Professional- 1

Professional Roles and Values Case Study Mary Kinsey Professor Nelson NVT2 Western Governors University February 2012

Professional- 2 In this case study many issues present concerns such as the lack of cultural care competence, the patients diagnosis of developmentally disabled, and under delegation by the family nurse practitioner (FNP). The FNP does not seem to have a solid understanding of the patients culture. To provide competent care the FNP needs to understand Ms. Rs cultural values, beliefs, behaviors, and intellectual level of understanding. The FNP verbalized frustration with the Latino patient who did not seek regular or preventive health care, missed appointments, and was always late. I believe that Ms. Ws lack of knowledge regarding Latino culture hindered the care she provided to the patient. A key factor to be considered is the fact that Latino/Hispanic cultures consider the area between the waist and knees to be extremely private and only discussed with a few select individuals. Usually that would be the mother of the patient however in this case that relationship is not intact. Latinos place a lot of importance on demonstrating respecto (respect) in interactions with others they see in a position of authority such as healthcare providers. They are quiet and hesitant to ask questions regarding their care and treatments because they believe it is disrespectful. American healthcare providers are time and task-oriented, whereas Latinos focus more on personal relationships. Many Latinos have a relaxed attitude regarding time and do not place much value on being on time to appointments, which is a socially accepted behavior in their culture. Latinos place value on physical gestures such as shaking hands, pat on the back, placing a hand on the arm to show caring and warmth by the provider. Latinos expect healthcare providers to be pleasant and polite and when a providers appears frustrated, upset, short, or business like to them they are unhappy with the care they received. This can result in noncompliance with the treatment plan and follow-up care. (Peterson-Iyer; K, Betanxourt, J.)

Professional- 3 The FNP should understand that individuals with developmental disabilities experience chronic conditions that may be either mental and/or physical in nature, and have problems with language and learning. With this knowledge the FNP should be aware that the way they communicate with a patient with a developmental disability is different and make appropriate modifications based on the individuals specific limitations. The following suggestions would help when talking with someone with an intellectual disability: make eye contact; use simple, clear explanations or questions that can be answered with yes/no; use a respectful calm tone; be patient, allow enough time for the individual to process the information presented before they respond; have the patient summarize the information using presented in their own words; and remember respect, touch and kindness places the patient at ease, happy with the care, and more compliant. The FNP verbalized frustration regarding the patients non-compliance with the medication ordered for her UTI and presenting again with symptoms of a urinary tract infection. It is important that healthcare providers understand the possible risks of pyelonephritis, preterm birth, low birth weight, and increased perinatal mortality to the patient and fetus associated with recurrent or untreated urinary tract infections in pregnancy. However, for this patient the FNP needed to stress in terms the patient could understand the importance of having a urinary tract infection during pregnancy and the correlation with premature labor with the initiation of treatment. Even though the patient was given instruction to call the office with any concerns regarding the treatment the FNP should have gone a step further and informed the patient that other medications were available to her if she had any trouble with the one prescribed. The patient does not need to understand the use of Class B medications during pregnancy such as ampicillin, nitrofurantoin, and the cephalosporins, but should have understand that more than one medication was available to help her get better.

Professional- 4 The nurse should explain on the patients level the importance of having an Rh negative blood type, and how Rh incompatibility can affect future pregnancies by starting an immune response in her body that could result in abnormalities and/or death of the next baby. The nurse should have educated the patient on the importance of getting the Rhogam shot at 28 weeks to prevent future complications. As the supervisor of the clinic I could help the FNP recognize her role in better utilizing the diverse workforce that is available in the clinic in the following ways. I would provide the FNP with the resource book Health Care Teamwork: Interdisciplinary Practice and Teaching by Clark and Drinka. Drinka describes the interdisciplinary health care team (IHCT) as a group of individuals with different education and competencies who work as a team to solve patient problems that are too complex to be solved by one provider. In order to provide efficient care they share leadership and information and work as a group to solve identified problems. As a unit they identify the goal(s) to be accomplished and work in collaboration with each other in treating the patient. Each member of the team brings their areas of specialty and defined role(s) to the group to provide the highest level of care. As the supervisor it is my responsibility to know the regulations/laws and scope of practice for all licensed personnel working in the clinic. I would provide the FNP with a written explanation of each staff members qualifications and role responsibilities. Further education regarding each staff members abilities could be presented in a conference format where each staff member could be informed of the FNPs patient situation and then each discipline could provide information to the FNP on what they could offer using the knowledge of their specialty.

