Effective Delegation and Supervision

Barbara Cherry, DNSc, MBA, RN, NEA-BC and Margaret Elizabeth Strong, MSN, RN, NE-BC

After studying this chapter, the reader will be able to:

1. Evaluate the effect of changes in the current health care system on nurse staffing patterns and responsibilities.

2. Outline six topic areas that the professional nurse should consider when making delegation decisions.

3. List nine essential requirements for safe and effective delegation.

4. Incorporate principles of delegation and supervision in professional nursing practice to ensure safe and legal patient care.

Key Terms

Accountability:

In the context of delegation, accountability means bearing responsibility for both the action and inaction of the nurse and those to whom he or she delegates tasks (National Council of State Boards of Nursing [NCSBN], 2005).

Assignment:

The distribution of work that each staff member is responsible for during a given work period; when making assignments, the RN supervisor directs a staff member to do something that he or she is authorized to do and is within the staff member’s scope of practice and/or job description (American Nurses Association [ANA] and NCSBN, 2006).

Competency:

The ability of an individual to perform defined behaviors proficiently by demonstrating the appropriate knowledge, skills, attitudes, and professional judgment required for a specific role or setting.

Delegation:

Transferring to a competent staff member the authority and responsibility to perform a selected nursing task that the staff member would not normally be allowed to perform; the RN retains accountability for the delegated task (ANA and NCSBN, 2006).

Unlicensed assistive personnel (UAP):

An unlicensed individual who is trained to function in an assistive role to the RN by performing patient care activities as delegated by the nurse; may include nursing assistants, clinical assistants, orderlies, health aides, or other titles designated within the work setting.

Supervision:

The active process of directing, guiding, and influencing the outcome of an individual’s performance of an activity or task (ANA, 2005).

Additional resources are available online at:

http://evolve.elsevier.com/Cherry/

Delegation—linking together for better patient care.

Vignette

Glenda Miller, BSN, RN, is the charge nurse on a medical-surgical floor of a hospital. She has just received report from the 7 pm to 7 am shift and is about to make assignments for the 7 am to 7 pm shift. The philosophy of the unit is that the registered nurse (RN) coordinates all patient care. Today on this 12-bed unit there are eight patients and 4 empty beds. The nursing staff consists of Ms. Miller, one RN, one licensed practical nurse, one nursing assistant, and one unit secretary. The following interprofessional team members are available for specific patient care needs: a respiratory therapist, physical therapist, occupational therapist, speech therapist, medical social worker, nutritional support nurse, and chaplain. The patients are medically complex with extensive nursing care needs including psychosocial and emotional support. The patients are described to Ms. Miller as follows:

502: Mr. A. is ventilator dependent with an infection that requires IV antibiotics every 12 hours. He needs to be out of bed in a chair twice a day. He has a stage I sacral decubitus ulcer and a PEG tube with bolus feedings. He is very hard of hearing, tries to speak, and becomes very frustrated and uncooperative.

503: Mrs. B., age 77, is on day 2 of 40 days of antibiotics for osteomyelitis. She is dehydrated with a central line in her right subclavian and on TPN. She needs to be out of bed and ambulated in the room. She receives a respiratory treatment every 4 hours and needs assistance with am care. Her daughter is at her bedside and is very upset that her mother may need to go to a nursing home.

504: Mr. C., age 52, is to be discharged to a rehabilitation hospital today. Discharge records need to be prepared for the transfer. The family is at his bedside and is extremely anxious.

507: Mr. D., age 64, has TPN infusing into a left subclavian catheter and is on multiple antibiotics. He has vancomycin-resistant Enterococcus in his urine and a stasis ulcer on his left leg that requires Pulsavac every day.

508: Mr. E., age 72, is a ventilator-dependent patient who will start weaning this am. He is on continuous tube feedings and IV antibiotics and needs to be assessed for a PICC line. He is to begin ambulation in the hall twice a day per physician’s orders. He also needs to have a pharyngeal speech evaluation scheduled.

509: Mrs. F., age 66, is 3 days after a CVA and unable to move her right extremities. She has an IV infusing via her left arm. Her blood pressure is 170/100. She needs total care with personal hygiene and feeding. The physician just ordered range-of-motion exercises every day. Her husband is at her bedside crying continually and asking, “What am I going to do now?”

510: Mr. G., age 52, has been off the ventilator for the past 24 hours and is doing very well. He continues on respiratory treatments every 4 hours. His TPN is being decreased, and his PEG feedings are increasing. He has glucose monitoring ordered every 4 hours, an indwelling urinary catheter to gravity drainage, and IV antibiotics every 12 hours. He needs to be out of bed, ambulating in the hall with assistance. If he stays off the ventilator, he will be discharged in 5 days. The family needs to find a nursing home for him; however, the family has not visited Mr. G. since his admission 18 days ago.

