Delegation

http://evolve.elsevier.com/Huber/leadership/

Delegation is a fundamental aspect of every nurse’s job. The effective delegation of work to others is essential in every type of health care setting and organization. Effective delegation skills also are important for managers whose function is to get work done through the efforts of others. For most nursing jobs, the zone of responsibility exceeds one person’s ability to complete all the tasks (Figure 9-1). This is especially true for the care coordination aspects of nursing care management. Nurses need to delegate parts of nursing care delivery to others because, at some point, it becomes impossible to do it all alone.

In the 1800’s, delegation was defined by Florence Nightingale (1859) as a critical skill: “But then again to look at all these things yourself does not mean to do them yourself… But can you not insure that it is done when not done by yourself?” (p. 17). Nurses delegate to nurses and paraprofessionals in the health care environment, whether to students, licensed practical nurses/licensed vocational nurses (LPNs/LVNs), orderlies or technicians, corpsmen, medication assistants-certified, nursing assistants, or some other form of nurse extender.

Weydt (2010) noted that nurses have to understand what patients and families need, then engage the right caregivers in the plan of care to achieve outcomes. Meeting the public’s increasing demand for quality health care that is both accessible and affordable has created a demand for health care providers and maximized the stress on every health care worker. As a result, the identification of which tasks are appropriate to nursing, which of these tasks can be delegated, and to whom they can be delegated is imperative. Delegation issues have become connected to issues of work overload, safety and quality of care, mix of staff, job security and turf, and nurses’ job satisfaction. It has been proposed that delegation of non-nursing tasks also helps reduce health care costs by making more efficient use of nursing time and the facility’s resources (Fisher, 2000). Delegation is at the fulcrum of quality and cost concerns.

DEFINITIONS

The American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN) in their Joint Statement on Delegation (NCSBN, 2006) defined delegation in nursing as “the process for a nurse to direct another person to perform nursing tasks and activities” (p. 1). The ANA described this as the nurse transferring responsibility, whereas the NCSBN called this the transferring of authority. The goal of delegation is workload distribution. It relies on trust. The delegator is the person—the RN or LPN/LVN—making the delegation. The delegate is the person receiving the delegation. Supervision is defined as the provision of guidance or oversight of a delegated nursing task. The availability of the supervising nurse occurs through various means of written and verbal communication. Assignment is “the distribution of work that each staff member is responsible for during a given work period” (NCSBN, 2006, p. 1).

The ANA (2005) defined unlicensed assistive personnel (UAP) as individuals who are trained to function in an assistive role to the registered professional nurse in the provision of patient/client care activities as delegated by and under the supervision of the nurse. In the past, a nurse extender meant a nursing assistant or a corpsman. A nurse extender is an ancillary person trained to perform some basic client care tasks who may have been given a client assignment or related tasks. The current term is nursing assistive personnel (NAP).

By definition, assistive personnel work under RN/LPN/LVN supervision. The danger is that organizations may deploy them instead of staffing an adequate number of RNs for the care needs and the extra duties of personnel supervision.

A basic distinction is whether the nurse extender performs direct client care. The definition of what assistive personnel can and cannot do is not exclusive and varies by state because of state-specific licensure laws. Alterations in the skill-mix percentage of RNs to assistive personnel occur over time. Nurses argue that inadequate staffing ratios can create a potentially dangerous situation for client care and safety. In California, nurses have minimum nurse-client ratios in acute care hospitals that were passed in legislation. This is controversial.

Client care activities include all tasks and activities, mental and physical, necessary to care for clients and produce nursing and health outcomes. Nursing activities involve actions, tasks and direct client contact, as well as the full scope of the nursing process. The act of delegating certain activities that are performed by nurses—but are not limited to them—does not create a situation in which nursing itself and the responsibility for it are delegated away. Core activities of the nursing process require specialized knowledge and judgment that only the nurse has.

BACKGROUND

Delegation of care originated from physician responsibilities being delegated to nurses. Nurses began to assume more and more tasks deemed as nursing care up to the point that they could not complete them all in the limited time frame. Thus phlebotomists, respiratory therapists, physical therapists, and NAP emerged to help provide more comprehensive care. The establishment of the health care team formed around these specialists needing to coordinate work. With this work structure, the need to delegate work arose.

The NCSBN has developed a number of tools relating to delegation and the roles of licensed nurses and assistive personnel which have been collected into the document Working with Others: A Position Paper (NCSBN, 2005). Key concepts are presented. The NCSBN’s position is presented. The delegation decision making process is presented. There are two helpful decision trees (visual flow charts): delegation to nursing assistive personnel (pp. 11-12) and accepting assignment to supervise unlicensed assistive personnel (pp. 16-17). There is a state-by-state review of statutes and rules, a summary of multiple organizations’ position statements, definitions, and a literature/case law review.