Professional- 5 As the supervisor I would educate the FNP as to when and how to delegate tasks to other disciplines by providing the following information. When you are deciding whether or not to delegate a task safely consider what the patients choices are. Is the patient stable? Are the outcomes predictable? What is the scope of practice and competencies of the provider you are delegating the task? Is there the possibility of harm to the patient? How often does the provider perform the task delegated? Are there areas of concern during the completion of the task? Is the task identified within the scope of employment guidelines? Is the task described appropriately and supported in the clinics policy/procedure guidelines? Can the patient do the task themselves or provide guidance to the provider how the task is performed? Additionally, the FNP would understand that she/he would retain responsibility for supervision of the delegated task and if they think the task is too complex, or requires a high level of supervision then the task should not be delegated. The supervisor/FNP is accountable for the delegation decision, the nursing process, supervision, and evaluation of the nursing care. Therefore, they need to consider the following five rights during the entire delegation process. First the right task which determines if the task to be delegated is identified in the other providers job description and in the clinics policies/procedures and standards of care. Second, the right circumstances which analyzes and identifies the nursing needs of the patient based on the health assessment. The supervisor/nurse must create a list and prioritize what the patient will need, available resources at the clinic, and determine if the supplies are available that are needed to meet the patients needs. The supervisor/nurse need to determine if the clinic has the identified staff and skill mix available to meet the patients needs. Communicating the chain of authority and how information will be documented and shared with team members and the patient are also responsibilities of the delegating person. The

Professional- 6 supervisor/nurse guides and delegates the delivery of care based on how complex the task being delegated is and on the stability of the patient. Consideration is also given to the competency of the available licensed staff and the amount of supervision required. Once the task has been delegated the supervisor/nurse will assist, monitor, and evaluate both the staff performing the task and how the patient is doing health wise. Third the right person, the supervisor/nurse bases delegation decisions on multiple factors such as the clinics standards, state and federal regulations and laws that identify what each licensed staff member may do based on their job description. Additionally, the supervisor/nurse provides guidance and evaluates the competency of the staff member the task was delegated to on a patient specific basis. Fourth the right direction/communication: The supervisor must clearly state and define acceptable tasks to be delegated, identify the qualifications and competencies of each staff member available. Identify how the delegated task will be monitored and evaluated by providing a description of standards of care, each staff members role descriptions and the clinics policies/procedures. The supervisor/nurse communicates the task to be delegated on a specific patient. Identify the information to be obtained and how and when the information is to be communicated to other team members. Clearly define specific task(s) to each team member they are accountable for and expected outcomes or possible problems that may occur and the fifth, and very crucial right of supervision and evaluation. The supervisor and/or nurse provides indirect or direct supervision of the task they delegated. The supervisor/nurse decision to delegate takes into consideration the competencies and qualifications of the individual being delegated the task, whether the task(s) is simple or complex, and how stable and predictable the patients health condition. It is the responsibility of the supervisor and/or delegating nurse to provide clear directions and expectations of how the task is to be completed and documented. To monitor the providers

Professional- 7 performance, provide assistance if needed, encourage and provide feedback. Upon completion of the task the supervisor/nurse evaluates the entire delegation process which includes how the patient is doing, what was done right, what was done wrong or could have been improved upon, and the performance of the staff member the task was delegated. (ANA) &(NCSBN) As the supervisor I would develop a staffing plan to help the FNP delegate the appropriate duties to each member of the team based on the needs of this patient, and the available mix of staff members. Recommendations would be clearly stated and written down to make sure that the communication provided to all the health care team is correct. For care to be patient specific the health care team must discuss the patients problem, troubleshoot concerns, solutions, and alternatives, and agree on a treatment plan. The health care team supervisor is responsible for coordinating the team members active in the plan of care, supervise the delegated tasks, provide guidance and assistance, evaluate the effectiveness, and make appropriate adjustments as needed. The Licensed Vocational Nurse (LVN) who has been trained to conduct patient education on labor and delivery, routine prenatal care, parenting, and infant care will be assigned the task of providing education and the corresponding rationale regarding labs and tests to the patient during her pregnancy. The patient will be told that a number of tests during her pregnancy will be recommended that will tell everyone how she and her baby are doing, and identify any areas of concern that could affect her or the babys health during the pregnancy. Education will be provided regarding what type of tests will be requested during her first, second, and third trimesters. Verbal and written documentation should be provided in the patients language and at her educational level. The patient should be informed that during the first trimester they

