Contact Investigation San Antonio, Texas November 5-7, 2008 Supervising Your Nursing Staff Linda J. Brown, RN, MS November 6, 2008 Supervising Your Nursing Staff Linda J. Brown, RN, MS Nurse Consultant Tuberculosis and Hansen s Disease Department of State Health Services 1
Objectives Describe key elements involved in the supervision of nursing staff Describe the role of the nurse in TB case management Identify steps in the nursing process with standards of care Identify methods evaluate performance Identify tools to assist in the supervision process Charting Nursing s Future Robert Wood Johnson Foundation 2008 Throughout the last century, nurses have formed the backbone of the public health enterprise. Today, the ability of the public health system to meet current and projected needs is being seriously compromised by a growing shortage of nurses, an expanded, post-9/11 mandate, and economic constraints at the local, state and federal levels. 2
Management Functions Organizing Analyzing Planning Implementing Evaluating Providing resources and tools Delegating Communicating NTNC Mission To advise and support the TB control officials of state, local, and territorial governments by providing, within NTCA, a coordinated nursing perspective on issues vital to the success of TB prevention and control programs. NTNC Website 3
NTNC Objectives Develop and provide a collective voice for nurses working in TB control activities to advance and advocate TB elimination throughout the nation. Work with coordinating organizations to define the public health nurse role and functions in TB. NTNC By Laws NTNC Objectives (continued) Articulate standards of practice for professional nursing in TB programs NTNC Bylaws 4
National Tuberculosis Nurse Coalition Survey 697 Responses 91% not members of NTNC/NTCA 60%: >20 years experience in nursing 23%: >20 years in public health 37%: >10 years in TB prevention and control 65%: 14%: County Health Departments State Health Departments National Tuberculosis Nurse Coalition Survey 49%: TB nurse case managers 34%: TB clinic nurses 5
National Tuberculosis Nurse Coalition Survey Increase in non TB related duties 46% Decrease in nursing positions 44% Loss of nursing expertise 30% Decrease in field staff 28% Increase in patients/case manager 25% Loss of ongoing training and 19% supervision National Tuberculosis Nurse Coalition Survey Changes in Case Management in Past 5 Years Increase in social, language and cultural barriers More co-morbid conditions Increase in drug resistant TB Increase in disease severity 6
National Tuberculosis Nurse Coalition Survey 34% will leave TB control in <5 years 74% will leave TB control in < 10 years Nurse s Role in Case Management In the context of TB programs, case management refers to: Assigning primary responsibility for coordination of patient care to ensure that the patient s medical and psycho/social needs are met through appropriate utilization of resources. The case manager ensures that the patient is adherent with and completes an appropriate course of therapy until cure, and coordinates a regular, systematic review of the patient s process in therapy. Drug-resistant Tuberculosis: A Survival Guide tor Clinicians, 2 nd edition. Francis J. Curry National Tuberculosis Center. Slide from Dawn Farrell, RN 7
Case Management includes meeting an individual s health care needs to attain quality, cost effective outcomes through: Assessing Planning Implementing Coordinating Dawn Farrell, BSN, RN Facilitating Advocating Monitoring Evaluating Why a Nurse? Public health nurses are knowledgeable about multiple strategies for intervention, from those applicable to the entire population, to those for the family, and the individual. Public health nurses translate knowledge from the health and social sciences to individuals and population groups through targeted interventions, programs, and advocacy. Kim Field, TB Program Manager, Washington State Department of Health 8
The TB Manager Assigns a case manager to each patient Establishes a case management team Delegates responsibility for development of a plan to ensure adherence and regular monitoring of progress Ensures continuity of care Implements containment activity if needed Dawn Farrell, BSN, RN Case Management Team What categories of health care workers are on your case management team? 9
Steps in Nursing Process ASSESSMENT The RN collects comprehensive data pertinent to the patient s health or situation Systematic, ongoing, organized Includes diagnostic tests Is documented Most programs have a data set in medical records that defines this comprehensive data Steps in Nursing Process Diagnosis Clinical response to actual/potential health conditions or needs Nursing diagnoses are derived from assessment data 10
Steps in Nursing Process Outcomes identification The RN identifies expected outcomes for a plan individualized to the patient or situation Outcomes are derived from diagnoses Measureable Judy Gibson s outcomes Steps in Nursing Process Planning The RN develops a plan that prescribes strategies and alternatives to attain the expected outcomes Includes continuity of care Developed with the patient Engagement of patient in process Judy s 15 11
