adequate, you must identify and remedy the factors con-
tributing to the person’s non-adherence. Common reasons for
a failure to cooperate include:
•
Lack of involvement by the person in the planning
phase of the process
•
Lack of family or other support
•
Lack of understanding about the benefits of adherence
to the plan
•
Low value attached to goals or related interventions
•
Adverse physical or emotional effects of treatment (such
as pain and fatigue)
•
Inability to afford treatment
•
Limited access to treatment.
DELEGATING CARE
Because of the pressure of escalating healthcare costs and the
increasing demand for nursing and midwifery services in the
midst of a critical shortage, many employers have increased
their use of enrolled nurses and unregulated care workers.
In Australia, enrolled nurses (ENs), also known as Divi-
sion 2 nurses, provide a second level of nursing care as
specified by the registering authority’s licence to practice,
educational preparation and the context of care (Australian
Nursing & Midwifery Council [ANMC], 2002; Australian
Nursing Federation [ANF], 2005). ENs are mainly educated
through advanced certificate or associated diploma level
courses in colleges of technical and further education, of
which the duration is less than three years. Their role is to
assist the registered nurse or midwife in the provision of
care activities as delegated by them (ANF, 2011). See
Chapter 4 for an overview of the role of the registered nurse,
the registered midwife and the EN.
Assistants in nursing (AINs), also known as personal care
workers in some healthcare settings, are unregulated care
workers who provide
direct or hands-on care
in community,
acute care or residential settings. ‘Hands-on’ care may
include assistance with activities of daily living such as
showering, dressing, eating, mobilising and assisting with
self-medication, and support activities such as diversional
therapy. In most healthcare settings, AINs operate under the
direction and supervision of registered nurses or midwives
and assist in providing nursing care. They may also assist
allied healthcare professionals in their activities.
In some cases, the increased use of AINs is concerning,
particularly when care is provided to frail, vulnerable and
dependent people by workers who are not regulated in the
same way as health professionals. In Australia this problem
was highlighted in the National Review of Nursing Educa-
tion’s
Our duty of care report
published in 2002. The report
recommendations included the development of a national
nomenclature, a minimum Certificate III TAFE qualification
for the health and community services training package, and
suitability checks for unregulated care workers by 2008.
Commonwealth, state and territory ministers for health sup-
ported these recommendations as a means of ensuring
quality care and public safety and establishing a national
standard for unregulated care worker education and
enhanced employment opportunities (National Nursing &
Nursing Education Taskforce [N
3
ET], 2006).
In this evolving healthcare environment, registered
nurses and midwives must understand their responsibilities
when delegating to both ENs and unregulated care
workers, and stay appraised of ongoing developments and
changes to delegation guidelines. ENs should also have an
understanding of their responsibilities in accepting dele-
gated aspects of nursing care from a registered nurse or
midwife.
The registered nurse or midwife assumes ‘accountability
and responsibility for their own actions and
delegation
of
care to enrolled nurses and healthcare workers. Delegation
takes into consideration the education and training of
enrolled nurses and healthcare workers and the context of
care’ (ANMC, 2006a, p. 2). They give ‘direction and
super-
vision
to ensure that delegated care is provided safely and
accurately’ (ANMC, 2006a, p. 10) (bolding added). Box 18-
2 outlines the key elements of the delegation and
supervision guidelines for nurses and midwives developed
by the ANMC. In New Zealand, the Nursing Council of
New Zealand and the Midwifery Council of New Zealand
are responsible for providing delegation guidelines. For
details on these guidelines go to their websites:
council.org.nz and midwiferycouncil.health.nz.
It is crucial for nurses and midwives to critically identify
which care interventions should be performed by them and
which can be safely delegated. This can be especially chal-
lenging for new graduates. The following are examples of
factors to consider when delegating aspects of nursing or
midwifery care:
•
What is the person’s health status?
•
Has the care plan been recently evaluated and modified
in line with changes in the person’s condition?
•
What comorbidities and/or disabilities must be
considered?
•
To what extent is the registered nurse or midwife
required and/or able to supervise and monitor the
activity being delegated?
•
What level of qualification, skill, knowledge and
experience is required of the practioner to whom the
activity is being delegated?
•
In what context is the delegated activity to be
performed?
•
Is it reasonable to expect the practioner to accept the
delegated activities?
•
Is the practioner able to manage the delegated activities
within their current workload?
•
Is the activity within that practioner’s role?
Delegation and the student
nurse/midwife
Student nurses and midwives may find themselves in a situ-
ation of delegated care where they cannot perform safely.
Unit III Thoughtful practice and the process of care
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