Delegation: An Art of Professional Practice



Delegation


An Art of Professional Practice


Patricia S. Yoder-Wise




Objectives



• Define delegation and its component parts.


• Evaluate how tasks and relationships influence delegation to a specific individual.


• Comprehend the legal authority for a registered nurse to delegate.


• Value the complexity of decision making related to delegation.



Terms to Know









The Challenge



All emergency departments (EDs) receive trauma patients at one level or another. Outlying EDs often receive trauma patients who are critical and are brought there as the first place for treatment. They are brought by emergency medical services (EMS) and by family members. Many level 3 and level 4 trauma centers have limited resources, so their challenge is to stabilize and transfer these patients to the closest level 1 trauma center. They also get “walk-ins” who have a laceration or broken bone that needs attention and can be more serious than it appears. Level 1 and level 2 trauma centers have their challenges also, because they need to use their resources to the maximum to provide the best care to those patients.


All of our hospitals use ED technicians. Recently we created a new classification for trauma technicians to provide a promotional opportunity for the ED technicians, who are not licensed and are more skilled than the traditional nursing assistants. To work in trauma situations, these technicians need specific skills. This mix of licensed staff (predominantly registered nurses) and unlicensed staff (the two levels of technicians) can be confusing in emergency situations in which everyone is supposed to respond to any event. Everyone has to be clear about what can be delegated to someone else and what cannot. We had to be sure the unlicensed staff members were trained sufficiently to participate at high levels without exceeding their designated role.


What do you think you would do if you were this nurse?





Historical Perspective


Until the early 1970s, registered nurses (RNs) were quite familiar with the art of delegation. Most care occurred in acute care hospitals, which were staffed by RNs (mostly diploma graduates, frequently prepared in the hospital in which they worked), licensed practical/vocational nurses (LPNs/LVNs), and nurse aides (commonly called unlicensed assistive personnel or unlicensed nursing personnel, or UAPs or UNPs, today). Note that the term unlicensed nursing personnel is used to distinguish those for whom nurses are accountable as opposed to the numerous unlicensed assistive personnel providing aid in other clinical disciplines. Team nursing was used, and staffing ratios were such that it was not uncommon for relatively few RNs to be present on a nursing unit. Much of the direct care was provided by LPNs/LVNs and aides. Of course, because there were few complex procedures, the direct care provided was related primarily to physical comfort and to what today would be called simple treatments.


As care became far more intricate and monitoring demands and expectations placed on nursing increased, moving to a higher ratio of RNs was logical. Thus, during the 1970s and 1980s, many nurses entered the profession with relatively limited experience or knowledge about the details of delegation—no one was in the clinical area to whom one could delegate anything related to patient care except the basic physical care. Sometimes the professional staff even dealt with that.


In the mid-1990s, a dramatic shift from primary nursing (an all-professional staff concept) to a multilevel nursing staff occurred. As a result, addressing the topic of delegation in some detail became critical to safe care. This return, however, was not to delegation as it was known earlier. In part, the difference today is based on the sophisticated demand for cost containment and reduction and the new complexities that are present in health care. As the healthcare industry emphasizes community-based care, the challenge of delegation and the resultant supervision become even more difficult. The increase, especially in UNPs, related in the past to a shortage of nurses. An even more dramatic one is predicted over the next several years, rising to a predicted need of 500,000 more RNs by 2025 (Buerhaus, 2009). Therefore, in addition to the supply of nurses and healthcare cost-control measures, the role of the RN will change to meet the increasing demands for care. Nursing’s flexibility to alter how we function based on the changes we find has allowed nursing to survive and sometimes thrive. The consistent element, irrespective of how we function, is care.


