6putsanonusonallservicestoworktogether,acrosssilosandboundariestodeliverthebestoutcomesforthepopulationofNI.

Itisrecognisedthatlinksexistacrossthehealthandsocialcaresystemandinallsectors,relatingtothefuturedirectionofservices.Accordingly,thefocusofthisframeworkiscentredonthepersonbeingcaredforandtheneedtoreachagreementonaschemeofdelegationthatsupportsservicestoenableandpromotehealth,independenceandwellbeingintheplaceoftheperson’schoice,asfarasispossible.

A FRAMEWORK FOR DELEGATION OF NURSING AND MIDWIFERY PRACTICE

1 NursingandMidwiferyCouncil(2018) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives.London:NMC.Page10.

2 Ibid,n1.3 Ibid,n1.4 DepartmentofHealth.(2016).Health and Wellbeing 2026: Delivering Together.Belfast,DoH.5 Ibid,n5.6 NorthernIrelandExecutive.(2016).Draft Programme for Government Framework 2016 – 2021. Availablefordownloadat:https://www.northernireland.gov.uk/sites/default/files/consultations/newnigov/draft-pfg-framework-2016-21.pdf

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ScopeThenursingandmidwiferydelegationdecisionframeworkwill:

•satisfytherequirementsoftheNMCCode

•supportthedeliveryofpersoncentredoutcomesforcareandservice

•workinprimary,secondaryandcommunitycarecontexts

•supportpracticedelegatedtostaffworkingwithinanemployedcapacitye.g.domiciliary,healthcaresupportstaff,classroomeducationsupportstaff

•utiliseanapproachthatinformseffectiveandconsistentdecisionmaking

Framework OverviewTheFrameworkfordelegationofnursingandmidwiferytasksanddutiesispictoriallyrepresentedbelowat Figure 1: Decision Framework for Delegation of Nursing and Midwifery Tasks and Duties.

Therepresentationbelowoutlinestheframeworkasawhole,themainpurposeofdelegationbeingtheachievementofperson-centredoutcomes.Theframeworkrecognisesthatsafe,effective,person-centreddelegationofnursingandmidwiferytasksanddutiesissupportedbypolicy,procedureandgovernancearrangementswithinorganisations,andthataccountabilityandresponsibilitytooverseeanappropriateprocessfordelegationoftasksanddutieslieswithemployers,delegatorsanddelegatees,atdifferentstagesoftheprocess.

Figure 1: Decision Framework for Delegation of Nursing and Midwifery Tasks and Duties

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Definition and PurposeDelegationforthepurposesofthisframework,isdefinedastheprocessbywhichanurseormidwife(delegator)allocatesclinicalornon-clinicaltasksanddutiestoacompetentperson(delegatee).

Thedelegatorremainsaccountablefortheoverallmanagementofpractice,forexample,inaclinicalcontext:theplanofcareforaserviceuser,andaccountableforthedecisiontodelegate.Thedelegatorwillnotbeaccountableforthedecisionsandactionsofthedelegatee7.

TheNMChasestablishedthatonoccasionnursesandmidwivesmaydelegatetasksordutiestootherregisterednursesormidwives.Inthesecases,theremaybeparticularcircumstanceswhereaccountabilityforeachelementofpracticeisclearlydefinedandagreed.Thisdoesnotreflecttheusualpracticeenvironment,however,whereeachregisterednurseormidwifeactsautonomously.

Thepurposeofdelegationistoensurethemostappropriateuseofskillswithinahealthandsocialcareteamtoachieveperson-centred outcomes. In aclinicalcontext,delegationofnursingandmidwiferytasksanddutiesshouldalwaysbefocusedontheneedsandwishesofthepersonreceivingcareorservices,andnotbasedonprofessional,systemororganisationaldriversexternaltothecare/serviceprocess.

Requirements to support decisions to delegate nursing and midwifery tasks and duties Delegationofnursingandmidwiferytasksanddutiestakesplaceinacontext,whetherthatisinanorganisationthatprovidescareandservices,client’sownhomeorotherareawherenursesandmidwivespractice.

Thecontextofpracticehasanumberofimportantconsiderationstounderpineffectivedecisionstodelegate.Thatwillincludeattentiongiventoenvironmentalarrangements,whetherthatisclinicalornon-clinical;governancearrangements;andprofessional,legislativeandregulatoryrequirements.Thesecontextualarrangementssupportthedeliveryofsafe,effectivepersoncentredcareandservices,thatmeettheneedsofthepopulationofNorthernIreland.

Thisframeworkdefinesthreemainrequirementstobeconsidered,thatunderpinandensurethesafetyandeffectivenessofanydecisiontodelegatetakenbynursesandmidwives.Organisationsandindividualsemployingorsecuringtheservicesofnursesandmidwivesareaccountableandresponsibleforensuringappropriatearrangementsareinplacetosupportthesafe,effective,person-centreddelegationofnursingandmidwiferytasksandduties.

7 AdaptedfromthedefinitionwithintheAllWalesGuidelinesforDelegation(2010).

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Care and Practice environmentsareorganisedtosupporteffectivedecisionmakingprocesses.Thisrequirementincludes:

• ensuringsafenurse/midwifestaffingratios

• appropriatelyskilledanddevelopedstafftomeetrequiredstandards8

• appropriateprovisionofresourcestomeetrequiredstandards

• appropriateorganisationofcareorpractice

• appropriateenvironmentsforpractice,careandtreatmenttobeprovided.

