Peer review systems can simply be informal feedback regularly shared among colleagues, or they may be comprehensive systems that are fully integrated into the formal evaluation structure of a healthcare organization. When a peer review system is fully integrated, the evaluative feedback from one’s peers is joined with the performance appraisals done by the nurse manager, and both are used to deter- mine pay raises and promotions for individual staff nurses. This is a far more collegial approach than the hierarchical one typically used, in which employees are evaluated only by their manager.
A comprehensive peer review system begins with the development of job descriptions (Figs. 3–1 and 3–2) and performance stan- dards (Fig. 3–3) for each level within the nurs- ing staff. When you compare Figures 3–1, 3–2, and 3–3, you will see that the job description is a very general statement, where- as the standards are specific behaviors that can be observed and recorded.
In some organizations, the standards may be considered the minimal qualifications for each level. In this case, additional activities and professional development are expected
before promotion to the next level. The can- didate for promotion to an advanced-level position prepares a promotion portfolio for review (Schultz, 1993). The promotion port- folio may include a self-assessment, peer reviews, patient surveys, a management per- formance appraisal, and evidence of profes- sional growth. Evidence of professional growth can be based on participation in the quality improvement program, evaluation of a new product or procedure, serving as a trans- lator or disaster volunteer, making postdis- charge visits to clients from the unit, or taking courses related to nursing.
In a participative environment, the stan- dards are developed by committees having representatives from different units and from each staff level, from the new staff nurse to top-level management.
Writing useful job descriptions and measur- able standards of performance is an arduous but rewarding task. It requires clarification and explication of the work nurses actually do that go beyond the usual generalizations about what nursing is and what nurses do.
Under effective group leadership and with 36 ❖ Essentials of Nursing Leadership and Management
Figure 3–1
SAMPLE JOB DESCRIPTION Clinical Nurse I (N 1)
The CN I supports the philosophy of pri- mary nursing by planning and coordinating nursing care for a group of patients within higher district.
It is the CN l’s responsibility to direct auxil- iary personnel for full implementation of the plan of care.
The CN I supports the management of the unit and uses resource persons and/or materi- als when the need arises. He/She has satis- factorily mastered the basic skills required to work on the assigned unit.
The CN l's scope of nursing practice is focused on a higher assigned group of patients and does not extend into the administrative aspects of the unit at large.
Figure 3–2
SAMPLE JOB DESCRIPTION
Clinical Nurse IV (CN IV)-Unit Clinician The CN IV is an advanced clinical nurse who supports the practice of primary nursing on the unit, as well as hospital-wide. He/She is recognized within the specialty area, as well as throughout the hospital, as being proficient in the delivery of complicated nursing care.
The CN IV has mastered the many facets of nursing care required at the CN II and CN III levels. This qualification is validated through the acquisition of national certification in the appropriate specialty area.
The CN IV coordinates and directs emer- gency situations, seeks out learning opportu- nities for the unit staff, and serves as a resource for all aspects of nursing care delivery.
The CN IV collaborates closely with physi- cians on the unit for the implementation of the plan of care. This may be facilitated through assessing special equipment needs, as well as planning multidisciplinary programs.
The CN IV works closely with the nurse manager in planning unit goals and objectives and unit specific orientation programs, as well as assisting with staff performance evaluations.
The CN IV acts as a liaison between his or her unit and the Departments of Nursing Education and Patient Education.
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Figure 3–3
SAMPLE PERFORMANCE STANDARDS
To patient 1. Plans care for
duration of stay on clinical unit.
To peers 1. Avails himself/
herself to co- workers at all times.