During the early part of the twenty-first century, both the National Council of State Boards of Nursing (NCSBN) and the American Nurses Association (ANA) became increasingly concerned about the quality of delegation decisions. The NCSBN stated it believes that “state boards of nursing should regulate nursing assistive personnel” (NCSBN, 2005, p. 160). This means that it believes the current approach in many states of having certified nursing assistants regulated through the health or hospital division of the state no longer meets the needs of nursing. In addition, the NCSBN has added an expectation that basic training for nursing assistive personnel includes an emphasis on the concepts related to how to receive delegation. The ANA (2005) focused on the principles of delegation that an RN must use. Together they created a joint statement on delegation to guide nurses in their practice (Joint Statement, 2009). Basically, the statement acknowledges that the authority for delegation resides within the nursing practice act of each state, acknowledges the value of unlicensed personnel in meeting patient needs, and acknowledges that decisions should be made based on protection of the health, safety, and welfare of the public. In addition, the statement identifies that the decision to delegate tasks is based on a variety of complex factors such as the patient’s condition, the complexity of the task, and the predictability of outcomes.


Although it is apparent that nursing’s need to delegate work will likely increase across the spectrum of care, content related to how to perform this task remains limited in schools of nursing, especially related to community settings. According to a report from the Nursing Executive Center of The Advisory Board Company (2008) of 36 competencies surveyed, nursing school leaders reported that they spent 1.8% of their instruction time teaching delegation. Of the six items with scores that tied this percentage or represented a lesser time, several related to delegation. For example, conflict resolution also represented 1.8% of the time, and conducting appropriate follow-up and ability to accept constructive criticism represented 1.7% and 1.6%, respectively. Although registered nurses do not supervise all unlicensed assistive personnel (e.g., physical therapy technicians), they often have exchanges with unlicensed nursing personnel and LPNs/LVNs. Further, only 10% of frontline leaders identified new graduates as proficient in delegation of tasks. Gaining experience and confidence in this important skill can enhance success early in the profession.


Delegation can be further complicated by multiple cultural factors such as ethnicity, age, and gender. Although it might be possible to speak in generalities about each of those factors (e.g., saying men are better leaders than women), various studies have shown commonalities across these cultural differences. For example, Deal (2007) identified that there are differences among employees based on age. Younger generations, for instance, tend to morph rules to fit their logic, whereas the traditional generation follows the details of the rules. Although these generational differences exist, the differences tend to be in demonstrated behavior. The values tend to be comparable across generations.



Definition


Delegate, or delegation, is defined in multiple ways. However, consistent elements can be found in each definition. Each definition calls for at least two people (a delegator and a delegatee), work, and some kind of transfer of authority and responsibility to perform the work. No definition suggests it is an abdication of accountability for the overall outcomes or performance or the abdication of the need to be involved. This is an important point because remaining in touch with others who are completing work on behalf of a delegator is sometimes difficult. Figure 26-1 shows that accountability remains fixed and that some portion of work is transferred along with the authority and responsibility for that delegated work. The importance of communication suggests that it must be constant to ensure basic, safe care. In fact, as tragic as Hurricane Katrina was when it struck in August 2005, critical healthcare lessons emerged. “Communication was the most critical factor in the determination to evacuate and the ease with which that process was completed” (McGlown, O’Connor, & Shewchuk, 2009, p. 277). Communication must be timely, often redundant, and reliable.


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FIGURE 26-1 A delegation framework: delegation to achieve care outcomes.

A definition of delegation, therefore, might be as follows: achieving performance of care outcomes for which you are accountable and responsible by sharing activities with other individuals who have the appropriate authority to accomplish the work. Acceptance of the delegated work must occur, either passively (i.e., no protest occurs) or actively (i.e., communication indicates acceptance). Therefore delegation can occur only when two people are involved in a mutual work situation and one of the persons has accountability and the other has some authority for performing specific tasks. When two RNs work together sharing activities, delegation does not occur. However, if one RN has specific accountability for an outcome and that nurse asks another RN to perform a specific component of the overall function, that is delegation (see the “Assignment versus Delegation” section on p. 527 for further information).


