Delegation

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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: