Vol. 6 Issue 16
The Learning Scope
Critical-thinking strategies you can apply to the challenges of delegating
This offering expires in 2 years: July 19, 2006
The objective of this article is to provide nurses with information about delegation skills they can apply to their practice. After reading this article, you should be able to:
1. Differentiate the roles of state law, professional organizations and healthcare facility policy in regulating delegation.
2. Describe the process of delegation.
3. Identify critical-thinking strategies that assist in making delegation assignments and improving delegating skills.
4. Name the Five Rights of Delegation as described by the National Council of State Boards of Nursing.
You can earn 2 contact hours of continuing education credit in three ways: 1) For im.mediate results and certificate, go to www.advanceweb.com. Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $15 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 45 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 an approved provider in California (No. 13230) and Florida (No. 3298).
Many nurses would prefer to directly deliver all the care their patients need. Holistic care is one of the hallmarks of professional nursing. However, today's nursing shortage and cost-effective staffing models require RNs to accomplish safe and effective care by delegating some aspects of care to others. How can RNs gain confidence that they can preserve their standards of holistic, high-quality patient care when they delegate?
The secret to effective delegation is both as simple and as complex as the words the National Council of State Boards of Nursing (NCSBN) uses to define delegation: "Delegation is transferring to a competent individual the authority to perform selected tasks in a selected situation. The nurse retains the accountability for delegation."1
This article analyzes the NCSBN definition, translates it into action and suggests critical-thinking strategies you can apply to the challenges of delegating.
You may have seen the popular poster that displays the motivational message, "Your attitude determines your altitude." That message applies to critical thinking in a very special way. Early critical-thinking theorists (Watson & Glaser) identified the attitude of inquiry as one of the three components of critical thinking.2 The attitude of inquiry drives critical thinking. A continuously inquiring approach takes you to higher and higher levels of critical thinking.
When nurses ask questions such as "What's wrong with this picture?" and persist until they receive satisfactory answers, they improve the safety and quality of patient care. You may question a physician about a drug order, or you may question why the IV drip rate is so fast when you have the pump set to deliver 100 mL/hr. By pursuing answers to either of those questions, you might well save a life.
The attitude of inquiry also plays a central role in effective delegation. This article identifies some of the key questions that can increase your expertise as a delegator. It also employs the critical-thinking skill of analysis by analyzing the NCSBN definition of delegation in search of actions that will make delegating more effective and satisfying.
Many RNs find it difficult to transfer authority. Some RNs express their frustration with statements such as, "I'm not comfortable with him practicing on my license," or "I don't want to set myself up on a pedestal telling these more experienced nursing assistants what to do."
How can critical-thinking skills help RNs gain confidence and comfort when transferring authority? An essential ingredient of critical thinking is using a knowledge base (a second of the three components identified by Watson & Glaser).2 The attitude of inquiry drives critical thinking and guides you to the facts and principles (the knowledge base) that are relevant to the problem at hand.
Your state's nurse practice act defines your RN practice and the role of licensed practical nurses (LPNs), also known as licensed vocational nurses (LVNs) in some states. States vary in their definitions. For example, in some states, legislation governs the role of unlicensed assistive personnel (UAP), and educational programs lead to certification of nursing assistants, mostly for long-term care.
Obtain your state's nurse practice act from your state Board of Nursing or access it at the NCSBN's Web site, www.ncsbn.org.
"While nursing tasks may be delegated, the licensed nurse's generalist knowledge of patient care indicates that the practice-pervasive functions of assessment, evaluation and nursing judgment must not be delegated."1 Most states describe the RN role to include the RN's responsibility for:
• assessing patients initially and ongoing;
• administering treatments and medications ordered by a licensed prescriber;
• initiating and coordinating the plan of care;
• teaching and counseling patients;
• promoting and maintaining health;
• delegating and supervising assistive personnel; and
• teaching and supervising students.
Most states identify the LPN's role as assisting in the nursing process as delegated by and under the supervision of an RN. State nurse practice acts usually do not specify particular medications, treatments or procedures reserved for the RN. For both the RN and the LPN, most states define the scope of practice to include performance of nursing acts based upon the knowledge, judgment and skill acquired by completing a state-approved educational program. Therefore, licensed nurses are individually accountable for acts they perform within the scope of their education and their practice as defined by the state.
Clearly, the RN license designates the RN's responsibility for delegation and supervision of other staff members. The LPN's license designates the RN's responsibility to delegate and supervise LPN practice.