Organisational governance arrangementsareinplacetosupporteffectivedelegationdecisions.Thisrequirementincludes:

• provisionofpoliciesandprocedures

• accessibilityforstafftoorganisationalpolicyandproceduredocumentsincludingclinicalandprofessionalstandards

• accessibilityofappropriatejobdescriptions

• accessibilityofappropriatelearninganddevelopmentopportunitiesforallstaff

• processesforimmediateraisingandescalatingofconcerns.

Professional, legislative and regulatory requirementsthatconferresponsibilityandaccountabilityonregisteredandnon-registeredstaffacrossandbetweenorganisationsareconsidered.Thisrequirementincludesconsiderationof:

• theNMCandotherregulatorycodesindecisionmaking

• accountabilityfordecisionstodelegate

• accountabilityfordeemingthedelegateecompetentatthepointofdecisionmaking

• accountabilityforconfirmingthatthedelegatedtaskhasmettherequiredstandardofoutcome

• thescopeofnon-delegabletasksanddutiesforexample:midwiferypractice,prescribinganddetentionundermentalhealthlegislation.

Thesafe,effective,person-centreddelegationofnursingandmidwiferytasksanddutiesassumesthattherequirementsoutlined,page5to6,havebeenconsideredandmet.UseoftheriskbasedDecisionSupportMatrixatTable 1,page12,ofthisdocumentisunderpinnedbythesupportingcontextdescribedwithintheseparagraphs.

8 Each‘task’willhaveadescribedoptimalstandardofprocessandprocedurewhichmustbeachievedtoensuresafety,qualityandperson-centredness.

Theyarethat:

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Nursing and Midwifery Decision Support Framework for Delegation. Considering: Accountability, Responsibility and Process.Anydecisiontodelegatenursingandmidwiferytasksanddutiesusingthisframeworkisunderpinnedbysevenelementsthatshouldbeappliedtoeachdecision.Theyare:

a.Accountability

b.Responsibility

c. Processwhichcomprisestheright:

i. Task

ii. Circumstance

iii.Person

iv. Direction

v. Supportandevaluation

Onmanyoccasionsthedecisiontodelegatewillbeastraightforwardone,withclarityoneachelementoftheframeworkprovidinganobviouschoicetodelegate.Thesedecisionsshouldoptimisetheskillofthenursingormidwiferyteamandenhancepersonalexperience.

Onotheroccasions,thedecisiontodelegatewillrequireanumberofrobustarrangementstobeinplacebeforedelegationoftasksanddutiesmayoccur,includingdescribedmechanismstoprovideevidencetothedelegatorthattheidentifiedoutcomesofthedelegatedtaskhavebeenachieved.

Accountability

Accountabilityinthecontextofnursingandmidwiferydelegationmeansthataregisterednurseormidwifeisanswerableforchoices,decisionsandactionsmeasuredagainstaspecifiedstandardorstandards.

Forthosewhoaredelegatingnursingand/ormidwiferytasksanddutiesthisincludesaccountabilitytoconsiderandadhereto:

•Professionalstandards

•Employmentstandards

•thedelegationdecisionmakingprocess

andforconfirming

•thesafety,qualityandexperienceoftheoutcomeagainstthedescribedstandard.

Forthoseindividualswhoareacceptingthedelegatedtaskorduty(delegatee),beingaccountablefortheirownactionsincludesadherenceto:

•thedescribedprofessionalstandards

•employmentstandards

•actingwithinorganisationalpoliciesandprocedures.

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ResponsibilityInthecontextofdelegationofnursingandmidwiferytasksanddutiestakingresponsibilitymeansthataregisterednurseormidwifeshouldbepreparedandabletogiveanaccountofhisorheractionsforanydecisiontodelegate.Delegatorsanddelegateeshaveresponsibilitiestosupportaframeworkfordecisionmakingtodelegatenursingand/ormidwiferytasksandduties.Theyincludethat:

The delegator has

•authoritytodelegatethetask

•competencerelatingtothetask9

•undertakenanassessmentofneedpriortodecisionmakingandobtainedanyrequiredconsent

•undertakenariskassessmentastowhetherornotthetaskisdelegableintheparticularcircumstance

•providedcleardirectiontothedelegatee,checkingcompetenceandunderstandingtocarryoutthetask

•providedthenecessarylevelofsupervisionforthedelegatee

•ensuredaprocessisinplacetoenableregularandongoingreviewandevaluationoftheoutcomeofthedelegatedtaskinthecontextoftheongoingassessmentofclientschangingneeds.

The delegatee

•confirmsacceptanceofthetask

•communicatestheoutcome(writtenand/orverbal)

•understandsthefactorsthatinformthedelegationdecisionmakingprocess

•communicatesorreportsrelevantchangestothedelegatorwhichmayimpactonsafetyortheoutcome,takingintoconsiderationthedelegationdecisionmakingfactors

•maintainshis/herowncompetence

•workstothetermsofhis/heremployment

•workstotheorganisationalpoliciesandstandardsincludingraisingandescalatingconcerns

•adherestorelevantcodesofpractice.

