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In this essay the author will explore the role transition from student nurse to qualified member of staff and discuss in brief some roles and responsibilities of the newly qualified nurse (NQN). Focus will be placed on delegation and administration of Patient Group Directions (PGDs) as two responsibilities of the NQN who is both a delegator and a dispenser of medicines. Delegation can be challenging for NQNs as it involves entrusting designated tasks to non-qualified member of staff while still retaining professional accountability. Administration of PGDs will be discussed as well as group protocol arrangements for medicines administration has become over the last few years valuable to nurses, especially those working in settings where immunisation programmes and family planning services are delivered.
Roles of the newly qualified nurse – Critical discussion (400 words)
Contemporary nursing has changed considerably in terms of its roles and responsibilities. A big turnaround came with the change in the European Working Time Directive which reduced drastically the working hours of junior doctors, leading to Registered Nurses (RNs) extending their roles and undertaking tasks traditionally carried out by medical professionals (McKenna et al, 2004; Kessler et al, 2010). In order to meet patient needs and to fill the gaps left by those nurses, Healthcare Assistants (HCAs) were then expected to start extending their skills and assume delivery of care that was previously the domain of registered staff (Kessler et al, 2010, Griffiths and Robinson, 2010). This was a positive step for modernising nursing careers with nurses now working across boundaries and with the creation of new specialist roles (DH, 2006a), but naturally it decreased at the same time engagement in direct patient care (Kessler et al, 2010).
Registered nurses (RN) in the United Kingdom are expected to acquire the necessary knowledge and skills to meet Nursing and Midwifery Council (NMC) standards, which aim at guiding and supporting them in the delivery of high quality care. Nurses are expected to delegate, lead and supervise other nurses and healthcare professionals and have therefore to gain and develop analytical, problem-solving and decision-making skills (NMC, 2010) both during their training and throughout their nursing career.
Even with development of the RN role
If nursing’s original professional identity is to be uphold, it essential that NQNs enter the profession sensitive to its core values and roles, even while trying to advance practice (Harmer, 2010).
Rationale for role choice (200 words)
The author chose the role of delegation both
Role 1 – Delegation (700 words)
RN are expected to organise and supervise the work of HCAs and the ability to delegate effectively is central to their success (Curtis and Nicholl, 2004)
The NMC Code of Conduct (2008b) stresses that RN must delegate effectively and establish that anyone they delegated to is able to carry out their instructions. In addition it states that nurses must confirm that the outcome of the delegated tasks meet required standards and that anyone they are responsible for, is supervised and supported.
The employer is in turn the one responsible for ensuring that HCAs have sufficient training and education to competently undertake the aspects of care which a RN is expected to delegate to them (NMC, 2008a). The NMC fails however to give a reasoned justification as to why the RN is still accountable for the delegated tasks if the employer is the one responsible for confirming competency or if indeed the RN is expected to confirm this her/himself how she/he is expected to effectively gain knowledge of the education, training and qualifications of all HCAs they work with in clinical practice (including bank staff). Both the RCN and the DH have sought in the past further clarification from the NMC as far as delegation and accountability are concerned as the advice provided by the body has been regarded as confusing (Harrison, 2007)
HCAs education and training is not mandatory and standardised in terms of content, assessment and accreditation (Griffiths and Robinson, 2010) and therefore there is no default quality assurance on their competencies so caution and uncertainty is to be expected from the RN when delegating work as she/he could see her/his registration put at stake for any error in judgement (Kessler et al, 2010. This is because although the HCA retains responsibility in their actions carrying out the delegated task, the RN is ultimately accountable (NMC, 2004, RCN, 2006a) to their regulatory and professional body.
Accountability is a key element of professional practice and it is intimately linked with delegation. RNs are professionally accountable to the NMC for any actions and omissions in their practice and must be able to justify their decisions. Failure to comply with the code may bring their fitness to practice into question and jeopardize their registration (NMC, 2008b). RNs are also accountable to both civil and criminal law, their employer (NMC, 2009, Dimond, 2008) and on a moral dimension, to themselves (Dimond, 2008).
If tasks are matched successfully against HCAs skills and knowledge though, delegation can result in improved productivity and efficiency as this makes best use of available human resources. In some cases if the clinical area is particularly understaffed, delegation becomes a necessity, rather than an option. Effective delegation can potentially enable RNs to focus on doing fewer tasks well, rather than many talks inadequately (Curtis and Nicholl, 2004) and can create a more motivated and co-operative team (Eaton, 2009). On the other hand studies suggest that excessive task delegation can lead to feelings of frustration as nurses end up having less contact with patients than they originally hoped for. Accountability issues can also lead to increased levels of stress (Takase et al, 2005).
Research has found that in order to comply with the code of conduct nurses can spend large amounts of time inducting, training and supervising HCAs (McKenna et al, 2004) on tasks that HCAs were theoretically undertaking to alleviate nurse’s workload (Kessler et al, 2010). Demands of supervision can also compromise the time NQN should be devoting to consolidate and develop their clinical skills (Griffiths and Robinson, 2010). Paradoxically, literature suggests that experienced HCAs frequently act as unofficial mentors to NQN and are seen as a significant source of formal and informal knowledge and guidance to less experiences members of staff (Griffiths and Robinson, 2010, Kessler et al, 2010). The process of delegation assumes inevitably a hierarchical command structure (Curtis and Nicholl, 2004) which could easily pose challenges for NQN, whom in real terms are expected to supervise and be accountable for HCAs who may be considerably more experienced.