Steps in Nursing Process Implementation The RN implements the identified plan Includes Incentives and enablers Coordination of care Health teaching and promotion Consultation Prescriptive authority for advanced nurse practitioners Steps in Nursing Process Evaluation Process of determining attainment of expected outcomes Systematic, ongoing Ongoing reassessment to revise diagnoses, outcomes, plan of care 12
Establishing the Nursing Role Need for a nurse manager/supervisor in the organizational structure Input regarding nursing process, standards and scope of practice Nursing Licensure Issues Peer review Continuing education Differentiation of the role of RN and LVN Dependent and independent practice Evaluation of individual performance Skills check list Interpretation of standards of care 13
Scope of Practice, RN and LVN Vocational Nurse Directed practice under the supervision of a registered nurse, physician assistant, physician, dentist or podiatrist. (Independent practice not permitted.) Registered Nurse Cannot engage in acts of medical diagnosis or prescription of therapeutic measures. May engage in independent practice within the scope of licensure Tools for the Program Manager Essential Components of a TB Prevention and Control Program -CDC Standards of performance Standing delegation orders Medical record forms Organized order of medical record Performance evaluation format 14
Essential Components Overall planning and policy Managing cases and suspects Identifying persons with clinically active TB Identifying and managing persons with LTBI Laboratory and diagnostic services Data collection and analysis TB training and education Standards of Performance A statement of the standards of care for the geographical jurisdiction of the program Program objectives in Co-operative Agreement with CDC Performance measures in contracts with local entities 15
Texas Medical Board Rules Relating to Delegation A physician may delegate to a qualified and properly trained person acting under the physician s supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate if, in the opinion of the delegating physician: Texas Medical Board Rules Relating to Delegation The act Can be properly and safely performed by the person ; Is performed in its customary manner; Is not a violation of any other statute; and The person does not represent to the public that (he/she) is authorized to practice medicine. 157.001, General Authority of a Physician to Delegate, Acts 1999, 76 th Leg., ch. 388, 1, eff. September 1, 1999 16
Texas Medical Board Rules Relating to Delegation The physician remains responsible for these delegated medical acts Applicability to non-licensed personnel Rules Relating to Delegation Direct physician orders for the individual patient 17
Standing Medical Orders Orders, rules or procedures prepared by a physician or approved by a physician or medical staff of an institution for patients which have been examined or evaluated by a physician and which are used as a guide in preparation for and carrying out medical procedures. Standing Delegation Orders Written instructions, orders, rules or procedures prepared by a physician and designed for a patient population with specific diseases, disorders, health problems, or sets of symptoms These instructions are to provide authority for and a plan for use with patients presenting themselves prior to being examined or evaluated by a physician to assure that such acts are carried out correctly and are distinct from specific orders written for a particular patient. 169.2 Definitions 18
Standing Delegation Orders Do not refer to treatment programs ordered by a physician following examination or evaluation by a physician, which are standing medical orders. Used for licensed nursing staff Should be developed and signed by the physician who is responsible for the delivery of medical care covered by the orders. 193.2 Standing Delegation Orders, Definitions Organized Medical Record Serves as a guide to patient assessment and management Forms and medical record should reflect the level of a quality assessment and plan Standards of Performance Forms, Records and Quality Assurance Guidelines Standing Delegation Orders 19
Evaluating Performance: Program Review Every 3 years for funded local health departments and state regional health departments Reviews core components Reviews medical records for adherence to standards of care Evaluating Performance: Program Performance Measures Staff performance will be reflected in program outcomes Performance measures 20
Evaluating Nursing Performance Organized staff performance evaluation format Include steps in nursing process and standards of performance Review of records Observation during patient visit Skills check list Ensuring current registration on hire and annually Summary TB programs are at risk of losing nursing expertise and institutional knowledge in the next 5-10 years Program Manager should designate a TB case management team based on available resources 21
Summary (continued) Steps in nursing process and standards Assessment Diagnosis Outcomes identification Planning Implementation Evaluation Summary (continued) Nursing licensure issues Tools for the program manager Essential Components Standards of performance Standing delegation and medical orders Organized medical record Staff performance evaluation format 22
Summary (continued) Program review Core components Medical record review Program performance measures 23