Professional- 8 following labs/tests will be done: a CBC, urinalysis with micro, urine culture and sensitivity, blood type, Coombs test, Hepatitis B screen, Rapid Plasma Reagin (RPR) , Rubella titer, PAP smear, cervical cultures for chlamydia and gonorrhea, and HIV testing. During her second trimester she will have an alpha-fetoprotein test to screen for spinal bifida at 1519 weeks; a sonogram at 1619 weeks to screen for fetal anomalies; and a CBC and 50g glucola test at 2528 weeks to screen for gestational diabetes and anemia. In the third trimester another CBCwill be obtained, and at 3236 weeks cervical cultures for chlamydia, gonorrhea, and group B streptococcus will be done. (OB Focus) The nutritionist as part of the interdisciplinary team can contribute to health promotion and illness prevention on behalf of the patient, and provide education regarding diet and impact on unborn child. Explain that ketonuria usually indicates dehydration and/or anorexia and could affect how the babys brain develops. Provide education regarding recommended treatment of 1500 to 2000 mls of intravenous fluids such as Lactated Ringers until the her urine is negative for ketones. In addition, the nutritionist could create a patient specific diet and address specific nutrition-related illnesses with the patient. As part of the team she/he would communicate relevant nutritional information to other health care providers regarding the patients health. The social worker would be delegated the task of investigating any cultural values, traditions, history, family issues, or beliefs that are contributing to the patients non-compliance in her health care regime. The social worker would identify cultural beliefs and traditions that may prevent the patient from discussing certain topics with the FNP. She/he could recommend the best way to communicate information to the patient regarding sexual or private matters such as urinary tract infections or labor and delivery. (Transcultural Nursing)

Professional- 9 The role of the social worker on an interdisciplinary team includes identifying the strengths and weaknesses of the patient, clearly explain goals of the treatment plan with the patient, identify barriers to medical compliance and assist others on the team in the management of the patient. The social worker could evaluate if the patients developmental disability is related to her presenting health care issues. The social workers assessment takes into consideration how well the patient is functioning physically (functional abilities), psychologically (affect, mood, attitude, personality characteristics, cognitive functioning), socially (vocation, social roles, support system, education, and financial status), culturally (values, beliefs regarding the causes of illness and medical treatments, communication), environmentally (living conditions) and spiritually (beliefs about people's roles and responsibilities, diet, and acceptable medical treatments). The goal of the social worker is to help the patient achieve the highest level of emotional and social functioning possible. The nurse with a BSN in community health has the knowledge of what community resources are available and can make the appropriate referrals. The community health nurse possesses valuable knowledge regarding available community resources, the skills in coordinating the needs of the patient with resources, and can function as an advocate for the patient. The nurse understands financial issues in regards to state, federal, and county programs. Community health programs focus around six elements of nursing practice; five are relevant to this case study: promotion of healthy living, prevention of health problems, and treatment of disorders, evaluation and research. The community health nurse must function in multiple roles such as care provider, educator, advocate, manager, collaborator, leader, and researcher. In this case the nurse should be utilized to determine with the patient what resources the patient and infant will need and make the appropriate contacts and referrals prior to the delivery of the infant.

Professional- 10 As the supervisor/nurse responsible for the patients care I would contact the obstetrician on call and inform him/her of all areas of concern regarding the patients care, and seek their medical advice regarding referring the patient to another facility. Because the physician is available only for deliveries and emergencies and is responsible for multiple rural communities within a 100mile radius of the clinic my concern would be access to care immediately should something happen. Since the patient is 30 weeks and missed several important labs and tests I believe careful monitoring and immediate access to care is vital. There are risks associated with every pregnancy and having a chronic condition(s) increases the risks of problems to the patient and fetus. Therefore the patient should be monitored closely so immediate intervention can occur. This patient has recurrent urinary tract infections, Rh incompatibility, and poor prenatal care and treatment compliance all of which place her in a high risk category. Therefore, it is important that the healthcare team consult with a physician using the identified consultation standards, and/or refer the patient to another health care professional. (Lehigh). The following information will help the FNP and other health care providers determine when to refer the patient for outside consultation rather than delegating within. Consistent with the Code of Ethics for Nurses with Interpretive Statements (ANA, 2001), the nurse must practice within the law and not delegate to others tasks that are not within their practice acts or job descriptions. If a nurse does not feel she/he has the qualifications to safely perform a task being delegated to them they have the responsibility to refuse the task and refer the task to others qualified to complete the task in the best interest of the patient. Supervision is the process of delegating, guiding and affecting the outcome of another providers completion of a task and can be either direct or indirect. (Matthews, J., 2010)

