Vol. 8 Issue 16
The Learning Scope
Examining the principles of this tool as both an art and a science
This offering expires in 2 years: July 17, 2008
The goal of this continuing education offering is to assist healthcare professionals in working with and delegating to the nonlicensed assistive personnel or ancillary worker. After reading this article, you will be able to:
1. Define the "five rights" of delegation.
2. Discuss factors to consider in deciding to delegate.
3. Discuss barriers to delegation.
You can earn 1 contact hour of continuing education credit in three ways: 1) For im-mediate results and certificate, go to www.advanceweb.com/nurses. Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. Make checks payable to Merion Publications Learning Scope (any checks returned for non-sufficient funds will be assessed a $25 service fee). 3) Fax the answer sheet (available with credit card payment only) to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 011-3-H-04), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. also is approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).
In performing an educational needs assessment of nurses, one of the most frequently requested topics is delegation. After attending a class, nurses will say they feel more knowledgeable about the principles of delegation, but in their work environment, they are hesitant to apply them.
Early in your career, it is human nature to manage a situation the way you were taught in school. Therefore, for nurses educated in the primary nursing model, the idea of utilizing others to accomplish healthcare-related tasks runs against a basic principle taught in school. However, to survive in a clinical setting that uses a different or blended delivery model, it is imperative to utilize assistive personnel appropriately. One possibility in achieving this outcome is to view delegation as both an art and a science.
Delegation is defined as "the act of empowering to act for another."1 The National Council of State Boards of Nursing (NCSBN) defines it as "transferring to a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains accountability for the delegation."2
Delegation is the process of entrusting others to perform job functions given the responsibility, authority and accountability. There is a causal relationship to the three factors that are difficult to separate. If I give you the responsibility by virtue of your job description and authority to delegate, then you will be held accountable for the care a patient receives both by yourself and the person you delegate to. This quality is what requires the artful handling of the process, rather than distinct linear steps.
When Is Delegation Appropriate?
There are four parts to answering this question.
1. The task must be allowed to be performed by individuals within their professional scope of practice.
2. The task must be allowed by their employer by virtue of their job description.
3. Staff members must have been properly trained to perform the task.
4. Staff members must demonstrate competency to be allowed to perform it independently.
First, it must be legal for a nurse to delegate to a nonlicensed person or other professional in that particular setting. State nurse practice acts and administrative regulations provide guidelines for nursing delegation. A review of all 50 states is provided in a chart within the NCSBN's 2005 report "Working With Others: A Position Paper."2 It is important nurses understand the guidelines for their particular state, which also should be taught in primary nursing programs and orientation programs for a particular setting. For example, in Oregon, "delegation cannot occur in acute care facilities or long-term care (LTC) facilities where there is a regularly scheduled registered nurse (by rule or statute)."3
Second, the tasks to be delegated must be within the delegator's and delegatee's job description. Therefore, in orientation, it is important RNs be given not only their job description, but also those of members of the healthcare organization to whom they might delegate.
Traditionally, delegatees were unit secretaries and nursing assistants. However, with the utilization of other categories of personnel, including volunteers, nurses now must be familiar with the job descriptions of these personnel, as well as their own, to ensure delegation is appropriate.
Additionally, when job descriptions change or new job descriptions are added, RNs must be educated on those changes for proper delegation to occur. In revising job descriptions for nonlicensed assistive personnel, it is critical to check with the appropriate state Board of Nursing to ensure additional items are within the board's definition of health-related or non-nursing functions. A sample listing can be found within the New York State Nurses Association position statement, "Registered Professional Nursing's Utilization of Unlicensed Assistive Personnel."4
Third, the employee to whom the RN delegates must be properly trained to perform the task. For example, if transporting patients is not within the unit secretary's job description and she was not trained, it would be inappropriate for the RN to ask her to take a patient to radiology. If that scenario did occur, and the patient or unit secretary was injured, the RN would be accountable for delegating inappropriately. Many states also have defined what should be contained within a training/education program for nursing assistants.