Responsibility CN I CN II CN III CN IV
a. Family/social concerns are addressed in the assessment process, as evidenced by nursing care documentation.
b. All admission documentation on assigned patients is recorded.
c. History reflects information relevant to current hospitalization.
d. Patient problem/
outcome statements are current and/or designated as achieved.
e. Patient teaching, transfer, and/or discharge preparation is documented.
a. Notifies peers when required to leave the clinical area.
b. Assumes responsibility for l.V.’s and orders of LPN on assigned patients.
c. Responds promptly to all emergency situations that arise in the district.
a. through k.
l. Collaborates with the Department of Patient Education in designing and revising patient teaching materials.
a. through f.
g. Coordinates/teaches two programs in conjunction with the Dept. of Nursing Education annually.
h. Conducts staff conferences to evaluate clinical competencies of personnel with documentation.
a. through e.
f. Utilizes nursing history for care planning by auditing charts for integration of problem statements.
g. Assesses supplies/
equipment and has them readily available for patient use.
h. Initiates discharge summary sheet prior to discharge.
a. through c.
d. Takes initiative to offer assistance to other nurs- es and with assigned patients.
e. Serves as preceptor to students/
orientees.
a. through h.
i. Identifies need for and/or initiates appropriate family/social referrals with documentation.
j. Assesses and documents cultural differences, patient support systems, and expectations for hospitalization.
k. Documents patient's response to teaching as identified in nursing care ducumentation.
a. through e.
f. Acts as senior resource coordinator in absence of nurse manager.
Source: Adapted from Professional Nursing Advancement Program, Baptist Hospital of Miami, Florida.
strong administrative support for this process, it can be a challenging and stimulating experi- ence. Without their support and guidance, how- ever, the committee work can be frustrating
when the group gets bogged down in details and disagreements.
When the job descriptions and performance standards for each level have been developed
38 ❖ Essentials of Nursing Leadership and Management and agreed on, a procedure for their use must
also be worked out. This can be done in sev- eral ways. In some organizations, an evalua- tion form that lists the performance standards can be completed by one or two colleagues selected by the individual staff member. The information from these forms is then used along with the nurse manager’s evaluation to determine pay raises and promotions in some organizations. In others, the evaluation from one’s peers is used for counseling purposes only and is not taken into consideration in determining pay raises or promotions. This second approach provides useful feedback but weakens the impact of peer review.
A different approach is the use of a profes- sional practice committee. The committee, comprising colleagues selected by the nursing staff, reviews the peer evaluation forms and makes its recommendations to the director of nursing or vice president for client care ser- vices, who then makes the final decision
regarding the appropriate rewards (raises, pro- motions, commendations) or penalties (demo- tion, transfer, termination of employment).
CONCLUSION
A comprehensive evaluation system can be an effective mechanism both for increasing the quality of care by improving staff skills and morale and for reducing the costs of providing that care by increasing staff productivity.
Constructive feedback demands objectivity and fairness in dealing with each other and leadership on the part of both staff members and management. Done well, it can provide many opportunities for increased profession- alism and learning as well as ensure appropri- ate rewards for high performance levels and professionalism on the job.
S T U D Y Q U E S T I O N S
1.Why is feedback important? Who needs to receive feedback? Who should give feedback to healthcare providers?
2.Describe the difference between constructive and destructive feedback.
3.Describe an ideal version of a 3-month performance appraisal of a new staff nurse. Why do nurse managers sometimes fail to meet this ideal when providing formal evaluative feedback? Can new staff nurses can do anything to improve these procedures in their place of employment?
4.What is peer review? How is it different from other types of evaluation? Why is it important?
C R I T I C A L T H I N K I N G E X E R C I S E
Tyrell Jones is a new UAP who has been assigned to your acute rehabilitation unit. Tyrell is a hard worker—he comes in early and often stays late to finish his work. But Tyrell is gruff with the clients, and especially with the male clients. If a client is reluctant to get out of bed, Tyrell often challenges him saying, “C’mon, man. Don’t be such a wimp. Move your big butt.’’ Today, you overheard Tyrell telling a female client who said she didn’t feel well, “You’re just a phony. You like being waited on, but that’s not why you’re here.” The woman started to cry.
1.You are the newest staff nurse on this unit. How would you handle this sit- uation? What would happen if you ignored it?
2.If you decided that you should not ignore it, with whom should you speak?
Why? What would you say?
3.Why do you think Tyrell speaks to clients this way?
