State policies regarding nursing delegation and medication administration in child care settings: a case study

Medication administration is an essential component of quality child care, and nurses play a central role in assuring high-quality training of child care providers. Through key informant interviews and review of public documents, this case study explored the development of state statutes and regulations for medication administration training of child care providers in the state of Connecticut, nursing liability issues related to the definition of this activity, and the role of the Connecticut State Board of Examiners for Nursing. This article also examines the interpretation of the nursing role within this context as delegation versus professional activity and the impact of such designation on nursing practice, child care providers' access to medication administration training by nurses, and children's health status in child care settings. As a result of this case study, the Connecticut State Board of Examiners for Nursing revised its policies, demonstrating an exemplar linkage among research, practice, and policy.     

Registered nurse leadership style and confidence in delegation

Saccomano S.J. & Pinto- Zipp G. (2011) Journal of Nursing Management 19 , 522–533
Registered nurse leadership style and confidence in delegation Background and aims Leadership and confidence in delegation are two important explanatory constructs of nursing practice. The relationship between these constructs, however, is not clearly understood. To be successful in their roles as leaders, regardless of their experience, registered nurses (RNs) need to understand how to best delegate. The present study explored and described the relationship between RN leadership styles, demographic variables and confidence in delegation in a community teaching hospital. Methods Utilizing a cross-sectional survey design, RNs employed in one acute care hospital completed questionnaires that measured leadership style [Path-Goal Leadership Questionnaire (PGLQ)] and confidence in delegating patient care tasks [Confidence and Intent to Delegate Scale (CIDS)]. Results Contrary to expectations, the data did not confirm a relationship between confidence in delegating tasks to unlicensed assistive personnel (UAPs) and leadership style. Nurses who were diploma or associate degree prepared were initially less confident in delegating tasks to UAPs as compared with RNs holding a bachelor’s degree or higher. Further, after 5 years of clinical nursing experience, nurses with less educational experience reported more confidence in delegating tasks as compared with RNs with more educational experience. Conclusions The lack of a relationship between leadership style and confidence in delegating patient care tasks were discussed in terms of the PGLQ classification criteria and hospital unit differences. As suggested by the significant two-way interaction between educational preparation and clinical nursing experience, changes in the nurse’s confidence in delegating patient care tasks to UAPs was a dynamic changing variable that resulted from the interplay between amount of educational preparation and years of clinical nursing experience in this population of nurses. Clearly, generalizability of these findings to nurses outside the US is questionable, thus nurse managers must be familiar with the Nurse Practice Act in their country in order to ensure proper delegation of tasks to appropriate assistive personnel. Implications for nurse managers It is imperative that nurse managers provide nurses with the educational opportunities necessary to develop delegation and supervision strategies to adapt to the changing RN role while adhering to differences in scope of practice. Globally, RNs are caring for increasing numbers of acutely ill patients with scarce resources ensuring an adequately trained RN/UAP team can help support optimal patient care.     

Effectively delegating nursing activities in home care

Delegating appropriate portions of nursing care to LPNs and home health aides is an essential RN skill and critically necessary in PPS. This article examines the concept of delegation and shows clinicians how to assess, plan, and evaluate delegation tasks to increase productivity.     

Nurses' evaluations of a novel design for an electronic medication administration record

An electronic medication administration record is at the intersection of several disciplines: medicine, nursing, pharmacy, and allied health; however, it is the centerpiece of nurses' work for medication administration in acute care settings. Despite the crucial nature of the electronic medication administration record, human-computer interaction and health literature are silent about design recommendations and evaluations for such records. This study determined critical on-line medication management tasks for acute care nurses through videotaped, semistructured interviews with nurses and then observations of nurses during medication administration tasks. Subsequently, a novel electronic medication administration record prototype was developed and evaluated. The usability evaluation of this new record was positive based upon scores from the Questionnaire for User Interaction Satisfaction and comments about the display. Mean scores for this questionnaire averaged 7.2 to 7.9 (on a scale of 1-9) or from 80.2% to 87.8%. Accuracy scores were low for tasks requiring nurses to examine data outside the immediate field of view. Specific design recommendations are made to alleviate accuracy errors for specific tasks in acute care settings.     