PROCESS OF DELEGATION

Delegation is a decision-making process that requires skillful nurse judgment. The decision to delegate should incorporate critical thinking and sound clinical decision making. The process outlined by the NCSBN (2005) starts with a preparation phase and then has a 4-step process phase. The steps are (1) assess and plan, (2) communication, (3) surveillance and supervision, and (4) evaluation and feedback.

In most cases, it is recommended that the nurse delegator and the delegate agree on the task, circumstances, and time frame and then arrange for feedback in which the delegate reports or the delegator evaluates progress toward completion of the task. One way to make certain that both delegator and delegate understand what the task is and how to complete it effectively is to follow up a verbal directive with written instructions so that each person can refer to them later. Figure 9-2 displays a sample delegation tracking form that can be generated by NAP to give to the nurse. As a vehicle for clear communication and verification of expectations and consensus, this form can be modified to be specific to each unit. The task should specify a time frame in which the entire task is to be completed. The decision to delegate needs to be consistent with the nursing process. Thus the nurse needs to ensure appropriate assessment, nursing diagnosis, planning, implementation, and evaluation in a continuous process.

Decisions to delegate need to be carefully and thoroughly evaluated. A reasonable first decision rule is to be able to delegate the care of clients whose care requirements are routine and standard. Because care is complex and variable, the competency of the delegate is critical. Once it is assessed that the person to be delegated to has the minimum competencies required for safe care and if the outcomes of care are relatively predictable, delegation is considered safe. If the client’s reaction to illness and hospitalization is not threatening to his or her mental health or sense of self, it also is relatively safe to assume that this care can be delegated to NAP. For example, a client experiencing an acute episode of hypertension would require the RN as opposed to NAP to monitor the vital signs.

In making a decision to delegate nursing tasks, the following five factors can be assessed (American Association of Critical Care Nurses [AACN], 2004):

1. Potential for Harm: The nurse must determine how much risk the activity carries for an individual patient.

2. Complexity of the Task: The more complex the activity, the less desirable it is to delegate. Only an RN should perform activities requiring complex psychomotor skills and expert nursing assessment and judgment.

3. Amount of Problem Solving and Innovation Required: If an uncomplicated activity requires special attention, adaptation, or an innovative approach for a particular patient, it should not be delegated.

4. Unpredictability of Outcome: When a patient’s response to the activity is unknown or unpredictable (depending on how stable the patient is), it is not advisable to delegate that activity.

5. Level of Patient Interaction: Will delegation of a particular activity increase or decrease the amount of time the RN can spend with the patient and patient’s family? Every time a nursing activity is delegated or one or more additional caregivers become involved, a patient’s stress level may increase and the nurse’s opportunity to develop a trusting relationship is diminished.

The over-arching determinant for the decision to delegate is the legal scope of delegation as set forth in the state’s nurse practice act. With the qualifications of both the delegator and the delegate as a baseline in place, the licensed nurse enters the continuous process of delegation decision making. The situation is assessed, and a plan for specific task delegation is established, considering patient needs, available resources, and patient safety. The nurse needs to ensure accountability for the acts and process of delegation. This includes supervision of the performance of the entire task, any necessary intervention, and evaluation of the task performance and the delegation itself.

The joint ANA and NCSBN (2006) statement identified nine principles of delegation specific to the RN, including the following:

• The RN may delegate elements of care but does not delegate the nursing process itself.

• The RN has the duty to answer for personal actions relating to the nursing process.

• The RN takes into account the knowledge and skill of any individual to whom the RN may delegate elements of care.

The decision of whether to delegate or assign is based on the RN’s judgment concerning the condition of the patient, the competence of all members of the nursing team, and the degree of supervision that will be required of the RN if an element of care is delegated.

The RN uses critical thinking and professional judgment when following The Five Rights of Delegation promulgated by the NCSBN (1995) as follows:

1. Right Task (element of care)

2. Right Circumstance

3. Right Person

4. Right Direction/Communication

5. Right Supervision and Evaluation

When determining the right task (element of care) to delegate, the nurse determines whether the element of care falls within the guidelines of established agency policies and procedures, the ANA Code of Ethics, and legal regulations for practice. The nurse then must consider whether the element of care can be delegated to any other staff members.

The right circumstance to perform the element of care indicates the delegate has the available resources, equipment, safe environment, and supervision to complete the task correctly.

The right person has the education and competency to perform the element of care. The right delegate, then, is legally acceptable to complete the element of care.