9 Aregistrantmaybeunfamiliarwithparticulartasksordutiesduetohis/herscopeofpractice–whereupdatingmayberequiredduetoachangeinpracticeprovision.ThisFrameworkreflectstheneedfornursesandmidwivestobecompetentinthetaskordutythemselvesbeforedelegatingtosomeoneelse.

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ProcessAccountability and responsibility underpinthedecisionmakingprocesstodelegatenursingormidwiferytasksanddutiestoanothermemberofstaff.Thisprocesshasfiveelementstoconsidertoassistdecisionmaking,particularlyforthosedecisionswhichmaybemorecomplex.

Forthepurposesofthisframeworkthefiveprocesselementshavebeencalledthefive‘Rs’–remindingnursesandmidwiveswhoaremakingdecisionsaboutdelegationtoconsiderwhetherornotconditionsforeachelementare‘right’toenabledelegationtooccursafely,efficientlyandinaperson-centred manner.

Theyare:

Confirmingtheright taskrequiresconsiderationwhetherornottheactivity:

•iswithintheauthorityofthedelegatortodelegate

•isperformedinsystematicstepsthatrequirelittleornomodification

•canbeperformedtogiveapredictableoutcomewithinagreedparameters

•doesnotinvolveassessment/decisionmakingbeyondthescopeofthetask.

Confirmingtheright circumstance requiresconsiderationof:

•theconditionofthepersonreceivingcare

•thepersonbeinginvolvedinthedevelopmentof,andisinagreementwith,his/herperson-centredplanofcare.

Confirmingtheright person to delegatetorequiresconsiderationofwhetherornotthedelegatee:

•hastherequiredknowledgeandskillstocarryoutthetaskcompetently

•hasthenecessarytimetoundertakethetask

•isconfidenttocarryoutthetask.

Providingandconfirmingtheright directionrequires:•apersoncentredplanofnursingormidwiferycare,basedonanassessmentofnursing/midwiferyneedsguidedbyappropriateriskassessments,whichhasbeendevelopedandagreedwiththepersonreceivingcare

•clearperson-centredcommunicationaboutthe:› delegatedtask› standardofoutcomebasedonprofessionalandorganisationalstandards,policiesandprocedures

› timerequirementforreview.

Providingandconfirmingtheright support and evaluation requiresthatthedelegatorputsinplaceasystemorprocessto:

•enableadviceinlinewiththepersoncentredplanofnursingandmidwiferycare

•enabletheraisingandescalatingconcernsappropriately

•determinetheoutcomeofthedelegatedtask.

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Risk Based Decision Support Itisimportanttorestatethat on many occasions the decision to delegate will be a straightforward one, clarity on each element of the framework providing an obvious choice to delegate, that optimises the skill of the nursing or midwifery team and enhances personal experience. A nurseormidwifewhodelegatestasksanddutiesmustbeablegiveaccountastowhyadecisionwastaken.Thisframeworkwillprovidestructureforevidencingdecisionstodelegatepracticeandalsotopromptthinkingaboutreviewofoutcomes.

Oneachoccasionwheredelegationofnursingandmidwiferytasksanddutiesoccurs,thedelegatorworkswithinaframeworktosupportdecisionmakingoutlinedwithinthisdocumentatpages5to9.Inapplyingthisframework,anumberofrequiredassumptionsaresatisfiedbeforeadecisionistakentodelegateataskordutytoanindividualorindividuals.

Thisdoesnotmeanthatawrittenrecordofeverydecisiontodelegateisnecessary.Aperson-centredplanofnursingormidwiferycareandevaluativesummarymustcontainsufficientinformationinrelationtodelegatedtasksanddutiestosupportdecisionmaking,includingevidenceofadiscussionwiththepersonreceivingnursingormidwiferycareandwherecapacityispresent,consent.Otherevidencethatsupportsnon-clinicaldelegationdecisionswillbefoundin,forexample,annualobjectives,professionalsupervisionrecords,actionplansorlearninganddevelopmentplans.

Onsomeoccasions,thedecisiontodelegatewillrequireanumberofrobustarrangementstobeinplacebeforedelegationoftasksanddutiesmayoccur,includingadescriptionofwaysinwhichevidencemightbeprovidedtothedelegatorthattheidentifiedoutcomesofthedelegatedtaskordutyhavebeenachieved.

Whereadecisiontodelegaterequirescriticalanalysisanddirection,itwillbehelpfultousethematrixdescribedat Table 1,page12.Thematrixassumesthatthefactorswithintheaccountability and responsibility sectionshavebeenconsideredandincorporatesthefiveelementsoftheprocesssectionoftheframework,thatis,therighttask, circumstance, person, direction and support and evaluation.

Thedecisionsupportmatrixconsiderstheelementsoftheframeworkacrossthreedomainsof:potentialforpatient/clientharm,complexityofcareandpredictabilityoftheoutcome.Thedomainscanalsobetranslatedfornon-clinicaldecisionmaking,describedsimplyas:potential for harm withtheexceptionoftheinclusionofthecriterion stability of condition of the person receiving care.

