1. Delegation and Supervision for Victorian Nurses and Midwives
Element 1: Regulatory requirements For nursing and midwifery leaders

2. Regulatory requirements
The Nursing and Midwifery Board of Australia (NMBA) undertakes functions as set by the Health Practitioner Regulation National Law.
NMBA sets the registration standards as well as professional codes, standards and guidelines that underpin safe and competent practice.
The NMBA’s requirements of nurses and midwives relating to delegation and supervision are outlined in its publication ‘A national framework for the development of decision-making tools for nursing and midwifery practice’.

3. Delegation and supervision guidelines for Victorian nurses and midwives
In order to become registered, nurses and/or midwives must meet the National Board’s mandatory registration standards.
To be effective, nurses and midwives need to have a clear understanding of the requirements.
Released in 2014, the guide seeks to reinforce the NMBA publications around decision making, by making practical recommendations and outlining a framework

4. Delegation and supervision guidelines for Victorian nurses and midwives
The guide was developed following consultancy with key stakeholders, discussions with Victorian nurses/midwives and an international literature review.
Makes a number of recommendations, assuming a shared responsibility between:
individuals,
employers,
education providers,
professional bodies, and the
Department of Health & Human Services.

5. Accountability when delegating
Delegation and supervision is, and always has been, a core responsibility of Registered Nurses and Midwives
The Registered Nurse or Midwife remains accountable for monitoring and evaluating the effect of any care that has been delegated

6. Accountability when accepting a delegation
Can include EN’s, unlicensed healthcare workers, junior RN/RM’s, other workers:
A staff member who accepts a delegation is accountable for their actions or decisions
A staff member should not accept a delegation if it is beyond their training and competency, and/or if they are not confident undertaking the delegation
Unlicensed healthcare workers include roles such as health assistants (nursing), assistants in nursing, health care assistants, personal care attendants, constant patient observers, orderlies, ward attendants.

7. Principles of Delegation
Delegation is an exercise in professional judgement by the RN/RM. It involves the transfer of authority to a competent person to perform a specific activity in a specific context.
Considerations when delegating include:
Patient health status (stability and complexity)
Complexity of the delegated activity
Context of care
Level of knowledge, confidence, skill and experience of the person to whom the task has been delegated
The expected outcomes of the delegated task
How outcomes will be monitored and communicated
Legislative requirements

8. The Five Rights of Delegation
Right Activity
Right Circumstances
Right Person
Right Communication
Right Supervision and Evaluation
Acknowledgement: National Council of State Boards of Nursing, 2005

9. Right Activity
The right activity that, in the professional judgement of the RN/RM:
can be safely delegated to another staff member who has the level of knowledge and competency to perform the task, and
is appropriate for the needs of the specific health consumer
The activity being delegated needs to be within the scope of practice of the enrolled nurse or role boundaries unlicensed healthcare worker accepting the delegation

10. Right Circumstances
Consideration of appropriate and right circumstances include:
The appropriate patient or patient group (based on the severity and complexity of their condition)
The resources available including skill mix, staff availability and capacity for supervision, and
other relevant factors including monitoring and communication of progress

11. Right Person
The right person is delegating the right activity to the right person with the right skills and knowledge to assist the right patient:
The delegating RN/RM can only delegate care that they themselves are competent to perform
The nurse/HA accepting the delegation needs to have the appropriate training and knowledge and competence to provide the required care
The Patient whose care is delegated must not require complex observations, decision making, critical thinking or nursing judgement

12. Right Communication
The right communication is clear, concise description of the activity to be undertaken, including the objective and expected outcomes.
The delegating RN/RM should ensure that the enrolled nurse or unlicensed healthcare worker clearly understands:
What activities are being delegated
Who and when to ask for assistance or report concerns
How concerns should be reported
The enrolled nurse or unlicensed healthcare worker must inform the delegating RN/RM if they have not been trained to perform an activity or if they are uncertain of any aspect of the delegation

13. Right Supervision and Evaluation
The right supervision and direction refers to appropriate monitoring, evaluation, intervention as needed, and feedback.
The delegating RN/RM retains accountability for ensuring that:
the delegated activities are performed to the required standard,
monitoring and evaluating the impact and outcome of delegated care is undertaken,
direct or indirect supervision is available as required,
the enrolled nurse or unlicensed healthcare worker performing the delegated activity has the necessary support and guidance.

14. Supervision
The NMBA identifies 3 types of supervision within nursing/midwifery practice; specifically managerial supervision, professional supervision and clinically focused supervision.
Clinically focused supervision
Clinically focused supervision specifically relates to supervision of delegated nursing and/or midwifery tasks and activities, including:
providing education, guidance and support for individuals who are performing the delegated activity
directing the individual’s performance
monitoring and evaluating outcomes, especially the consumer’s response to the activity

15. Supervision
The level of supervision should be appropriate to the degree of risk of the activity
Direct Supervision
Is when the supervisor is present and personally observes, works with, guides and directs the person being supervised
Indirect Supervision
Is when the supervising RN/RM is on site and easily contactable and available for reasonable access but does not directly observe the activity

16. Responsibilities when delegating
The professional’s responsibilities include:
teaching (although this may be undertaken by another competent person, and teaching alone is not delegation)
competence assessment
providing guidance, assistance, support and clinically focussed supervision
ensuring that the person to whom the delegation is being made understands their accountability and is willing to accept the delegation
evaluation of outcomes
reflection on practice.

