DELEGATION DELEGATION Doing It Right

Our Objectives To delegate patient care task safely & appropriately To understand laws & regulations affecting nursing practice & delegation

Delegation  A management principle used to obtain desired results through the work of others  A legal concept used to empower one to act for another  A means of facilitating effective utilization of health care resources  A concept, an art, a skill  A skill that can be developed – A critical skill these days!

Changes in the Health Care Industry - Changes RN Role RN Role - less direct patient care / More care coordination

Why Delegate? An effective strategy to accomplish work To enhance our work To increase our impact on patient care To benefit patient care Cost containment To accomplish care in a timely manner

Who are they? What can they do? UAP: any unlicensed personnel, regardless of title, to whom nursing tasks are delegated Nurse extender, Nurse Aide, Nurse Assistant, Surgical Technician, Orderly, Patient Care Partner, Patient Care Associate Training - varies widely

Advantages of Using UAP Ability to meet some patient care needs more quickly Achievement of desirable patient outcomes Potential positive benefits for RN & UAP – effective distribution of workload – better use of RN time & education – increased job satisfaction Reduction of health care costs More effective use of resources & less staff turnover

Decreased nurse liability - how? The use of appropriate delegation promotes positive patient outcomes with efficient use of resources Lawsuits are less likely to occur when positive patient outcomes are achieved However – when done ineffectively or inappropriately, delegation can place patients, nurses & health care organizations at risk!

Outcomes of Effective Delegation Protection of public/patient safety  Achievement of desirable client outcomes  Achievement of potential benefits for the RN & the UAP  Reduction of health care costs  Facilitates access to appropriate level of health care  Decreased nurse liability - promotes positive client outcomes with efficient use of resources; lawsuits and discipline actions are less likely when positive client outcomes are achieved

Sources of Authority  Federal or State laws  State Statutes  Nursing Practice Act State Rules & Regulations - BRN  Employer Policies & Standards  Professional Nursing Standards  Other Standards - JCAHO, National Committee for Quality Assurance

Delegation Defined  Delegation of nursing care refers to a decision by a registered nurse to have one or more patient care tasks done by an LVN or UAP  Transferring to a competent individual the authority to perform a selected nursing task in a selected situation  Entrusting the performance of selected nursing tasks to competent persons in selected situations. The nurse retains the accountability for the total nursing care of the client and the delegation NCSBN 1990

You remain accountable & responsible however Supervision: provision of guidance by a qualified nurse for the accomplishment of a nursing task or activity with initial direction of the task or activity and periodic inspection of the actual act of accomplishing the task or activity. (NCSBN, 1990) Once you delegate you must supervise

Responsible - Accountable Responsibility - your actions - responsible for the process Accountability - results - accountable for outcomes

You are accountable for: 1.assessing the patient's needs 2.planning the desired outcome 3.making the decision to delegate  assessing the competency of the UAP  giving clear directions and obtaining acceptance from UAP  following up on the completion of the task  providing feedback to the delegate

Definitions….. Assignment: – Designating nursing activities to be performed by an individual consistent with his/her licensed scope of practice – Nurse retains accountability for the outcome Authority: – The source of power to act – The source of authority is always legal – In the act of delegation, the nurse transfers authority to the UAP to perform the delegated activity Evaluation: – The final & critical step in the nursing process – Involves reviewing the nursing care provided Supervision: – The provision of guidance or direction, evaluation, and follow up by the RN for accomplishment of the work & the achievement of patient outcomes

Common Concepts applicable to delegation among nursing practice acts  Only nursing tasks can be delegated - the practice of nursing cannot be delegated  The RN must assess the needs of each patient before delegating care tasks  The LVN does not practice professional nursing; they work under the direction & supervision of the RN  The RN delegates based on the knowledge & skill of the assistive staff member  The RN determines the competency of the person delegated to