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How to Use the Decision Support Matrix

Havingworkedthroughtheassumptionstoassurethatappropriatearrangementsareinplace,anurseormidwifewishingtomakeadecisiontodelegateshouldthinkthrougheachoftheeightcriteria(fordetailsofthecriteriarefertoTable 1,page12)toconsiderthesubjectmatterofthedecision.Responsestothecriteriaaresituatedwithinthreecolumnsdependingonthelikelylevelofrisk:greenforlowrisk,amber,mediumriskandredhighrisk.

Whereconsiderationofthedecisionleadstoresponsessituatedentirelywithinthegreen–lowriskcolumn,thetaskordutymaybedelegated.

Whereconsiderationofthedecisionleadstoresponsessituatedwithinthegreenandambercolumnsonly,thetaskordutymaybedelegatedwithmitigatingsupportiveactionsrequired.Professionaljudgementandcriticalthinkingshouldbeusedbythenurseormidwifetoensurethatanydecisiontodelegateissupportedappropriately.Onoccasion,followingconsiderationofthefacts,itmaybethatadecisionistakennottodelegate,orindeedtodelegatetoanotherperson,whoisforexample,moreconfidenttoundertakeaparticulartask.

Whereconsiderationofthedecisionleadstoanyresponsessituatedwithinthered–highriskcolumn,thetaskordutymustnot bedelegatedatthistime.Wherecircumstanceschangeacrossthecriteria,thedecisiontodelegatecanbereviewedandtakenatadifferentpointintime.Similarly,mitigatingsupportiveactionsmayleadtoadifferentdecisionatalaterstage,forexampledelegationtoacolleagueorpeerwhohastherequiredknowledge,skillsandconfidence.

Theuseofthematrixwillenablecriticalthinkingrelatingtodecisionstodelegatenursingandmidwiferytasksordutiestherebyprovidingopportunitiesforreflection,discussionandsolutionfocusedthinkingbetweenstaffmembers.

Anumberofscenarioshavebeendeveloped,asaresultofaperiodoflivetestingwhichtookplacefollowingtheinitialdevelopmentoftheframework.Theyhavebeenproducedtoactasaguideintheuseoftheframeworkandthedecisionsupportmatrix.TheycanbefoundatAppendix 1,page13.ConclusionThisdocumentsetsoutadecisionsupportframeworkfordelegationoftasksanddutiesbyregisterednursesandmidwivesinNorthernIreland.

Itdescribesrequirementstosupportdelegationinarangeofpracticeenvironmentsandconsiderationsunderwhichadecisiontodelegatecanbetaken.

InMarch2018,theCentralNursingandMidwiferyAdvisoryCommitteetotheChiefNursingOfficer,agreedtheframeworkforusebynursesandmidwivesinNorthernIreland.

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TABL

E 1:

DEC

ISIO

N S

UPP

ORT

MAT

RIX

Ass

umpt

ions

:1.

Accoun

tabilityan

drespon

sibilityha

vebeenconsidered

and

assured

.

2.

Ape

rson

cen

tred

planofnursing

ormidwife

rycareisinplace,based

onan

assessm

ento

fnursing

/midwife

ry

need

sgu

ided

byap

prop

riateriskassessm

ents,w

hichhasbeen

deve

lope

d an

d ag

reed

with

thepe

rson

receivingcare.W

herecap

acityiscom

prom

ised

,the

planshou

ldbegu

ided

bythepe

rson

’sknow

npreferen

ces,

orbythepe

rson

(s)w

ithparen

talrespo

nsibility/le

galgua

rdian.

3.

Processesareinplaceto

allowim

med

iateescalationofneedorcon

cern,sho

uldthecircum

stan

cearise.

Pote

ntia

l for

[pat

ient

/clie

nt] h

arm

Low

Ris

k of

Har

m

Med

ium

Ris

k of

Har

mH

igh

Risk

of H

arm

Canthelim

itsofthe

taskbeclearlyde

scribe

dwith

outd

ecisionmaking?

Clea

r ta

sk li

mit

s –

Doe

s no

t in

volv

e de

cisi

on

mak

ing

beyo

nd t

he s

cope

of t

he t

ask

Task

has

lim

its

that

may

cha

nge

wit

hin

desc

ribe

d pa

ram

eter

s us

ing

deci

sion

sup

port

Crit

ical

and

ana

lyti

cal d

ecis

ion

mak

ing

nece

ssar

y

Hasth

ede

legateeap

prop

riateknow

ledg

e,

skillsan

dconfi

dencetocarryoutth

etask?

Com

pete

nt a

nd C

onfi

dent

Requ

irin

g so

me

addi

tion

al k

now

ledg

e an

d sk

ills

deve

lopm

ent

and

/or

exp

ress

ed n

eed

for

som

e ad

diti

onal

sup

ervi

sion

Not

com

pete

nt a

nd /

or n

ot c

onfi

dent

Wha

tlevelofp

erson-centredcommun

ication

toth

ede

legateeisreq

uired?

Sim

ple

com

mun

icat

ion

requ

ired

abo

ut t

he

task

and

exp

ecte

d ou

tcom

eSo

me

com

plex

com

mun

icat

ion

requ

ired

abo

ut

the

task

and

exp

ecte

d ou

tcom

eCo

mpl

ex c

omm

unic

atio

n re

quir

ed a

bout

the

ta

sk a

nd e

xpec

ted

outc

ome

Com

plex

ity

of c

are

Unc

ompl

icat

edM

ediu

m le

vels

of c

ompl

exit

y H

ighl

y Co

mpl

ex

Canthetaskbepe

rformed

insystematicsteps?