Delegation of medication administration: an exploratory study

AIM: To examine the delegation of medication administration, including the frequency of delegation, whether delegation was to a care worker or a registered nurse (RN) and whether care workers were directly supervised when administering medication. METHOD: Administration of 1313 medication doses was observed on two inpatient psychiatric wards for older people. RESULTS: Administration was delegated by the nurse preparing the medication for four out of every five doses, usually to another registered nurse (78% of delegated doses), but also to care workers (22%). Care workers were more likely to administer medications to confused and aggressive patients than were registered nurses. CONCLUSION: Care workers who undertake delegated medication administration should receive regular training to ensure safety. Nurses remain accountable for delegated medication administration.     

School nurses' experience with administration of rectal diazepam gel for seizures.

The purpose of this study was to determine school nurses' knowledge of state and school district policies, their experience regarding the administration of rectal diazepam gel in the school, and the perceived benefits and barriers of providing this treatment. Four hundred nineteen nurses responded to a survey conducted during the National Association of School Nurses Annual Meeting. Seventy-one (18%) nurses surveyed had administered rectal diazepam gel in a school setting, while 54 (13%) nurses reported that either their state practice act or school district prohibited them from giving rectal medications in the school. Medication administration benefits, such as early intervention for treatment of acute seizure emergencies, were noted. Barriers were also identified, with lack of privacy as the most frequently listed. Scope of practice as it pertains to administering medication in the school and the extent to which delegation of duties can be used in the situation of administering rectal medication in a seizure emergency remain issues for school nurses.     

An investigation of the role nurses play in Norwegian home care

Registered nurses' (RNs') role in Norwegian home care services exists in a state of flux owing to the early discharge of patients from hospitals, more time-consuming and complex care for young patients, and a growing number of older care recipients. The aim of this study was to investigate the RN role through an integrative research review, with a focus on nursing activities and competence. This study found that RNs and assistant nurses often perform the same tasks, providing assistance with personal hygiene, medication and wound management. The change towards more medicalized and complex home care entails that requirements pertaining to RNs' competence, the allocation of RNs' time and skills to those in most need of nursing care, and the assignment of assistant nurses to lower care levels activities must be delineated. Norwegian home care must examine how care activities can be better allocated between RNs, social educators, assistant nurses, and informal care-givers.     

Public attitudes toward some changes in the division of labor in medicine.

This study examined public attitudes toward the delegation of medical tasks to nonphysician health workers. Data were obtained in household interviews of a probability sample of the adult residents of Cuyahoga County, Ohio (N = 808). The proportions of the sample giving approval to care from nonphysicians varied widely among the 18 tasks on which opinions were elicited. The results of the public survey were compared to those from an earlier national survey of physicians. Physicians' responses paralleled the responses of the lay public regarding most tasks. However, with respect to regular checkups on babies and prenatal checkups, markedly higher proportions of the physicians than the public were willing to delegate to nonphysicians. The analysis indicated that public attitudes toward task delegation in medical practice do not bear strong relationships to social status indicators, political self-designations, or preceived health status.     

The diffusion of innovation in nursing regulatory policy: removing a barrier to medication administration training for child care providers

Safe medication administration is an essential component of high-quality child care. Its achievement in New Jersey was impeded by a controversy over whether teaching child care providers medication administration involves registered nurses in the process of nursing delegation. Through the theoretical framework of the Diffusion of Innovation, this paper examines how the interpretation of regulatory policy related to nursing practice in New Jersey was adjusted by the Board of Nursing following a similar interpretation of regulatory policy by the Board of Nursing in Connecticut. This adjustment enabled New Jersey nurses to continue medication administration training for child care providers. National data supporting the need for training child care providers in medication administration is presented, the Diffusion of Innovation paradigm is described; the Connecticut case and the New Jersey dilemma are discussed; the diffusion process between the two states is analyzed and an assessment of the need for further change is made.     