17. Responsibilities when accepting a delegation
The recipient’s responsibilities include:
negotiate, in good faith, the teaching, competence assessment and level of clinically focussed supervision needed
notify in a timely manner if unable to perform the activity for an ethical or other reason
be aware of the extent of the delegation and the associated monitoring and reporting requirements
seek support and direct clinically focussed supervision until confident of own ability to perform the activity
perform the activity safely
participate in evaluation of the delegation.

18. Decision making tree Do not delegate Delegation is appropriate
Is it the right activity?
Has there been a RN/RM assessment of patient care need?
Are there organisational guidelines that support the delegation?
Can the task be routinely performed without complex observations, decision making or clinical judgement?
Do not delegate NO
YES
Is it the right circumstance?
Does the RN/RM have the skills and knowledge to safely delegate?
Does the skill-mix in your ward/unit/environment enable you to undertake appropriate supervision? NO
YES
Is it the right person?
Is the task within the scope of practice or role parameters of the person you are delegated to?
Does the person you are delegated to have the appropriate knowledge, skills and competency to perform the delegated tasks? NO
YES
Is it the right communication?
Does the person being delegated to understand and accept the delegated task; know when and who to ask for assistance, and who to report to? NO
YES
Is it the right supervision and evaluation?
Is there ongoing monitoring and evaluation of the outcomes of care by the supervising RN/RM? NO
YES
Delegation is appropriate
Acknowledgements:
National Council of State Boards of Nursing, 2005
Nursing Council of New Zealand, 2011

19. Strengthening nursing and midwifery delegation within your organisation
The guideline outlines a framework to support to enhance nursing/midwifery delegation and supervision.
Framework based on recommendations on skill and knowledge development, alongside the development of tools and activities to support safe and effective practices.
All parties play a role. As a nursing/midwifery leader, you play a vital role in the area of regulation within your organisation, by setting direction and enabling best practice to occur.

20. Framework
Decision making consistent with stated delegator/delegatee requirements
Required skills and knowledge
Recommended tools and activities
Element 1:
Regulatory
Checklist tool
Flow chart/summary card
Policy and procedure
Capability framework
Roles and responsibilities
Element 2: Organisational
Position descriptions
Role clarity statements and activities
Competency and credentialling processes
Organisational and unit-level direction and leadership
Leadership and management
Communication and team interaction
Element 3:
Individual
Interpersonal skill development training package and activities
Supporting activities
Frequently asked questions resource
Comprehensive learning packages (covering all three key elements)
Partnering with education providers – pre-registration preparation
Partnering with nursing and midwifery leaders

21. Check-list of possible actions
Leadership:
Consider obtaining a baseline, by asking staff about their current delegation and supervision skills
Ensure your nursing leaders are aware of and understand the key regulatory, organisational and individual factors that influence safe and effective delegation and supervision.
Consider including a specific focus on critical thinking, effective communication and team engagement into ongoing leadership developmental and educational programs.
Ensure that your managers are aware of rostering requirements relating to maintaining an appropriate skill-mix, to enable safe and effective delegation and supervision to occur.

22. Check-list of possible actions
Governance:
Ensure you have a clear and consistent organisational policy relating to safe and effective delegation and supervision of nursing/midwifery tasks and activities, that aligns with NMBA requirements and Victorian legislation.
Ensure all other policies align and are consistent with the overarching nursing/midwifery delegation and supervision policy.
Ensure policies are inclusive of roles and responsibilities for delegators/supervisors and delegatees/supervisees.

23. Check-list of possible actions
Role Clarity:
Ensure that the position descriptions for nurses, midwives and assistive staff are clear and informative.
Consider the development and implementation of a capability framework to assist registered nurses/midwives to identify skills and competency.
Ensure that the role differentiation between registered nurses/midwives, enrolled nurses and assistive staff is clearly documented.
Ensure that registered nurses/midwives have access to and knowledge of the approved duty list and competency levels achieved by any unlicensed assistive worker.

24. Check-list of possible actions
Education:
Ensure delegation and supervision is a core component of the ongoing education program for your nurses and midwives
Ensure that your nurses, midwives and assistant staff have access to a range of educational learning tools addressing effective and safe delegation and supervision.
Consider working closely with your education providers and university partners to enhance the opportunities to prepare pre-registration students for the role as delegators and supervisors.

25. Check-list of possible actions
Awareness:
Consider utilising tools and promotional material to raise awareness of delegation and supervision requirements within your nursing, midwifery and assistant workforce.
Consider the utilisation of a point-of-care tool to support effective delegation and supervision.

26. Questions and discussion
More information available:
Nursing in Victoria
Nursing & Midwifery Board of Australia Statements/Codes-Guidelines.aspx#dmf
Full reference list included in the guideline.