The laws can alleviate RNs' concerns about another caregiver "practicing on my license" and about "setting myself up on a pedestal." Individual caregivers are responsible for the care they are trained to give, or licensed to give in the case of LPNs or other RNs. Under the law, the RN is expected to delegate and supervise. The RN's accountability is for safe, appropriate delegation.
Although allegations of malpractice may be brought against an individual RN for inappropriate delegation, the doctrine of respondeat superior protects both the RN and any individual to whom the RN delegates within the scope of their employment.
"Under the doctrine of respondeat superior, an employer is liable for the conduct of an employee while he is acting within the scope and course of his employment."4 Though quoted from Illinois law, the doctrine is reflected similarly in the law in most states. The doctrine holds the employer responsible even when the only act of negligence or incompetence was on the part of a UAP to whom an RN delegated appropriately.
Although respondeat superior applies to only the employer, an RN, LPN, UAP and other employees are nevertheless responsible for their own actions. The RN may be sued individually for delegation that is inappropriate according to the state's nurse practice act and the policies of the facility.
Elements of Negligence
It is important to remember allegations of negligence or malpractice can be sustained only when all four of the following elements are established:3
• Duty. Establishing a nurse-patient relationship creates the duty to provide care consistent with standards of practice.
• Breach of duty. Duty is breached when the standard of care is not met. This is established when a patient's record fails to document that care was delivered according to standards and an expert witness testifies the nurse failed to act as a reasonable, prudent RN with comparable training and experience would have acted in the same or similar circumstances.
• Causation. There was a relationship between the breach of duty and the injury, known as proximate cause.
• Damages. The patient has suffered quantifiable damages as a result of the injury the breach of duty caused.
If an RN delegates inappropriately, the RN may face disciplinary proceedings conducted by the state Board of Nursing against her nursing license. The RN might also face disciplinary action from the employer, as might a UAP or other who performs delegated tasks incompetently.
Standards of nursing practice established by the American Nurses Association and nursing specialty organizations identify the RN's accountability for the outcomes of nursing care. Consult the standards of your nursing specialty for more specific information.
To further refine the broad statements in nurse practice acts and professional standards, healthcare facilities establish policies, procedures, standards of care and standards of practice to provide facility-specific expectations.
Know your facility's policies, procedures and standards concerning delegation. Any legal or disciplinary proceeding holds the nurse accountable for functioning within the policies, procedures and standards of the facility. In addition, in most cases, only the healthcare facility regulates the training and practice of UAP.
Some facilities create more than one role for UAP or more than one level of UAP. Some UAP roles include performing selected sterile procedures or technical duties specific to the needs of a particular unit, such as attaching cardiac monitor leads. UAP roles may differ from one unit to another within the same facility. Some facilities create more than one level of LPN roles as well. Know the roles and titles of all staff members on any unit you work.
Foundations of Critical Thinking
Critical thinking begins with a knowledge base, as does effective delegation (see Table 1).5 The relevant knowledge base begins with the law, standards, policies and procedures that govern delegation. The knowledge base also includes the competencies of the individuals to whom you delegate.
Using a knowledge base means more than accumulating facts. Using a knowledge base means selecting the relevant facts and principles and differentiating among pieces of information.
When it comes to building your knowledge base about the roles of LPNs and UAP, it is more helpful to compare their roles and characteristics than to simply describe each role (see Table 2).5
What Do You Know?
Apply the attitude of inquiry to your knowledge base about LPNs and UAP: What do these differences mean to you as a delegator? Some examples are as follows.
Differing backgrounds among staff members imply you cannot assume they will understand your directions as you intended. Brief or nonspecific communication to UAP is associated with more negative patient outcomes.7 Give sufficient detail to aid understanding. Observe the same safety practice you use to assure accuracy in verbal orders; ask the staff member to repeat back the directions you have given.
The knowledge base of LPNs and UAP places little emphasis on rationale for actions. Their training programs do not develop skills in decision-making and clinical judgment. As an RN, you must translate direction into understandable terms and be judicious in explaining rationale. Rationale may not be helpful without the requisite knowledge base. Explanations of rationale may detract attention from action priorities, as well as consume precious time to no avail.
• To obtain the assessment data you need, differentiate expectations for reporting for each specific patient.
• Provide cues and clues based on patient condition and status.
• If reasonable, provide reporting checklists for frequently encountered patient conditions.