Fourth, it is not sufficient for the employee just to be trained to perform a task. They must be able to demonstrate ongoing competence in performing it independently, usually on an annual basis by the employer.
See Table 1 for questions to consider when considering delegating a task.
Process of Delegation
After ensuring delegation is appropriate, the process may begin with assuring the "five rights" of delegation: right task, right circumstances, right person, right direction/communication, right supervision/evaluation. In determining if it's the right task, the nurse needs to decide if it's delegable for a particular patient.
The right circumstances include if the task is delegable in a particular patient setting with the resources available. For example, it may be appropriate for a home health aide to give a patient a tube feeding at home, but it may not be appropriate for a nurse's aide to give the same patient a tube feeding once they are transferred to a LTC facility, where nurses are available to perform the function.
The right person is selected both in terms of the delegator and the delegatee based on patient care assignment and competency. For the right communication/direction to occur, there must be a clear, concise message with the objective clearly outlined, time limits given and performance expectations explained.
An example is the following direction from RN to CNA: "Dr. Smith just drew an INR on Mrs. Jones because he feels she may be getting too much Coumadin based on her bruising. I told him you were the first to notice it as you were bathing her today. Would you please take the specimen to the lab now, so they can run it stat? Is there anything you need me to cover while you are gone? Thanks, I really appreciate it."
In addition to the essential elements of delegation, the example provides the artful communication by acknowledging the observation of the CNA and expressing gratitude for the cooperation.
Points to Consider
The American Association of Critical-Care Nurses outlines five issues affecting the decision to delegate, which include the task and patient assessment in terms of potential for harm, complexity of task, problem-solving and innovation required, unpredictability of outcome and level of patient interaction.5 When the potential for harm is high or unknown, and the task is complex and might require immediate problem-solving based on the patient's response and/or the outcome is not predictable, then the task should not be delegated.
The level of patient interaction is important to consider, since adding more caregivers can increase a patient's and/or family's stress levels, especially during critical periods. When it is essential to delegate, the stressful effect can be reduced somewhat if the RN who has a relationship with the patient/family introduces the additional caregivers and the functions they will be providing. Part of the art of delegation is not just to the delegatee, but also to the recipients of the delegated tasks.
RNs are accountable for the nursing care a patient receives; therefore, it is essential there be follow-up to all delegation. The questions that must be addressed include: Was the delegated task completed? Did it occur within the appropriate time frame? Was the performance satisfactory or improved and, if so, was it acknowledged by the delegator? If a problem occurred, was it addressed and resolved?
Because the decision to delegate can be a multifactorial process, several states have outlined the steps in the form of an algorithm or decision-tree format. Since each state has a specific nurse practice act and administrative regulations, it is best to check with each state's board of nursing or access its Web site for specific guidelines. The NCSBN also has a universal "Decision Tree-Delegation to Nursing Assistive Personnel" contained within its 2005 position paper.2
Barriers to Overcome
When addressing barriers to delegation, perhaps the best explanations come from nurses themselves.
Concern for supervising support personnel: "How can I delegate to others, when I can't seem to organize myself? Am I liable for what they do?"
Lack of communication among care providers: "The ancillary staff has been here a long time and refuses to do what I ask them or don't say anything and then just don't do it."
RN can perform in less time than teaching others: "It's just easier to do it myself."
Lack of trust: "I tried to delegate, but the nursing assistant called the union representative and I found myself in the middle of this meeting with my supervisor for asking the CNA to do her job."
Concern for level of competence: "Will I be sued for something that someone else did?"
Successful delegation can be accomplished by making a commitment to improving one's skills. The first step is to be aware of your own barriers (see Table 2).
Improving communication is an ongoing process that begins by respecting others in the communication cycle. When nurses complain about CNAs, it is usually reciprocal that CNAs complain about the RNs. Their comments can include the following: "They only talk to us when they want something." "They'll order out for food and never ask us if we want anything." "They all talk about their vacations but never ask any of us if we had a nice time or if we were out sick if we are feeling better."