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R E F E R E N C E S
Beer, M. (1981, Winter). Performance appraisal: Dilemmas and possibilities. Organizational Dynamics,24.
DeMarco, R.F. (1998). Caring to confront in the work- place: An ethical perspective. Nurs Outlook, 46(3), 130–135.
Fonville, A.M., Killian, F.R., & Tranberger, R.E. (1998).
Developing new nurse leaders. Nurs Economics, 16(2), 83–87.
Gabor, D. (1994). Speaking Your Mind in 101 Difficult Situations. New York: Stonesong Press (Simon &
Schuster).
Gellerman, S.W., & Hodgson, W.G. (1988). Cyanamid’s new take on performance appraisal. Harvard Business Review, 88(3), 36–41.
Glaser, S.R. (1994). Teamwork and Communication.
Management Communication Quarterly, 7(3), 282–296.
Hansen, M.R. (1986). To-do lists for managers.
Supervisory Management, 31(5), 37–39.
Kelly, J.A., & Aiken, E. (1999). Creating a legacy of lead- ership in the South. In Vance, C., & Olson, R.K. (Eds.).
The Mentor Connection in Nursing(pp. 164–167). New York: Springer.
Kron, T. (1981). The Management of Patient Care: Putting Leadership Skills to Work.Philadelphia: W.B. Saunders.
Matejka, J.K., Ashworth, D.N., & Dodd-McCue, D.
(1986). Discipline without guilt. Supervisory Management, 31(5), 34–36.
Rosen, R.H. (1996). Leading People: Transforming Business from the Inside Out. New York: Viking Penguin.
Schultz, A.W. (1993). Evaluation for clinical advancement system. J Nurs Adm, 23(2), 13–19.
Watson, T., & Harris, P. (1999). The Emergent Manager.
London: Sage Publications.
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C H A P T E R 4
Delegation of Client Care
C H A P T E R 5
Managing Client Care
C H A P T E R 6
Time Management
C H A P T E R 7
Organizations, Power, and Empowerment
C H A P T E R 8
Dealing with Problems and Conflicts
C H A P T E R 9
People and the Process of Change
C H A P T E R 1 0
Work-Related Stress and Burnout
C H A P T E R 1 1
The Workplace
Leading and Managing
U N I T I I
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43
Delegation of Client Care
O U T L I N E Introduction to Delegation
The Nursing Process and Delegation Coordinating Assignments
The Need for Delegation Safe Delegation
Criteria for Delegation Task-Related Concerns Ability
Priorities Efficiency Appropriateness
Relationship-Oriented Concerns Fairness
Learning Opportunities Health
Compatibility Preferences
Barriers to Delegation Experience Issues
Licensure Issues Quality-of-Care Issues Assigning Work to Others Conclusion
O B J E C T I V E S
After reading this chapter, the student should be able to:
• Define the term delegation
• Define the term unlicensed assistive personnel
• Understand the legal implications of making assignments to other healthcare personnel
• Recognize barriers to successful delegation
• Make appropriate assignments to team members
C H A P T E R 4
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Mary Ann is a new graduate and has just fin- ished her orientation. She works the 7 p.m. to 7 a.m. shift on a busy monitored vascular surgical unit. The client census is 48, making this a full unit. Although there is an associate nurse man- ager for the shift, Mary Ann is charge nurse for the shift. Her responsibilities include receiving and transcribing orders, contacting physicians with any information or requests, reviewing laboratory reports and giving them to the appro- priate staff members, checking any new medica- tion orders and placing them in the appropriate charts, relieving the monitor tech for dinner and breaks, and assigning staff to dinner and breaks.
When Mary Ann comes to work, she discovers that one registered nurse (RN) called in sick. She has two RNs and three unlicensed assistive per- sonnel (UAPs) for staff and a full census. She panics and wants to refuse to take report. After a discussion with the charge nurse from the pre- vious shift, she realizes that this is not an option.
She sits down to evaluate the acuity of the clients and the capabilities of her staff.