DELEGATION OF CLIENT CARE

Objectives Define the term delegation Define the term unlicensed assistive personnel Understand the legal implications of making assignments to other healthcare personnel Recognize barriers to successful delegation Make appropriate assignments to team members

DELEGATION

Definition of Delegation According to the American Nurses’ Association (ANA) The reassigning of responsibility for the performance of a job from one person to another. (ANA: Registered Professional Nurses and Unlicensed Assistive Personnel, ed 2. ANA, Washington, DC, 1996.)

Concepts of Delegation Is not a new concept – Moses was instructed to identify 70 elders so they would share the burden of the nation and the people would no longer have to carry the burden by themselves. – Florence Nightingale discussed delegation in her Notes on Nursing in 1859. Delegation is a process that transfers to a competent individual the authority to perform a selected nursing task in a specific situation

CONCEPTS OF DELEGATION The responsibility for the task is transferred. Accountability remains with the person who is delegating tasks. Delegation may be either direct or indirect.

DIRECT DELEGATION Usually verbal direction The registered nurse (RN) decides which staff member is capable of performing a specific task

INDIRECT DELEGATION Contained in a listing of tasks that has been approved and established by an institution Tasks permitted may vary with different institutions

ASSIGNING TASKS The RN may assign a more skilled individual to perform specific tasks. The RN may not assign an individual to perform a task that is outside that individual’s job description or scope of practice.

DELEGATION VERSUS SUPERVISION

SUPERVISION Usually more direct than delegation Requires directly overseeing the work or performance of others Includes checking in with individuals throughout the day May entail the delegation of tasks and activities (i.e., the nurse manager performs both delegation and supervision)

NURSING PROCESS AND DELEGATION

Compare Delegation Process to the Nursing Process Assessment Delegation – Planning – Implementation Monitoring Evaluation

ASSESSMENT Is the foundation of the delegation process, just like the nursing process or any scientific process Assess patient needs. Without accurate and thorough assessment, there can be no delegation Set patient goals. Match staff members who have appropriate skills to care for that patient.

PLANNING Planning prevents future problems. Mentally identify the person who is best suited for the task or activity.

IMPLEMENTATION Assign staff members who have the appropriate level of expertise that is necessary to deliver the patient care and perform the activities.

FIVE RIGHTS Right task Right concern Right person Right direction/communication Right supervision

AS AN RN YOU SHOULD ALWAYS ASK- “Can this task be delegated safely?” “Is there anything about the client’s condition or the environment which would preclude this assistant from performing the task as delegated?” – Every client is different and the same activity may differ in each situation “Is the task within the scope of practice of the individual I am asking to perform it?”

“Have I communicated clearly and directly what is expected in the performance, reporting and documentation of this task?” “Will I be available and accessible to this individual while he/she completes the delegated task?” “Do I have the requisite skills to assist the individual in completing the task as delegated?”

ASSESSMENT RED FLAGS Unidentified client needs Complex nursing activity Unidentified client needs Requisite knowledge and skills missing Insufficient opportunity to train Insufficient opportunity to monitor/supervise

DELEGATION PROCESS Communication of task to be elegated Mutual agreement Transfer of Authority

• Communication of the specific task – Generally do not use the term assignment when dealing with unlicensed assistants. – Assignment is defined as designating nursing activities to be performed by an individual consistent with his/her licensed scope of practice. Since assistants do not have a legal scope of practice, they cannot accept assignments but they can accept delegated tasks.

The outcome of assignment and delegation is the same (the nursing activity is completed), the decision making process is similar, but the authority to perform the activity must be transferred to the assistant, while the licensed nurse already has legal authority.

Mutual agreement – by both the person delegating and the assistant that the task is to be delegated and that there is acceptance of the task to be performed by the assistant.

Transfer of the authority to perform the task from the delegator to the assistant – The nurse must still retain the accountability for its completion and for the outcomes of the task. – The source of authority is always legal (nursing license) and may be managerial (position description), • Managerial authority cannot supersede legal authority.

– A common use of the term assignment is to designate the overall workload, including delegation and assignment. – Do not confuse the general use of the term to list the workload for which all staff members are responsible with the legal use of the term that designates nursing activities.

DELEGATION WHO will do WHAT by WHEN and HOW, WHERE, and WHY it will be done No delegation can be complete without the above

DIRECTIONS Priority of activity Expected timeliness Guidelines for consulting mid activity Reportable conditions Guidelines for reporting task completion Role as delegator and supervisor

• Use of written and visual resources may be used to reinforce direction • The communication style of the nurse and that of the assistant directly affects the working relationship. • Repeat the directions • Look at the priority of activities • Provide a checkpoint throughout the process

IN COORDINATING ASSIGNMENTS, REMEMBER • Plan your time around these activities • Do high-priority activities first • Determine which activities are best done in a cluster • Remember that you are still responsible for activities delegated to others • Consider your peak energy time when scheduling optional activities

DELEGATION RED FLAGS • Refusal to accept delegation • Incomplete directions • Failure to confirm expectations • Failure to communicate Your delegation may be inappropriate

CHANGE IN HEALTH CARE ENVIRONMENT In the 1990s the nursing shortage, health care reform, an increased need for nursing services, and demographic trends brought about changes The ANA defines an unlicensed assistive personnel. Remember, certification differs from licensure

DELEGATION PROCESS-MONITORING This one frequently causes the most problems It is easy for someone to forget to check in

SUPERVISION Provision of guidance or direction, evaluation and follow up by the licensed nurse for a process and the outcomes of a delegated task. – Supervision includes monitoring the performance, intervening if necessary, and ensuring that proper documentation of the task is completed.