Yes

Yes

- som

e w

ith

deci

sion

s re

quir

ed b

etw

een

step

sN

o –

crit

ical

and

ana

lyti

cal d

ecis

ion

mak

ing

nece

ssar

y be

twee

n st

eps

Doe

sthetaskreq

uirem

odificatio

n?N

oSo

me

wit

h d

irec

ted

deci

sion

sup

port

Ye

s - C

riti

cal a

nd a

naly

tica

l dec

isio

n m

akin

g ne

cess

ary

Pred

icta

bilit

y of

the

out

com

eH

ighl

y pr

edic

tabl

eM

ediu

m le

vels

of p

redi

ctab

ility

Lo

w p

redi

ctab

ility

Isth

eou

tcom

eofth

etaskpredictab

le?

Yes

Pred

icta

ble

unde

r ce

rtai

n co

ndit

ions

No

Isth

econd

ition

ofthe

personreceivingcare

stab

le?

Yes

- Sta

ble

Pron

e to

fluc

tuat

ion

wit

hin

pred

icta

ble

desc

ribe

d lim

its

No

- Uns

tabl

e

Aretheretim

elyfeed

backm

echa

nism

sto

confi

rmth

eou

tcom

e?Ye

sYe

s bu

t a

dela

y m

ay o

ccur

in fe

edba

ck o

f ou

tcom

e –

som

e m

itig

atio

n m

ay b

e ne

eded

No

Key:

Allgreen

–

delegate

One

or

mor

e am

beran

dno

red–profession

al

judg

emen

tand

mitigatin

gactio

nre

quir

ed

One

ormorered–

donotdelegate

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APPENDIX 1: USING THE DECISION SUPPORT MATRIX: SCENARIOS IN PRACTICE

EXAMPLE OF LOW RISK:DELEGATE TASK

YES NOMAYBE

✔ ✘DECISION

AmyapproachesDeliaandexplainsthatLindaneedstobeaccompaniedtothebathroomasthisisherfirsttimeoutofbedpost-operatively.DeliadiscusseswithAmyherexperienceofundertakingsimilartasksinherpreviousplaceofemployment.DeliaassuresAmythatsheunderstandstheneedtoraisethealarmifLindafeelsunwellatanystageanddescribeswhatshewoulddointhateventtoAmy’ssatisfaction.AmydelegatesthetaskofaccompanyingLindatoDeliaandrecordsthisinLinda’snursingrecordwhensheisevaluatingthenursingplanofcare.

ASSESSMENT

Lindais46yearsoldandhasbeenadmittedtoadaysurgeryunittohavehergallbladderremovedbylaparoscopy.Shereturnstothewardareafollowinganuncomplicatedprocedurewithtwosmallwoundsthatarecoveredwithsurgicaldressings.Shewishestogetoutofbedandwalktothebathroompostprocedure,priortodischarge.

ASSESSMENT

StaffNurseAmyisresponsibleforLinda’scarebeforeandafterherprocedure.Anursingassessmentpriortotransfertotheatrehadnotrevealedanynursingneedsbeyondpreandpost-operativecareincludinghealtheducation.Lindawasfullyindependentpriortoadmission.AmyhasbeenmonitoringLindasinceherreturnfromrecovery.Allvitalsignshavebeenwithinappropriateranges,basedonLinda’spre-assessmentinformationandbaselinemeasurementsonthemorningofsurgery.Linda’swoundsaredryandshehashadpainmedicationadministeredorallywhichhasrelievedherpain,followingtheprescriptiononherpost-operativemedicationschart.

AmyconsidersthedecisionsupportframeworkandrealisesthattheonlyquestionsheisunsureofiswhetherornotDelia,arecentlyappointedSeniorNursingAssistant,isconfidenttotakeonthetaskunsupervised.

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EXAMPLE OF MEDIUM RISK:PROFESSIONAL JUDGEMENT REQUIRED

ASSESSMENT

AnassessmentismadebytheDistrictNursingSister,Ginawhomanagestheteam,andaplanofnursingcaredescribedworkingwithJohntoagreeanappropriatelevelofcare.Usingthedecisionsupporttool,Ginarealisesthatmostoftheindicatorsforthetaskofcaringforthevalvecouldpotentiallybe‘green’allowingdelegationtooccur,iftheteamhadtheknowledge,skillsandconfidencetocarryoutthetask,theprocessforthetaskperformedinstepsandtheoutcomeconsistentlypredictable,linkedtothestabilityofJohn’scondition.Bothregisteredandun-registeredstaffwithintheteamarenotcompetentincaringforalaryngectomyvalveandthestabilityofJohn’sconditionisnotknown.Thevisitswillberequiredindefinitelywhichwillhaveanimpactonthecapacityoftheteam.

YES NOMAYBE

✔✘

ASSESSMENT

Johnisa58yearoldmanwhohashadalaryngectomyvalveinplacefor22years.HiswifeJoanhascarriedoutthetwicedailycleaningofthevalvebecausehehasalwaysfounditdifficulttomanagehimself.Joanhasrecentlydevelopedsightdifficultiesandisnolongerabletocleanthelaryngectomyvalve.Therearenootherfamilymembersabletoprovidecare.JohnhasbeenreferredtotheDistrictNursingteam.