Professional- 11 A nursing supervisor is still accountable for the delegation process even when they do not have control of the delegated task based on the nurse practice act guidelines and standards of practice identified by the board of nursing. They are expected and held accountable to understand the state and federal regulations regarding acceptable practice and delegation based on staff qualifications. In addition the supervisor is held accountable for delegation by making sure the clinic has appropriate resources and the correct mix of staff required for the delegation process. This includes having appropriate documentation of competencies for all staff members that provide patient care accessible to the individual delegating nursing tasks. According to the Indiana Board of Nursing; section 5 (a) a clinical nurse specialist provides and assists other health care providers with patient care, helps meet health goals, and consults and collaborates with other providers in complex patient situations. In section 1 (848 IAC 2-1-3) under competent practice of nurse practitioners it states that a nurse practitioner shall perform as an independent and interdependent member of the health team (p 82). Collaboration, consulting, referral, managing the plan of care, and guiding patients and other team providers, is defined in IC 25-23-1-19.4 by the board. Understanding ones own knowledge and experience limitations and when it is appropriate to consult/refer patients to other health care is identified by Indiana code 25-23-1, as well as tasks that can be delegated and the fact that the supervisor/nurse delegating still remains professionally accountability for the delegated task. According to rule 3, 848 IAC 4-3-1a competent supervisor/clinical nurse specialist provides indirect nursing care, helps plan, guide, direct, and evaluate other staff members in the provision of patient care. As a supervisor they serve as a consultant and resource person for the care providers directly involved with the patient care. Supervisors play an important role in organizing resources, establishing

Professional- 12 expectations of patient care and outcomes, defining roles of the team members within the organization, and enabling the team process. It is important for a nursing supervisor to develop skills associated with the authority of delegation because supervisors are held accountable to the organization, state and federal organizations, providers, and patients for all delegated care provided. The supervisor assumes multiple responsibilities which include the ability to identify and prioritize duties and then delegate the right task to the appropriate staff member. The supervisor plans, guides, organizes, and delegates patient care to the different staff disciplines based on the supervisors knowledge of the different staff members practice act, experience, comfort level, state and governmental regulations and organizational policy/procedures. Organizations hold the supervisor accountable for safe and competent care, which meets regulatory requirements, is cost effective, and meets the organizations policies/procedures. Supervisors play an important role in gathering resources, defining patient care and outcomes, and defining the roles of the different team members. The supervisor is responsible to make sure that the task(s) delegated are performed safely and effectively, and result in good patient outcomes. A nursing supervisor must collaborate with all members of the team to clearly identify what task(s) need to be done and determine which staff member(s) has the qualifications to complete the task, is willing to accept the assignment, and feels competent to complete the task. Some providers may believe the task delegated to them could result in harm to the patient because they have not performed it before (or on a limited basis) even if the task falls within their scope of practice. Patient safety remains at the forefront of all delegation decisions therefore the supervisor needs to assign the task to another health care provider.

Professional- 13 References American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN). Joint Statement on Delegation. http://www.tnaonline.org/Media/pdf/nursingdelegation-guides.pdf Betancourt; Joseph R .Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches; http://www.commonwealthfund.org/usr_doc/betancourt_culturalcompetence_576.pdf Drinka, Theresa J and Clark, Phillip G. (2000). p 47 Health Care Teamwork: Interdisciplinary Practice & Teaching. Westport, CT: Greenwood Publishing Group. Lehigh Valley Health Network. Guidelines for Consultations. http://medicalstaff.lvh.org/c_images/pdf/Consultation_Guidelines.pdf Matthews, J., (May 31, 2010) "When Does Delegating Make You a Supervisor?" OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 2, Manuscript 3 http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Ta bleofContents/Vol152010/No2May2010/Delegating-and-Supervisors.html National Association of Social Workers. Social Work Speaks: NASW Policy Statements (2000b) and the NASW Code of Ethics (2000a), which charges social workers with the ethical responsibility to be culturally competent. (NASW, 2000b, p. 61). www.socialworkers.org. NASW Standards for Cultural Competence in Social Work Practice. National Association of Social Workers. http://www.socialworkers.org/practice/standards/NASWCulturalStandards.pdf OB Focus. http://www.obfocus.com/prenatal/firstpreg.htm

Professional- 14 Peterson-Iyer; Karen. Culturally Competent Care for Latino Patients: Introduction; http://www.scu.edu/ethics/practicing/focusareas/medical/culturally-competent-are/hispanic.html Transcultural Nursing http://www.culturediversity.org/hisp.htm