The terms delegators and delegatees represent the two key roles enacted in a delegation situation. Delegators are registered nurses who convey a portion of a patient’s care to another person. Delegatees comprise licensed practical/vocational nurses and unlicensed personnel, which may be referred to as aides, assistants or technicians.


Delegation occurs when an RN assigns an LPN/LVN or UNP to perform a specific function or aspect of care. The term UNP incorporates a variety of workers, such as nursing assistants, orderlies, nurse associates, and patient care assistants. This role, as the word assistive conveys, provides help to the registered nurse who is accountable for care. Most UNPs today are prepared in some formal program, but that program may range from less than a week to several weeks. Consistency in preparation and job descriptions for UNPs is lacking! The NCSBN (www.ncsbn.org) has expressed concern about preparation inconsistency and suggests that programs and UNPs both need greater public accountability.


The RN needs to be aware of the qualifications needed by a delegatee to perform safely. Authority is a critical component. It may be designated by law, such as the nursing practice act, or it may be designated by educational preparation/certification. Typically, a position description further defines what the nature of the authority is for a specific position. Knowing someone’s abilities is critical to successful delegation—that is true for both the delegator and the delegatee.


Although the study is fairly old, Standing, Anthony, and Hertz (2001) found the two most common errors associated with poor patient outcomes related to (1) giving improper directions and (2) providing improper follow-through of agency protocol. These findings suggest that communication and agency protocols are crucial to achieving positive performance outcomes. Examples of improper directions could include not indicating when to report important findings or not alerting the delegatee to what the important findings might be. Examples of improper follow-through of agency protocol might be found when the delegator fails to validate findings that are not anticipated or when the delegator encourages the individual to perform functions beyond the stated position description for the delegatee. In addition, failure of the delegatee to report findings is an example of failure to follow through.



Achieving Outcomes


Achieving performance outcomes is the driving force of all health care. If what someone does has little or no benefit in improving the delivery of care, it is, of course, ineffective. Therefore all care is based on attaining expected outcomes, whether that care is provided directly by an individual or group of professionals or whether that care was shared between professionals and assistants. Performance of care outcomes relates to the profession’s keeping its trust with the public, that is, to perform safely and competently. Standing et al. (2001) suggest that negative outcomes seem more related to delegation situations in which the nurse is less experienced in practice and the UNP is less experienced in a specific setting. In ever-changing healthcare settings, it is critical to know that you must delegate to achieve all that is expected of you. In essence, this means that if you cannot trust others or if you are frustrated because you cannot do it all yourself, you will be very frustrated with the way in which health care is delivered and your career opportunities will be fairly limited.


Learning about another and developing trust are critical to success. Lencioni, in what is now an established, classic publication (2002), cites lack of trust as the number-one dysfunction of a team. Comfortable, confident delegation requires considerable trust to function as a smooth pairing. Hansten (2008) pointed out that few nurses planned specific times to check with assistive personnel and thus much time was spent looking for each other. She recommends a minimum number of checks being done before and after breaks and meals.



Accountability and Responsibility


The terms accountability and responsibility refer to the legal expectation the state has vested in persons with the designation of RN. Accountability means that someone must be able to explain actions and results. Legally, the RN is accountable for nursing care. Responsibility refers to reliability, dependability, and obligation to accomplish work. It also refers to each person’s obligation to perform at an acceptable level. Thus assistants, whether UNPs or LPNs/LVNs, are obligated to perform that which they can at acceptable quality levels. Those individuals are also responsible for informing the delegator what limitations, if any, would prevent the accomplishment of expected outcomes. The Code of Ethics for Nurses, Provision 4 (ANA, 2008), identifies the expectation of accountability and responsibility and makes specific reference to delegation. For example, even when some portion of care is delegated to someone else, each individual nurse is accountable and responsible for his or her practice, including the decision to delegate and the outcome of the delegated tasks.