Role 2 – PGD (700 words)
PGDs provide a legal mechanism to administer and/or supply medicines to patients by a specific range of health care professionals, without the need of consultation with a doctor or a dentist (NPC, 2009).
A PGD is written instruction for the supply or administration of a licensed medicine(s) in a specifically identified clinical scenario that is not aimed at a specific patient, but rather at any patient that meets the criteria established on that PGD. The PGD must be written up at a local level by a multidisciplinary team including a doctor, a pharmacist and a representative of any professional group expected to dispense under the PGD. For a PGD to be valid it must be signed by a doctor or a dentist and a senior pharmacist, ideally the ones involved in developing the direction. It must also be authorised by the PCT or NHS trust which will use it (MHRA, 2010a).
PGDs can only be administered by registered healthcare professionals such as nurses, midwifes, health visitors, paramedics, radiographers, etc. Each PGD must however, list individually the names of the registered professionals allowed to dispense under the direction. A senior individual in each profession should assume the responsibility to ensure that all designated dispensers in the PGD are fully competent, registered and trained professionals. (DH, 2006b).
A PGD can act as a direction to a nurse to supply and/or administer prescription-only medication to patients that meet the criteria, based on the nurse’s assessment of their needs and without needed to refer to a doctor for an individual prescription (RCN, 2006b)
The supply and administration of medicines under a PGD should be reserved for specific circumstances where it is advantageous for patient care, it does not compromise patient safety and is consistent with professional accountability (MHRA, 2010a, NPC, 2009, DH, 2006b), as the nurse must always act within their own expertise and competence (DH, 2006b). PGDs are a convenient way of recognising nurse’s ability to use medication to the benefit of the patient and any registered professional dispensing medication under the terms of a PGD should act in accordance with the NMC Code of Conduct and the NMC Standards for Medicines Management (RCN, 2006b).
The legislation requires that every PGD must contain key information: the place where the PGD will be used (eg. primary or acute care), the date the directive comes into force and the date it expires (it is recommended good practice that PGDs should be reviewed every two years), a description of the medicine to which the PGD applies (both the name and the purpose of the medication should be included, eg. analgesic or oral contraceptive), class of the healthcare professional able to supply/administer the medication (the PGD should clearly state which of the professional groups can use but each individual can only do so if she/he is named individually), the signature of a doctor/dentist and a pharmacist (only approved prescribers as doctors/dentists), signature by a representative of an appropriate health organisation (eg. chief executive of a trust), the clinical condition to which the PGD applies to (a description of the problem a patient must present with in order to receive medication under the directive), a description of patients that are to be excluded from treatment under the PGD (detailed guidance on which circumstances a patient should be excluded and provided with an individual prescription, eg. complex medical condition or a specific medical problem), a description of when further advice should be sought from a doctor/dentist and when to arrange for referrals (a patient might meet the criteria set on the directive but depending on which specifics they present, further advice might still be needed from a medical professional), details of the appropriate dosage, maximum total dosage, quantity, pharmaceutical form and strength, route, frequency of administration, minimum and maximum period over which the medication should be administrated and the legal status of the drug should all be specified (this ensures that the correct medicine is given in the right dose for the appropriate length of time), relevant warnings including potential adverse reactions (as with any medicines it is essential to be aware of any contra-indications of potential adverse effects), details of any follow-up action and under which circumstances (a patient might need to be seen again in order to detect if the medication had the desired effect) and finally a statement of records to be kept for audit purposes (the directive must specify which records need to be kept, eg. as a minimum full patient details and full information regarding the drugs that has been administrated) (MHRA, 2010a, NPC, 2009, RCN, 2006b)
PGDs cannot be used in independent and public sector care homes or independent sector schools that provide healthcare services outside the NHS. (MHRA, 2010b) PGDs can only be used in the NHS and other services funded by the NHS but provided by the private, voluntary or charitable sector. Certain non-NHS organisations such as independent hospitals, agencies and clinics registered under the Care Standards Act 2000, prisons healthcare services and police services, and defence medical services can however use PGDs for the sale, supply and/or administration of medicines (NPC, 2009)
NQN registered with the NMC and on the live register are allowed to administer medication under a PGD, providing they are one of the named dispensers on the directive. However, because robust clinical judgement is necessary to assess the patient prior to administration, a more experienced member of the nursing team is likely to be named over a NQN. Both the RCN and NMC offer no specific recommendations for the administration (or not) of medicines under a PGD, by a NQN. There are also no specific national training programmes for PGD, however individual organisations must ensure that any professional administering medication under a PGD is competent to do so (DH, 2006b)
Conclusion (300 words)
The role of the RN has expanded considerably over the last years. NQN now enter the profession expected to assume roles of leadership, delegation and supervision very shortly afterwards being students nurses and working with alongside and under the protection of their mentors. As soon as they gain their pin number and join the NMC register a whole new raft of expectations is placed upon them. Many NQN however reportedly feel unprepared and overwhelmed by their new responsibilities, making the period of transition very stressful rather than exciting and truly enjoyable. Delegation is a fundamental skill every RN and NQN must gain and develop in order to be able to manage their workload effectively in clinical practice. Delegating as a NQN can be challenging as often the recipient of the task is a more experienced member of the team, for whom she/he is still yet professionally accountable. Medicines administration is another responsibility of the RN. PGDs have become increasingly important tools for nurses working in clinical settings delivering immunisation, working in travel clinics and family planning services. With many NQN now opting to join community services, PGDs become increasingly relevant to them.
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