Debate in the USA on nurses' delegation of duties to assistants

In the today's rapidly changing practice environment, more nurses than ever are facing delegation dilemmas. The main issues of the debate on delegation of task and activities from nurses to less qualified personnel are reported. Nurses can delegate tasks but remain accountable for the final result. The main rules for delegation are discussed and the need for a correct communication and education to delegate is stressed.     

Dynamic role boundaries in intermediate care services

This paper examines the impact of intermediate care service delivery on the role boundaries of service providers. Two intermediate care teams were selected as case studies to explore the roles of workers in the context of an admission avoidance and assisted discharge service. Data were collected through semi-structured interviews with 26 intermediate care staff, including physiotherapists, occupational therapists, nurses, a social worker and support workers. The study found that therapists' roles were most closely aligned with each other, whilst nurses perceived their roles as being distinct from therapists, with a more medical emphasis. Therapists and nurses delegate a range of tasks to support workers, although the nature of task delegation differed across the two teams. A number of factors were associated with the role flexibility of staff including the setting, duration and nature of care, access to alternative care providers and the ability of staff to undertake joint visits. Contrary to previous research, the practitioners were not threatened by overlapping roles, and recognised that confidence in their own roles and an understanding of the roles of other workers was necessary to avoid feeling threatened. The study concludes that intermediate care can promote role overlap across a range of workers. Role overlap can enhance clinician confidence in their own area of expertise whilst optimising patient care. Role overlap has the potential to optimise limited staff resources in an interprofessional working environment. Interprofessional working can be enhanced in the workplace through joint visits and shared working practices.     

Palliative care for patients with cancer: district nurses' experiences

AIM: This paper reports a study exploring district nurses' experiences of providing palliative care for patients with cancer and their families. BACKGROUND: There is an increasing demand for palliative care in the community, as many patients wish to die at home. District nurses are central to providing palliative care in the community, but there is a dearth of literature on district nurses' experiences in palliative care. METHOD: A Husserlian phenomenological approach was adopted with a purposive sample of 25 female district nurses. Data were collected using unstructured, tape-recorded interviews and analysed using Colaizzi's seven stages of data analysis. FINDINGS: Four themes were identified: the communication web; the family as an element of care; challenges for the district nurse in symptom management and the personal cost of caring. CONCLUSIONS: District nurses' experiences of providing palliative care to family units was challenging but rewarding. The emotive nature of the experience cannot be under-estimated, as many district nurses were touched by the varying situations. Whilst acknowledging the need to maintain an integrated approach to care, district nurses should be identified as the key workers in the complex situation of palliative care.     

Changes in practice at the nurse-doctor interface. Using focus groups to explore the perceptions of first level nurses working in an acute care setting

A unique combination of factors has recently triggered a rapid change in the clinical practice of nurses in the UK. This study was carried out to explore the consequences of changing practice at the nurse-doctor interface, as perceived by first level nurses working in an acute care setting in the UK. Qualitative data were collected using focus group interviews and analysed thematically. Findings suggest that role change to these nurses is represented by a 'shift' in the practice of technical activities from junior doctors and a corresponding delegation of nursing activity to care assistants. It is suggested that the wholesale incorporation of technical interventions into the role of the nurse without an increase in the number of qualified nurses is turning nursing back to a task system of care delivery. This has the potential to depersonalize patients and reduce work satisfaction for nurses.     

Nurses and doctors communicating through medication order charts in critical care.

The structure and content of written forms of communication dynamically interact with the social and historical conditions underlying critical care nursing activities. One important form of documentation regularly used in the critical care area is the medication order chart. This paper considers the ways in which medication order charts are used to structure interactions among nurses and between nurses and doctors. The critical ethnographic study upon which this paper is based involved a research group of six nurses who worked in one critical care unit. Data collection methods involved professional journalling, participant observation and individual and focus group interviews. Data analysis identified four major issues for consideration: imbalance between medical knowledge and legal authority; the nurse as go-between and medication expert; coaching the doctor; and the self policing nurse. The critical care nurse's role extends beyond the traditional passive activity of medication administration. By exploring the power relations underlying this role, there is greater opportunity for improved nursing relationships and patient care.