511: Mr. H., age 49, is a new admission that will be coming from ICU sometime during the shift.

In addition to the tasks mentioned, routine activities of taking vital signs, giving scheduled medications, updating care plans, and answering call lights must be assigned. When reviewing the tasks to be accomplished, Ms. Miller must consider several issues to make safe and effective assignment and delegation decisions.

Questions to Consider While Reading This Chapter

1. Which of the above tasks must the RN perform as required by your state’s nurse practice act?

2. Which of the above tasks can be delegated to the nursing assistant?

3. How can the training, skills, and competencies of the licensed practical nurse (LPN) or licensed vocational nurse (LVN) and nursing assistant be determined?

4. How can other members of the interprofessional health care team contribute most effectively to meet patients’ needs?

Chapter Overview

The delivery of patient care is the fundamental goal of every health care organization. To accomplish this goal cost-effectively, teams of diverse professionals and assistants are used to deliver care. Because the RN is most often responsible for coordinating care provided by the various team members, he or she must clearly understand and be able to effectively use the management processes of delegation and supervision to ensure high-quality, safe patient care. This chapter highlights issues that influence staffing patterns and delegation and supervision processes. The chapter also discusses the RN’s role and responsibility in delegating to and supervising staff members, including unlicensed assistive personnel (UAP) and LPNs or LVNs, and it provides useful guidelines for establishing a safe and effective delegation and supervision practice.

Delegation and Supervision in the Health Care System

Several factors influence staffing patterns and the provision of patient care in today’s health care system. First, reduced reimbursement from Medicare, Medicaid, and private insurance companies has led to cost-cutting measures. Second, the growing uninsured population is forcing health care organizations to provide care in the most cost-efficient manner possible. Third, the strong focus on safety and quality is requiring health care systems to make rapid changes for continual improvement. Fourth, advances in medical technology are causing a sharp increase in the cost of providing care. Finally, the nursing shortage combined with an increase in patient acuity and complex treatments contribute to health care environments struggling to address multiple complex priorities with dwindling resources. Using UAP, such as nursing assistants and patient care technicians, is one strategy to increase cost-effectiveness of providing patient care.

As the use of UAP increases, the RN is forced to delegate more tasks to a person who does not have clearly defined parameters for education, training, job responsibilities, and role limitations. Therefore, it is up to the RN to know the laws and regulations that govern nursing practice. It is also important that the RN work closely with nonclinical administrators and managers to make sure they understand the assessment and decision-making activities that must be performed by the RN according to state law.

There is a growing concern that the roles and responsibilities of care providers, including RNs, LPNs or LVNs, and UAP, are significantly overlapping. In some practice settings, LPNs or LVNs are functioning as managers and supervisors and are performing more complex and invasive procedures. In some states, UAP are trained to perform complex procedures, such as venipunctures and catheter insertions. This trend has prompted many nurses, nursing organizations, and state boards of nursing to reexamine the scope of nursing practice and the nurses’ delegation and supervision responsibilities.

The issue of health care errors and the RN’s essential role in keeping patients safe was brought to the nation’s attention through the Institute of Medicine’s (IOM) report Keeping Patients Safe: Transforming the Work Environment of Nurses. This report effectively highlights how nurses improve patient outcomes through the ongoing monitoring of patients’ health status, coordinating care, educating patients and families, providing essential therapeutic care, and intercepting health care errors before they can adversely affect patients (IOM, 2004). RNs must learn to delegate nursing tasks safely and effectively so that they will be available to deliver these most important aspects of professional nursing care.

In support of the role of UAP in delivering patient care, the Joint Statement on Delegation (ANA and NCSBN, 2006) states, “There is a need and a place for competent, appropriately supervised, unlicensed assistive personnel in the delivery of affordable, quality health care” (p. 2). As health care facilities continue to seek more cost-effective ways to provide care, RNs must learn new ways of managing care and delegating tasks.

Because RNs are becoming increasingly responsible for delegation and supervision in today’s health care system, it is imperative that they have confidence in their delegation skills and understand the legal responsibility that they assume when delegating to and supervising licensed personnel and UAP. RNs should know what aspects of nursing and health care can be delegated and what level of supervision is required to ensure that the patient receives safe, competent, and effective care.

What is Delegation?

Delegation is a legal and management concept that involves assessment, planning, intervention, and evaluation. Delegation as defined by the American Nurses Association (ANA, 2005) is “the transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome” (p. 4). Although RNs can transfer the responsibility and authority for the performance of an activity, they remain accountable for the overall nursing care. When delegating tasks, the nurse should understand the delegatee’s competencies, communicate succinctly, offer clear guidelines in advance, monitor progress, and remain accountable for the final outcomes of care.

Delegation is a two-way process in which the RN requests that a qualified staff member perform a specific task. When delegating, the RN delegator is accountable for the following: