NUR 4280 Module 2 Delegation and Conflict Analysis Example

The Orthostatics That Were Never Done: Delegation, Teamwork and Conflict on a Syncope Observation Pathway

Student Name

Bachelor of Science in Nursing, Thomas Edison State University

NUR-4280: Leadership and Management In Nursing

Mentor Name

Month Day, Year

The Orthostatics That Were Never Done: Delegation, Teamwork and Conflict on a Syncope Observation Pathway

On our observation unit, patients placed for syncope follow a pathway that requires orthostatic vital signs at admission and again before discharge. One night last spring, a seventy-eight-year-old patient on the syncope pathway was ready for discharge at 0600, but the second set of orthostatic vital signs had not been done. The day physician would not discharge without them, the patient's ride left, and the stay extended by five hours. The registered nurse had delegated the measurement to a patient care technician at 0400; the technician said the instruction had been to take vital signs, not orthostatic vital signs. By 0700 the two were arguing at the nurses' station. This paper analyzes the event using the national guidelines for nursing delegation, a model of missed nursing care, and a framework for conflict, and describes what I did as charge nurse.

What Delegation Requires

Guidelines written jointly by the National Council of State Boards of Nursing and the American Nurses Association describe delegation (National Council of State Boards of Nursing, 2016) as allowing a delegatee to perform a specific nursing activity, skill or procedure that is beyond the delegatee's traditional role but within the delegator's scope, while the registered nurse retains accountability for the outcome. They organize the decision around five rights, covering what is delegated, when, to whom, how the instruction is given and checked, and how the nurse follows up afterward. They also describe responsibilities that sit with the employer, such as defining which tasks may be delegated and ensuring that delegatees are trained and competent.

Measuring orthostatic vital signs is a reasonable task to delegate on our unit. The hospital's job description for patient care technicians includes it, every technician completes a competency check at hire, and the measurement does not require nursing judgment to perform, only to interpret. The task, the circumstances and the person were therefore right. The failure lay in the fourth and fifth rights. By the nurse's own account, the request to the technician was to get a set on room 14 before the doctor comes; the word orthostatic was never used, the pathway went unmentioned, and no time was set for the results. Without a check-back, neither person noticed the gap until the discharge was blocked.

Why the Task Was Missed

Kalisch et al. (2009) describe missed care as required care that is left undone, partly done or done late, and describe three groups of contributing factors: antecedents that force decisions about priorities, such as workload and resources; elements of the nursing process, such as communication and handoffs; and the internal values and perceptions of the people involved. All three groups were present that night. The unit had two admissions from the emergency department between 0300 and 0500, so the nurse was prioritizing under pressure. The instruction was given verbally in passing, with no written cue on the technician's worksheet. And the technician, who had worked on a medical unit where routine vital signs are taken at 0400, heard the request through that habit.

Seeing the event this way changed the conversation I later had with both staff members. It was not a story of one careless person. It was a predictable result of a busy hour, a verbal instruction and two different mental models of what a set of vitals means on a syncope pathway. The same combination could produce the same miss on any night, with any two staff members, which is why a fix aimed at the individuals would not have lasted. The technician involved had completed the orthostatic competency; the knowledge was there, and the cue to use it was missing.

The Conflict and How It Was Handled

Thomas and Kilmann's model, set out in the instrument described by Kilmann and Thomas (1977), places conflict-handling behavior on two dimensions, assertiveness and cooperativeness, and from those two axes derives five ways of handling a disagreement, ranging from pressing one's own position hard to stepping away from the issue entirely. At the station that morning, both staff members were competing, each asserting that the other was at fault. My first instinct as charge nurse was avoiding: day shift was arriving, the patient had already been told about the delay, and I could have sent both home and dealt with it later. I also considered accommodating the nurse, who is more senior, by agreeing that the technician should have known.

Instead I chose collaborating, which is high on both dimensions and takes more time. I asked each person separately, after report, to describe the instruction as they remembered it. I then brought them together for ten minutes and asked what would have prevented the miss, without revisiting who was right. The technician suggested that pathway tasks be written on the worksheet; the nurse suggested a quick check-back for any delegated task tied to discharge. Both ideas addressed the actual failure, and both people left with something they had contributed. Collaborating is not always the right mode. In an emergency, competing is appropriate, and for a trivial disagreement, compromising is efficient. Here the conflict exposed a system weakness, which made collaboration worth the time.

Changes to the Unit

Two changes followed. First, the technicians' assignment sheet now lists pathway-specific tasks for each patient, so that orthostatic vital signs on a syncope patient appear in writing before the shift starts. Second, we adopted a check-back for any delegated task that a discharge depends on: the nurse states the task and the time, and the technician repeats it. The check-back is borrowed from TeamSTEPPS team communication training (Agency for Healthcare Research and Quality, 2023), and it takes seconds. In the two months since, the unit has had no discharge delayed by a missing orthostatic measurement, although two months is too short to call the problem solved.

The event also changed how I delegate on busy nights. I now finish every delegation with a time and a reason, for example, orthostatics on room 14 by five, because the syncope discharge needs them. It is a small habit, but it carries the task, the timing and the purpose in one sentence, which is what the guidelines mean by the right direction and communication.

References

Agency for Healthcare Research and Quality. (2023). TeamSTEPPS 3.0: Pocket guide. https://www.ahrq.gov/teamstepps-program/index.html

Kalisch, B. J., Landstrom, G. L., & Hinshaw, A. S. (2009). Missed nursing care: A concept analysis. Journal of Advanced Nursing, 65(7), 1509-1517. https://doi.org/10.1111/j.1365-2648.2009.05027.x

Kilmann, R. H., & Thomas, K. W. (1977). Developing a forced-choice measure of conflict-handling behavior: The MODE instrument. Educational and Psychological Measurement, 37(2), 309-325. https://doi.org/10.1177/001316447703700204

National Council of State Boards of Nursing. (2016). National guidelines for nursing delegation. Journal of Nursing Regulation, 7(1), 5-14. https://doi.org/10.1016/S2155-8256(16)31035-3