Common Concepts applicable to delegation among nursing practice acts  The RN cannot delegate an activity requiring the knowledge or skill of a professional nurse  The RN is accountable and responsible for the delegated task  The RN must evaluate patient outcomes resulting from the delegated task  Healthcare facilities should develop specific delegation protocols that are consistent with state board delegation guidelines (Hall-Johnson, 1996)

Delegation Decision Making Process Assess situation - client needs, plan of care, supervision Plan for the activity - match client needs with UAP qualifications Assure appropriate accountability - nurse assumes responsibility for nursing care & verifies that UAP accepts delegation & responsibility for carrying it out correctly

Delegation Decision Making Process Supervise the performance of the activity - supervision includes communicating directions & expectations for completion of activity; monitoring performance of activity; ensuring proper documentation; assist & support the UAP Evaluate the entire delegation process - a continuous process that is basically FOLLOW UP; provides Feedback to UAP; was the expected outcome obtained?

The 5 Rights of Clinical Delegation 1.Right TASK 2.Right CIRCUMSTANCES 3.Right PERSON 4.Right DIRECTION & COMMUNICATION 5.Right SUPERVISION & EVALUATION

The Right TASK "Tasks which require a substantial amount of knowledge and technical skill may not be assigned to UAP. Examples of restricted tasks requiring a substantial amount of scientific knowledge or technical skill include, but are not limited to, pre-procedure assessment and post- procedure evaluation of the patient, handling of invasive lines, sterile technique or procedure on a patient, parenteral medication or lines, nursing process including patient assessment, monitoring or evaluating; triaging of patients; patient education". – (BRN Report, 1994)

Calif. Nursing Practice Act: Delegates tasks to subordinates based on the legal scopes of practice of the subordinates and on the preparation and capability needed in the tasks to be delegated, and effectively supervises nursing care being given by subordinates.

3 elements of nursing may not be delegated per ANA (1995) Initial assessment & subsequent ones requiring professional judgment Nursing diagnosis, care plan & care goals Interventions that require professional knowledge or skill (Ask yourself what degree of critical thinking is required)

What can I delegate to whom? Task must be within your RN scope of practice Task must fall within the role of the UAP (job description, policy) UAP must be competent to perform the task Task must be congruent with legal requirements (NPA) Must consider patient needs, circumstances, patient safety

Right Circumstances Consider the situation Match complexity of the activity with UAP competency and level of supervision available Provide appropriate monitoring and guidance Does the UAP have the time & skill? Do you have the time to supervise? Patient safety is the main concern

Right Person Select the right task for a competent person in each situation Decision based on: – patient status & acuity – goals for the patient – plan of care – outcomes desired RN is accountable for determining the situation in which delegation will be used & for selecting the right person to do the right task

Right Person Is the UAP qualified to perform the task? What is their training & experience? Potential Sources of Performance Weakness –Unclear expectations –Lack of feedback on performance –Education needs –Need for additional supervision & direction –Individual characteristics such as past experience, motivation, personal issues

Right Direction / Communication The 4 C's of initial direction: – Clear – Concise – Correct – Complete In other words, explain exactly what you mean by "significant change” MAJOR STEP IN THE DELEGATION PROCESS

Right Supervision /Evaluation Feedback SUPERVISION MAY BE DIRECT OR INDIRECT Feedback Formula: – ask the individual for their input first – give credit for effort & accomplishments – share your perceptions with each other – explore differing points of view; focus on shared outcomes – ask for the other person's input to determine steps to take to ensure desired outcomes & resolution – agree on a plan for the future including timeline for follow up – revisit the plan & results achieved

What Can & Cannot Be Delegated? Broadly speaking, RN can only delegate tasks within RN scope of practice & within UAP job description & training

Nursing Activities That Should Not Be Delegated Overall assessment Nursing diagnosis Planning Evaluation Triage Teaching Priority setting Telephone advice

Legal Aspects The State Board may discipline a RN who delegates patient care tasks in an incompetent or grossly negligent manner. The RN is not held liable for the negligence of subordinates but is liable for incompetence in delegating tasks.