DECISION

Thedistrictnursingteammembersagreedthattheywerenotcompetentincareofalaryngectomyvalve.Threemembersoftheteamattendedalocalcaresettingofexcellenceinpracticetoundertaketraining.ThisensuredallregisteredstaffwerecompetentincareoflaryngectomyvalveBEFOREconsideringdelegationtoaSeniorNursingAssistant(SNA).Thecurrenttrustpolicydidnotincludecareofalaryngectomyvalveinacommunitysetting-whichrequiredchanging.AprocesstoassureandmonitortheongoingcompetenceofSNAswasapprovedandimplemented.Registeredstaffcarriedoutthetaskforaperiodoftimetoassessthepredictabilityoftheoutcome,thesystematicstepsintheprocessandthestabilityofJohn’scondition,beforedelegating.HavingassuredandrecordedallofthisinformationthetaskwasdelegatedtocompetentSNAteammembers,withregularreviewbytheDistrictNursingteam.

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EXAMPLE OF HIGH RISK:DO NOT DELEGATE

ASSESSMENT

Ben,theDeputyChargeNurse,isresponsibleforErnest’scareonshift.HereceiveshandoverfromMonicaonnightshift,andrealisesthatErnestwillneedsignificantassistancewithhispersonalhygiene,mobility,nutritionalandpsychosocialneeds.WorkingwithhimontheteamisAshaaseniornursingassistant.Theyarelookingafter8peopletogether,witharangeofacuityanddependencyneeds.BenknowsAshahasworkedinthewardteamfor5yearsandisveryusedtoworkingwithpeoplewhohaveexperiencedstroke.ShehasundertakentraininginspecialistmovingandhandlingtechniquesandiscompetenttoassistErnest.Ben’sinitialassessmentleaveshimuneasyaboutdelegatingErnest’spersonalcaretoAsha.

YES NOMAYBE

✔ ✘

ASSESSMENT

Ernestisan84yearoldmanwhohasbeenadmittedtohospitalwithanextensionofapre-existingstrokehehad12monthsago.Heisorientatedandalthoughdrowsymostdays,hehascapacityandisabletoprovideconsentforcareandtreatment.Hehasbeenaggitatedsinceadmissionduetothefurtherlossofmovementhehasexperienced,andmildslurringofhisspeech.HispressurepointswereassessedonadmissionandErnestwasdeemedhighriskforpressuredamagewithaBradenScoreof10.Heisexhibitingsignsofdepressionrelatedtohisrehabilitationandisrefusingtobeassistedoutofbed.

DECISION

Bendecidestousethedelegationdecisionsupporttooltoreflectonhisinitialprofessionaljudgement.HedecidesthatanursingassessmentofErnestisrequiredwhilstundertakingthetasksassociatedparticularlywithhispersonalhygieneneedsandskinassessment.ThistaskrequiresalevelofclinicaljudgementthatisoutsideofAsha’scompetence.HeassureshimselfthathecannotdescribealloftheelementsthatAshaneedstolookforinasuccintinstruction,andadditionally,givenErnest’slowmoodandaggitation,apsychosocialassessmentcanbeundertakenwhilstcaringforhispersonalneeds.BendecidesnottodelegatethetasktoAsha.

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InJune2014theCentralNursingandMidwiferyAdvisoryCommittee(CNMAC)agreedthatthepracticeofdelegatingnursingandmidwiferytasksanddutiesinNorthernIrelandrequiredfurtherexploration.Subsequently,arangeofactivitiesweretakenforwardbytheHealthandSocialCare(HSC)ClinicalEducationCentre(CEC),andNorthernIrelandPracticeandEducationCouncilforNursingandMidwifery(NIPEC)underthecommissionoftheChiefNursingofficer(CNO),DepartmentofHealth(DoH).AnumberofprioritieswerepresentedtoCNMACinDecember2015,todetermineimmediateandfutureaction,ensuringthattheprocessofdelegationofnursingandmidwiferytasksanddutiesatalocalandregionallevelwouldmeettherequirementsoftheNursingandMidwiferyCouncil(NMC)Code10andsupportthehighestpossiblelevelofpatient/clientsafety.Theprioritiesincluded:

• Areview/refreshoftheexistingDelegationFrameworkfornursingandmidwiferyStaff11withinamulti-disciplinaryapproachifpossible.

• Considerationofassessmentofriskalongwithguidanceandtheeffectiveuseofatrafficlightsystemthatisexplicitregardingactivitythatshouldnotbedelegated.

NIPECwascommissionedbytheCNOtoleadtheproductionofanapproachtodelegationofnursingandmidwiferytasksanddutiesthataddressedthosepriorities.KathyFodey,DirectorofRegulationandNursing,RegulationandQualityImprovementAuthority(RQIA)andColumConway,ChiefExecutive,NorthernIrelandSocialCareCouncil

(NISCC)wereaskedtojointlychairaTaskandFinishGrouponbehalfoftheCNO.ThefinalproductwastobereportedtoCNOviaCNMAC.