The right direction/communication of delegated elements of care will be a clear, concise description of the task, including its objective, limits, and expectations. The nurse allows for clarification without the fear of repercussions.

The right supervision of an element of care includes appropriate monitoring, intervention, evaluation, and feedback as deemed necessary. A process should be in place for the delegate to report to the RN both that the task was completed and the client’s response.

In addition to the five rights, the following three organizational principles are to be considered:

1. The RN acknowledges that there is a relational aspect to delegation and that communication is culturally appropriate and the person receiving the communication is treated respectfully.

2. Chief nursing officers are accountable for establishing systems to assess, monitor, verify, and communicate ongoing competence requirements in areas related to delegation, for both RNs and delegates.

3. RNs monitor organizational policies, procedures, and position descriptions to ensure that the nurse practice act is not violated, working with the state board of nursing if necessary.

The five rights can quickly help analyze whether a delegation decision will most likely result in a safe outcome. To facilitate the delegation process in a way that will ensure the client’s personal health needs are addressed and the nurse’s professional goals are achieved, effective communication techniques must be used (Marthaler, 2003). Box 9-1 outlines a personal checklist for the delegator to use for self-evaluation.

BOX 9-1

Delegator’s Checklist

• Develop a good attitude.

• Decide what to delegate.

• Select the right person.

• Communicate responsibilities.

• Grant authority.

• Provide support.

• Monitor the delegation.

• Evaluate.

Data from Nelson, R. (1994). Empowering employees through delegation. Burr Ridge, IL: Richard D. Irwin.

Delegation Facets

True delegation is real to the delegate. Delegators let delegates go on their own but only after instilling in them the highest standards of performance and adherence to a shared vision. The delegate then functions within the standards set by the delegator, who has given authority to do the job, make independent decisions, and be responsible for seeing that the job is done well. True delegation trust is earned over time. Effective delegation requires that the delegate have the authority to accompany the responsibility. The delegator monitors the element of care completion and is alert for variances or other problems.

The essence of the element of care being delegated is often overlooked. Recognition of the potential vulnerability of the client, and thus the presence of an inherently moral element to health care practice, has raised concerns in relation to proper moral regard and respect for clients (Niven & Scott, 2003). This means that nursing judgment about which elements of care are to be delegated requires consideration of the client’s unique individual needs at that point in time. For example, obtaining vital signs on a client who is dying may be a reasonable delegation to NAP. However, because a nurse has spent much time explaining the process of the “do-not-resuscitate” status to the family, a trusting relationship has been established. The client’s or family members’ preferences for treatment/care need to be considered in delegating care activities.

Safety is a major facet of delegation, addressed over the years by The Joint Commission’s (TJC) Hospital National Patient Safety Goals. For example, The Joint Commission’s 2007 Patient Safety Goal Requirement 2E, Implement a standardized approach to “hand-off” communications (TJC, 2007), is applicable to delegation. Its provisions include the opportunity to ask and respond to questions. This assists in determining whether delegation can safely occur when a responsible delegator is not physically present.

The Joint Commission’s (2013) National Patient Safety Goal to maintain and communicate accurate patient medication information (NPSG.03.06.01) is an example of an effort to collect, reconcile, and communicate medication use to enhance patient safety. It speaks to the complexity and fluidity of care and how discrepancies in communication affect safety, especially in the context of multidisciplinary and team-based care systems where gaps can occur.

Communication is a major factor in missed care results of delegation. Research has shown no relationship between leadership style and delegation confidence, although there is an interaction between educational preparation and clinical nursing experience (Saccomano & Pinto-Zipp, 2011). There is, however, a bundle of best practices for delegation and supervision skills that includes planning assignments, including NAPs in shift handoffs and rounding, check-in points, evaluation of organizational practices about delegation and supervision, and coaching and mentoring (Gravlin & Bittner, 2010; Hansten & Jackson, 2009).

Delegation to unlicensed staff is common in long-term care (LTC) and assisted living settings. Thus delegation is a major strategy for care delivery. UAPs can be certified nursing assistants, personal care workers, or other types of unlicensed personnel. Lightfoot (2011) outlined the following eight principles for RN delegation:

1. Delegate tasks only within the RN’s scope of practice, expertise and knowledge

2. Assess the patient’s condition and stability

3. Only delegate tasks that the UAP is competent to perform and within his/her educational preparation/ability

4. Provide direction and assistance

5. Do not delegate tasks requiring complex nursing skill/judgment

6. Supervise, observe, and monitor UAPs

7. Evaluate the effectiveness of the delegated task

8. Document the delegation.