Duties of LPNs, UAP and various levels of each may differ among healthcare facilities and among units within a healthcare facility. Verify the expectations, especially when you are new to the setting and when you float or transfer to a unit new to you.
UAP come to their roles from very divergent types of work and life experience. Take the time to find out the previous experience of UAP and clarify potential scope issues. Emergency medical technicians, nursing students and others unwittingly may overstep the UAP boundaries.
Healthcare facilities train UAP in the skill sets needed for their roles. They usually readily recognize their skill limitations and do not attempt to adjust IV rates, give medications or perform complicated procedures. However, the lines may not be so clearly defined for interpersonal interactions. More mature UAP may be accustomed to giving advice in their families and communities. Clarify the patient teaching and counseling role as one reserved for the RN.
The finding that tenure of UAP on a particular unit is associated with fewer negative patient outcomes cautions you to allow UAP to grow in their competence and confidence, not expecting too much too soon.
Use the critical-thinking skill of validating information and assumptions to gain confidence in staff members' competency. Critical thinkers rely on the attitude of inquiry to establish the credibility of information and to determine whether assumptions are valid.
Whose word do you take for the expected competencies of staff members on your unit? Is there a policy? Is a competency checklist available for each employee? Do you take another RN's assessment of a staff member's competency as your only source of information?
Assumptions can be dangerous. Based on previous experience, you may assume your UAP will measure and record all daily weights and intake and output at 0600 because that's the way it was on your previous unit. Or, you may assume the LPN will give all medications to assigned patients because that was how it worked last night with another LPN. If you acted on either of these assumptions and they proved false, some unpleasant surprises could await you at the end of the shift. To prevent misunderstandings, ask the right questions about unit practices and an individual's competencies before you begin work.
Can you assume a UAP is proficient in a skill because someone has checked it on a competency list? It may be that the UAP performed that skill only in the training environment and has not had experience with it during 6 months on the unit. Skills atrophy through disuse. One of UAP's frequent complaints is RNs do not allow them to perform all the skills they learned in training. Before you delegate, validate the individual's competency. Not only ask, "Do you know how to do a blood glucose test using this equipment?" but ask more specifically, "How many times have you done a blood glucose test with this specific equipment?" Do not hesitate to ask more specific follow-up questions about technique if you have any reason to be uncertain of the staff member's capabilities.
One assumption can be accepted as true regarding delegation: If your staffing plan includes LPNs and/or UAP, administration expects you will make optimal use of the skill sets of these staff members. The workload will be such that you will need to rely on others to care safely for the patient load. Your delegation skills are crucial. There is no acceptable excuse for unsafe staffing. If you sincerely believe staffing conditions are unsafe, it is your duty to pursue the issue with the chain of command.
Breaking the connection between selected tasks and selected situations compromises safe delegation. Though a staff member is competent in a particular task, such as vital signs, it may not be safe to assign that staff member to take vital signs for an unstable patient.
The Delegation Decision-Making Grid8 identifies parameters for the RN to use when delegating:
• level of patient stability;
• level of UAP competence;
• level of RN competence (both in patient care and in the delegation process);
• potential for harm;
• .frequency (with which the UAP performs the specific nursing care activity);
• .level of decision-making (related to the specific activity, the patient and the patient's situation); and
• ability for self-care (amount of assistance needed by the patient).
Additional criteria further clarify the decision-making parameters:9
• predictability of the outcome;
• .degree of patient interaction required (calling family member versus patient teaching);
• .whether or not infection control measures are required; and
• .level of problem-solving (required by the UAP).
The most complex aspect of delegation is selecting tasks and situations for delegation. Bring all your clinical expertise to bear on assessing patients and their needs. Hone your skill in assessing the competency of your ancillary staff.
Apply your critical-thinking ability to consider multiple perspectives. Learn and respect the patient's perspective to the greatest extent possible. For example, some patients may be very uncomfortable with personal hygiene assistance from staff members of the opposite gender, regardless of the staff member's skill. When such situations arise, not only must you respect the patient's wishes, if possible, but you also may need to clarify any change in assignment with the UAP.
The perspectives of other RNs on the unit are important in at least three ways.
• Some staffing plans call for more than one RN to delegate to a single UAP. Assure that you and any other RN who delegate to the same staff member clarify and prioritize your expectations both with each other and with the UAP.
• When you delegate to another RN, assure good rapport by clarifying expectations about the authority by which you are delegating, for example, "I'm in charge tonight and so..." Remain willing to consider another RN's perspective, particularly a more experienced RN. But, if you indeed are in charge, accountability for delegation will rest with you; therefore, you must be confident in the rationale for your judgment.