WorkingwiththeCo-Chairs,theleadofficerinNIPECproducedaprojectplanandoutlinemethodology,whichincludedtheconveningofaworkshopattendedbyawiderangeofrepresentationacrossstatutory,non-statutory,education,policyandstaff-sideorganisations.Thepurposeoftheworkshopwastobringtogetherarangeofnursingandmidwiferycolleaguesfromacrosssectorstodiscusstheirunderstandingofdelegationinnursingandmidwifery,ideastosupporteffectivedelegationandthentestanoutlineframeworkwhichwasbasedonbestevidenceinthisarea.Withaviewtotheintersectionofnursingandmidwiferycareandserviceswithsocialcare,anumberofsocialworkcolleaguesattendedtheeventtolistenandcontributetothediscussion,toenablefuturethinkingforsocialcaresettingsandinter-professionalteams.

Theintentionwastodrawontheconsiderableworkwhichhadtakenplacebyothercountriestodate,evidencedthroughpublicationsandframeworksalreadyinexistenceandengagewithdelegatesregardingproposalsforanoutlineframework.Colleaguesengagedinarangeofexercisestostimulatediscussionandcommentontheoutlineprovided,includingscenariotestingofadecisionsupportmatrix.AtvariouspointsthroughoutthedaytheCo-ChairsandProjectLead,NIPEC,facilitatedfeedback.

ADDENDUM 1: PRODUCTION OF THE FRAMEWORK

10 Ibid,n1.11 CentralNursingAdvisoryCommittee.(2009).Central Nursing Advisory Committee Delegation

Decision Making Framework.Belfast,DHSSPSNI.

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DelegateswereinvitedtooptintomembershipofaTaskandFinishSubGrouptotaketheworkforward.NameswereofferedbyindividualsandweresubsequentlyagreedbyExecutiveDirectorsandCNO.MembershipoftheSubGroupisatAddendum 2,page19.ThisgroupwasconvenedinearlyJanuary2017torefinetheframeworkbasedonthefeedbackobtainedthroughtheOctober2016workshop.Followingaperiodofreviewandfinalisation,theframeworkwastestedinarangeofnursingandmidwiferypracticesettingstoenablefinalrefinementandfeedback.

Overwhelmingly,theregisterednurseswhoengagedintestingthedraftframeworkfoundituseful.Manystatedthattheyfeltthestructureandclarityofthematrixempoweredautonomousdecisionmaking,enablingthemtoarticulatearationaleastowhytheyhadmadeparticulardecisionstodelegatenursingtasksandduties.

Throughoutthetestingphasesitwasapparentthattherewereanumberofcomplexschemesofserviceprovisiontowhichthedelegationframeworkmightapplyandforwhichacollectivesolutionshouldbeconsideredtosetinplaceprinciplesforaregionalcross-agency,multi-professionalapproach.

Asmallnumberofactionswereidentified,therefore,relatingtonecessarynextstepsthroughforconsiderationbytheTaskandFinishSubGroup,CNMACandtheChiefNursingOfficer.

ThefirstphaseanddecisionsupportframeworkwerepresentedtoCNMAC23rdMarch2018forapproval.

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EVIDENCE THAT INFORMED THE PRODUCTION OF THE DECIDING TO DELEGATE DECISION SUPPORT FRAMEWORK

TheDecidingtoDelegateframeworkworkedforwardfromevidencegatheredfromascopingexercisecarriedoutbytheHealthandSocialCareClinicalEducationCentre(HSCCEC)12andaworkshopeventhostedjointlybyNIPECandHSCCECtotheCentralNursingandMidwiferyAdvisoryCommittee(CNMAC)inDecember201513.

Inadditiontothesereports,arangeofliteratureandresourcesinformedthethinkingrelatingtotheproductionoftheframeworkincluding:

AustralianNursingFederation.(2011).ANF Guidelines: Delegation by registered nurses and registered midwives. Availablefordownloadat:http://www.anmf.org.au/documents/policies/G_Delegation_RNs_RMs.pdf

Gillen,P.andGraffin,S.(2010).NursingDelegationintheUnitedKingdom.OJIN:The Online Journal of Issues in Nursing. 15(2).Manuscript6.

Hasson,F.,McKenna,H.andKeeney.S.(2013).Delegatingandsupervisingunregisteredprofessionals:thestudentnurseexperience.Nurse Education Today.33:229–235.

NationalHealthScotlandFlyingStartProgramme:Delegationavailableat:http://flyingstart.scot.nhs.uk/learning-programmes/communication/delegation/

NationalLeadershipandInnovationAgencyforHealthcare(2010).All Wales Guidelines for Delegation.Llanharan,NLIAH.Availableat:http://www.wales.nhs.uk/sitesplus/documents/829/All%20Wales%20Guidelines%20for%20Delegation.pdf

NursingandMidwiferyCouncil.(2018).The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. London:NMC.Availablefordownloadat: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf

RoyalCollegeofNursing.(2011).Delegation: A Pocket Guide.London,RCN.

RoyalCollegeofNursing:AccountabilityandDelegation:https://www.rcn.org.uk/professional-development/accountability-and-delegation

Ruff,V.A.(2011).Delegation Skills: Essential to the Contemporary Nurse. MasterofArtsinNursingTheses.Paper21.

Stonehouse,D.(2015).Theartandscienceofdelegation.British Journal of Healthcare Assistants.9(3):150–153.