It is difficult for the delegation process to work when a positive working relationship doesn't exist. It is important to note the learning deficit in these instances is not delegation, but rather, team building. Often, it's more important to educate all members of the staff about how to work together as a team, and effective delegation flows from those improved skills.
For nurses who believe it's easier to handle tasks themselves, there can be many motivators for this thinking. There might be a perfectionist aspect, an unwillingness to share information since it can be powerful in any group situation, or simply a dislike for teaching or supervising.
But an old Chinese proverb states: "If you give a man a fish, he eats for a day. If you teach him how to fish, he eats for a lifetime." This is helpful to remember in dealing with the barrier of feeling it is better to do it on your own than to teach others.
Trust & Experience
For delegation to be successful, nurses must be receptive to working with and through others. They must trust those they work with, for delegation implies a trustful attitude between staff members. There must be a willingness to let go and not do everything. This also can include releasing the right to make certain decisions that can result in allowing others to make mistakes, so long as they do not affect patient safety.
Delegation cannot be avoided for fear of doing it incorrectly. Mistakes can serve as a valuable education if one is asked, "What have you learned from this and how would you do it differently the next time?" If individuals defend their mistakes without insight as to the lesson learned, they are minimizing the learning opportunity and will probably do the same thing again. Mistakes in delegation should be viewed as an investment in personal development, since it is a skill that develops with practice and experience.
"As necessary and as effective as true delegation seems to be, it does not occur automatically," noted Max Depree, author of Leadership Jazz. "It is one of the most precious gifts leaders must choose to give. It may remain a gift that goes ungiven. It's up to you."6
1. Merriam-Webster. (2005-2006). Delegation. Retrieved July 1, 2006 from the World Wide Web: http://www.m-w.com/dictionary
2. National Council of State Boards of Nursing. (2005). Working with others: A position paper. Retrieved March 13, 2006 from the World Wide Web: http://www.ncsbn.org/pdfs/Working_with_Others.pdf
3. Oregon State Board of Nursing. (2004). Division 47: Delegation and teaching. Retrieved March 7, 2006 from the World Wide Web: http://www.osbn.state.or.us/OSBN/delegation_process.shtml
4. New York State Nurses Association. (2004). Registered professional nursing's utilization of unlicensed assistive personnel. Retrieved March 13, 2006 from the World Wide Web: http://www.nysna.org/programs/nai/practice/positions/position1_04.htm
5. Snyder, D.A., et al (2004). American Association of Critical-Care Nurses delegation handbook (2nd ed.). Retrieved March 13, 2006 from the World Wide Web: http://www.aacn.org/AACN/practice.nsf/Files/DBEd2/$file/1editedrevisedAACNDelegationHandbook%207-1-2004.pdf
6. Depree, M. (1992). Leadership jazz (p. 166). New York: Dell Publishing.
Sally Ann Corbo is president of Epicare Associates Inc., West Caldwell, NJ.
Table 1: Questions to Consider Prior to Delegation
What work should you delegate?
What authority and limits are you delegating?
Have you ensured the delegatee is adequately educated to perform the task at hand?
Are you able to delegate the task according to your state's nurse practice act?
Is the delegatee looking at the task with a fresh eye?
Are too many steps involved in the process of the delegated task?
Is the delegatee able to complete the task in a timely and competent manner?
What support and feedback will your delegatee need/require?
How clear is the delegatee on the scope of authority and decision-making?
Is an ongoing assessment system in place to identify any issues/problems with the delegated task?
What improvement in care will result by delegation of this task?
What cost savings can be realized by delegation of this task?
Is a continuous quality improvement process in place so delegation continues to improve?
Table 2: Barriers to Delegation
An "only I can do it right" frame of mind
Being inexperienced as a delegator
Losing control of tasks
Staff not being competent to perform task
Reluctance to delegate a task that might make you look good in front of your superior
Not having the right equipment for a delegated task
Dealing with fear
Being too busy