DEGREE OF SUPERVISION REQUIRED DEPENDS ON – Client needs – Stability of the client – Competency of the assistant – Nature of the task – Available supervision

MONITORING RED FLAGS Change in other client’s condition with impact on workload Failure of assistant to report unexpected events or client outcomes Work completed incorrectly Work not completed Inadequate direction from delegator Inadequate or lack of monitoring from delegator

The occurrences indicate that the delegation may be inappropriate and that the delegation decision should be revisited to insure that the 5 Rights still apply

EVALUATION THIS IS YOUR FOLLOW-UP Oversee the care and activities provided by the employees. Determine if patient care needs have been met. Allow for feedback. Evaluation of the delegator / assistant should be done Evaluation is often the missing link in the delegation process

DESIRED OUTCOMES Protection of client safety Achievement of desired client outcomes Reduction of health care costs Access to appropriate levels of health care Decreased nursing liability

INAPPROPRIATE DELEGATION MAY RESULT FROM: – Inadequate resources – Conflict of employee policies and law – Inappropriate employer direction – Lack of knowledge about delegation – Failure to accept accountability for nursing care provided

CORRECTIVE ACTION • Educate and train • Restate expectations • Return skill demonstration • Identify specific checkpoints • Increase frequency of check ins • Evaluate directions

EVALUATION RED FLAGS Failure to evaluate delegation effectiveness Failure to evaluate the delegator/assistant relationship Failure to learn from work experience

COORDINATING ASSIGNMENTS

METHODS TO HELP ORGANIZE CARE • Critical pathways • Computerized information sheets • Personalized worksheets • Delegation tree

TIPS FOR ORGANIZING CARE • Plan time around activities that must be done at a certain time. • Perform high-priority activities first. • Cluster activities that may be performed together. • Consider your peak time when performing optional activities.

THE NEED FOR DELEGATION

CHANGES IN THE HEALTH-CARE ENVIRONMENT • A nursing shortage • Health-care reform • An increased need for nursing services • Demographic trends • Use of unlicensed assistive personnel

UNLICENSED ASSISTIVE PERSONNEL (NA) • Trained to assist the nurse • Perform tasks delegated by the nurse • Under the RN’s direct supervision • May or may not be certified

Delegation of Unlicensed Assistive Personnel

TASKS Unlicensed assistive personnel perform numerous tasks such as: • Taking vital signs • Demonstrating skills learned through special training (e.g., drawing blood or administering an electrocardiogram [ECG]) • Measuring intake and output • Performing nonnursing duties

SAFE DELEGATION

CRITERIA FOR SAFE DELEGATION • Potential for harm • Complexity of the task • Problem solving and innovation are necessary to complete the task or activity • Ability of the individual • Fairness of the task

TASK-RELATED CONCERNS

ACCOUNTABILITY • Being answerable for the actions or omissions of self or others in the context of delegation. • Accountable to – Self – Clients – Employer – Licensing Board – Profession

NURSE’S ACCOUNTABILITY • For Decision to delegate – Ultimate accountability for the management and provision of nursing care • Delegated task • Client outcomes

ASSISTIVE PERSONNEL ACCOUNTABILITY FOR – Decision to accept delegation – Performance

ASSISTIVE PERSONNEL ACCOUNTABILITY TO • Self • Delegating Nurse • Employer

PRIMARY CONCERN Does the individual assigned to the task have the ability to perform it?

OTHER TASK-RELATED CONCERNS • Employee’s abilities • Priority of various tasks • Employee’s level of efficiency • Appropriateness of the assigned task

RELATIONSHIP-ORIENTED CONCERNS The RN should consider the following when assigning tasks to employees: • Fairness • Learning opportunities • Health • Compatibility • Preferences

• Is the workload evenly distributed – One might have less physical work to do, yet have the work may require more emotional care – Discuss with your team decisions you have made that may be considered unfair – If possible, allow the team to participate in making decisions regarding assignments.

Assign so your staff will be stimulated and motivated to learn • Rotate your members through more difficult jobs • Work at helping your team to develop better working relationships • Explain your rationales and decisions

SUMMARY OF PROFESSIONAL EXPECTATIONS • Respect from others • A reasonable workload • Appropriate wages • Determining his or her own priorities • Ask for what he or she wants • Be accountable • Give and receive information in a professional manner

DELEGATION BARRIERS

BARRIERS • Level of experience • Licensure • Quality of care • Having to assign work to others

REMEMBER-THE FIVE RIGHTS OF DELEGATION • Right task • Right circumstances • Right person • Right direction and communication • Right supervision and evaluation

CONCLUSION

POINTS TO CONSIDER • Delegation is not new. • Delegation is essential for good working relationships. • Organizational skills are a prerequisite for delegation. • An understanding of patient needs is essential for appropriate delegation.

THE RN MUST UNDERSTAND: • The state’s Nurse Practice Act • The capabilities of each staff member • The tasks that may be delegated • His or her accountability when delegating tasks

REMEMBER TO: • Communicate continuously • Value all team member contributions • Develop trust between co-workers • Learn from experience