12 HSCClinicalEducationCentre.(2015).Summary Report on the Delegation of Nursing Care for Central Nursing and Midwifery Advisory Committee. Belfast,CEC.

13 HSCCECandNIPEC.(2015).RegionalWorkshopToConsiderAspectsOfTheDelegationOfNursingCare:ReportToCNMAC.Belfast,NIPEC.

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NAME ORGANISATION

Finlay,Heather DoH

Wallace,Verena DoH

Martin,Jillian DoH

Higgins,Patricia NISCC

Rodigues,Ethel UNITE

Martin,Garrett RCN

Hughes,Breedagh RCM

UNISON

Pelan,Aisling BHSCT

Rafferty,Esther BHSCT

Devlin,Nuala BHSCT

Brown,Fiona NHSCT

Hume,Allison NHSCT

Pullins,Suzanne NHSCT

Burke,Mary SHSCT

Hamilton,Grace SHSCT

Holmes,Sharon SHSCT

Kelly,Linda SEHSCT

McRobertsSharon SEHSCT

Mills,Paul SEHSCT

Taylor,Janet SEHSCT

ElaineCole SEHSCT

McGarvey,Brian WHSCT

McGrath,Brendan WHSCT

Witherow,Anne WHSCT

Brown,Oriel PHA

Devine,Maurice CEC

Watson,J-P Ind&Vol

ADDENDUM 2: MEMBERSHIP OF TASK AND FINISH GROUP SUB-GROUP

Responsibilities of Sub Group Membership:• Contributetotheachievementoftheaimsandobjectives

• ParticipateinplannedactivityrelatedtotheproductionoftheFramework

• Participateinrespectful,opendebate

• Welcomeandprovideconstructivechallenge

• Consultwithindividualsofappropriateexpertiseasrequiredinformingtheproductionoftheframework

• Activelyparticipateintestingthefinaldraftframework

• Manageinformationrelatedtotheworkplanresponsibly,ensuringconfidentialitywhenrequired

• AttendallmeetingsrequiredtodevelopafinaldraftFrameworkforcirculationtothewiderTaskandFinishGroup

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Term Used Term Descriptor

Appropriate Suitableorproperinthecircumstances.

Carer Acarerisanyonewhocares,unpaid,forafriendorfamilymemberwhoduetoillness,disability,amentalhealthproblemoranaddictioncannotcopewithouttheirsupport.

Capacity Theabilityorpowertodoorunderstandsomething.

Competence Theknowledgeskillsattitudeandabilitytopracticesafelywithoutdirectsupervision.

Competent Havingthenecessaryability,knowledgeorskilltodosomethingsuccessfully.

Consent Permissionforsomethingtohappenoragreementtodosomething–inhealthcarethisisaccompaniedbytheboundariesofinformedagreement,i.e.anindividualhasbeenprovidedwiththeappropriateinformationtomakeadecision.

Delegate Toentrustataskordutytoanotherperson.

Delegatee Competentpersonwhoagreestoacceptthetaskordutydelegatedtothembythenurseormidwife.

Delegator Nurseormidwifewhodelegatesataskordutytoacompetentotherperson.

Midwife ApersonwhohasundergonetrainingandeducationtomeettheNursingandMidwiferyCouncil(NMC)standardsforpre-registrationorpost-registrationmidwiferypractice,anddeemedcompetenttojointheNMCregister,thereafterrenewingtheirregistrationeverythreeyearsthroughrevalidation.MidwivescommittoupholdingprofessionalstandardswithintheNMCCodeofpracticeandbehaviours.

Non-registered ApersonwhohasnotbeentrainedandeducatedtotheNursingandMidwiferyCouncil(NMC)standardsforpre-registrationnursingormidwiferyandisthereforenotapartoftheNMCregister.

Nurse ApersonwhohasundergonetrainingandeducationtomeettheNursingandMidwiferyCouncil(NMC)standardsforoneormoreofthefourpre-registrationnursingspecialisms:adult,children’s,learningdisabilitiesandmentalhealth,anddeemedcompetenttojointheNMCregister,thereafterrenewingtheirregistrationeverythreeyearsthroughrevalidation.NursescommittoupholdingprofessionalstandardswithintheNMCCodeofpracticeandbehaviours.

GLOSSARY

Thefollowingdescriptorsaredefinedwithinthecontextofthisdocument

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Term Used Term Descriptor

Protocol Theacceptedorestablishedcodeofprocedureorbehaviourinanygroup,organisation,orsituation.

ScopeofPractice Theareaofsomeone’sprofessioninwhichtheyhavetheknowledge,skillsandexperiencetopractisesafelyandeffectively,inawaythatmeetsthestandardsoftheirrespectiveregulatorand/oremployeranddoesnotpresentanyrisktothepublicortothehealthprofessional.

ServiceUser Apersonwhousestheservicesofahealthprofessionaloranyotherrelevantservice.

Skill Theabilitytodosomethingwell;expertise.

Supervision Theactiveprocessofdirecting,guidingandinfluencingtheoutcomeofanindividual’sperformanceofatask.

Taskorduty Apieceofworktobedoneorundertaken.

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DECIDING TO DELEGATE: A DECISION SUPPORT FRAMEWORK … · responsibility and accountability on...

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