Organizational accountability is another aspect. Making solid decisions depends on how well the organization provides adequate resources, including appropriate staffing and mix. Organizations that function in positive ways, such as Magnet™ organizations, typically have supportive environments that help teams function effectively. The NCSBN concurs with the ANA that the driving principle in decision making is patient (public) safety.



Sharing Activities


Sharing activities may sound simplistic; however, when someone with the legal accountability for a role shares tasks, that individual is not giving away those tasks. In essence, sharing does not negate the nurse’s accountability for the total care. So, when delegating, the nurse is merely sharing activities or functions to ensure total outcomes. The delegation definition emphasizes that care itself is not delegated—only tasks (activities) are. Thus accountability rests with the delegator. Sharing may consist of many strategies ranging from asking an assistant to perform a specific task to expecting the same performance as the day before. For delegation to be effective, the RN must accept that sharing activities is important and benefits patient care. Professional aspects of care may never be delegated—only basic skills (frequently thought of as daily living/personal hygiene activities). In addition, some monitoring/technical skills may be delegated. Some organizations provide a two-level or three-level approach to UNP positions, with each level allowing more skills to be performed. In the future, we might anticipate that more, rather than fewer, skills might be delegated to others as the stability and predictability of those skills increase and the need to assist nurses in more ways increases.



Span of Control


The registered nurse may have responsibility for a group of people who work as part of the team he or she leads. Those people may include persons with no formal preparation or recognition (e.g., unit secretary), those with dependent status (e.g., LPNs/LVNs who function under the direction of a physician or RN), or others who are designated as being accountable to the delegator (e.g., other RNs or healthcare providers who report to a designated delegator, such as a nurse manager).


Span of control is an important concept to keep in mind when interacting with others to achieve care. This term refers to how many people for whom you have responsibility. For example, if a nurse has responsibility for 5 staff members, each of whom cares for 10 patients, the nurse, in effect, has responsibility for 5 staff members and 50 patients. This may not be as overwhelming as it may seem at first if the patients are in stable condition and their needs are predictable; if the staff are well-prepared, experienced providers of routine care; and if the geographic area is restricted. On the other hand, if any of these factors is lacking, this responsibility may be overwhelming, even if each staff member provides care for only 5 patients. Thus, if others render elements of care, multiple factors must be assessed to determine how manageable the situation is.



Appropriate Authority


Appropriate authority to perform certain functions stems from various sources. For example, the practice of LPNs/LVNs is defined by state titling or practice acts, as well as by institutional policies. UNPs, such as certified nursing assistants, are prepared to meet a specific set of functions. As mentioned, the preparation of UNPs varies considerably. That preparation, coupled with institutional policies, defines what UNPs may do. Position descriptions may provide more specific insight about the authority designated in certain positions. These elements—the titling or practice acts, position descriptions, and policies—form the expectations for what individuals in certain categories are expected to be able to do.


All organizations have descriptors of what tasks may be performed by someone in a particular position. When a position description contains functions that are normally performed or are believed to be an essential part of the practice of a licensed person (e.g., physician, nurse, pharmacist), the person performing in that role is doing so through a passive delegation act. There is, in essence, no active decision being made by the RN in determining what to delegate or to whom. When active delegation occurs, the RN assesses the situation, determines what is best for patient care, directs a UNP to perform certain tasks, and holds the person accountable. Even when organizational protocols indicate that someone else may perform a task on behalf of the RN, the employee must be competent to perform the tasks. This expectation suggests that the delegator will make initial and ongoing assessments related to the delegatee’s performance in addition to assessment of patients and their needs. Furthermore, state laws governing the practice of professional nursing typically define what the RN must do when someone else assumes certain tasks.

Related posts:

  1. Context
  2. Patient Safety
  3. Developing the Role of Manager
  4. Managing Personal/Personnel Problems

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Aug 7, 2016 | Posted by in NURSING | Comments Off on Delegation: An Art of Professional Practice

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