• Seek peer advice and support in delegation. Your RN co-workers can suggest approaches and validate your approaches. In the event of a charge of malpractice or a disciplinary proceeding, your actions would be judged against expert witness testimony (or testimony about what another nurse with similar experience would have done in the situation). More experienced RNs have obtained more positive patient outcomes through delegation than RNs with less experience.7 Proactively seek the benefits of your colleagues' experience.
Apply the attitude of inquiry and ask questions to learn and clarify the other's perspective. Then, clarify your perspective and needs for the other individual. Together, create a workable plan. Anyone who affects your delegation or is affected by it has a perspective that is pertinent. Who else's perspectives have a bearing on delegation in your practice setting?
Accountability for Delegation
Your knowledge base for delegation is multifaceted. Yet, some RNs who have a sound knowledge base feel uncomfortable with delegation and fail to make optimal use of their resources. The knowledge base is not enough to produce effective delegation.
To delegate effectively, cultivate the third component of critical thinking: skill in application (Watson & Glaser).2 As when developing any other skill:
• use a systematic approach;
• accept coaching from others; and
Effective supervision requires different approaches depending upon the competence, confidence and willingness of the staff members you are supervising.10
• Take a directive approach with those who lack competence, confidence and willingness. Tell them exactly what to do in detail, follow up to assure the task is completed satisfactorily and give feedback accordingly.
• Take a coaching approach with those who lack competence but show confidence and willingness. Give encouragement about needs for improvement.
• Take a supportive approach with those who show competence but lack confidence and willingness. Give specific positive feedback about performance. Emphasize the person's positive contribution to patient care. Let the person know she has every right to feel confident. Ask what would help the person feel more confident and assist in creating a confidence-building atmosphere.
• Take a true delegating approach with those who show competence, confidence and willingness. Avoid interfering or micromanaging performance. Perform assessments and other RN-only duties with their patients and verify completion of their assigned tasks, but communicate your respect for their competence, confidence and willingness.10
Differences in competency, confidence and willingness are important, but other differences are important as well. Consider the differences of education, life experience and work experience to enhance your effectiveness when you direct and give feedback.
Plan systematic follow-up based on patient needs and staff competencies. Implement follow-up in walking rounds. More positive outcomes of delegation have been observed when RNs employ close, planned, intentional supervision. RNs have experienced increased confidence in their delegation when they used a system or grid (such as the NCSBN Delegation Decision-Making Grid).7
Tips for Better Delegation
When you experience problems in delegation, use the attitude of inquiry to direct you to the source of the problem. For example:
• Does the staff member lack necessary knowledge, skill or attitude?
• Has the staff member misunderstood priorities?
• Was the staff member confused about work assignments?
Investigate all possible sources of the problem. You can achieve an effective solution only when you solve the right problem. Each of the sample problems above requires different actions.
Use the critical-thinking skill of reflection to continuously improve your delegation. Reflect on:
• your observations of those to whom you delegate;
• the effectiveness of the directions you gave them;
• the effectiveness of the questions you asked them;
• the effectiveness of your follow-up; and
• the outcomes you achieved with your patients through other caregivers.
By reflecting, you will elaborate your knowledge base. You will identify what worked and what did not in specific patient-care situations. You will figure out what to do differently next time.
Critical thinkers use evidence to support actions. Research on nurse staffing has identified areas of patient risk related to high patient-to-nurse ratios. Though the research is specific to RN workload, these findings also may apply to safe delegation. Higher patient-to-nurse ratios have been associated with:
• .an increased risk of death following common surgical procedures;11
• less likelihood of saving the life of a patient who develops a serious complication12-14 (death among patients with serious complications is also referred to as failure-to-rescue);
• increased needlestick injuries;14
• increased family complaints;15,16
• increased falls with injuries;15,16
• increased medication errors;15,16 and
• .increased hospital-acquired infections.15,16
How can you better protect your patients from these risks when delegating aspects of care? Which patients, tasks and situations must you reserve as your assignment? What signs and symptoms can you insist that ancillary personnel report promptly to reduce failure-to-rescue? What precautions can you direct ancillary personnel to take to prevent patient falls? What can you delegate in order to increase your undivided attention to medication preparation and administration?
Other research has identified the positive effect of overall staffing levels, including RNs, LPNs and UAP. Increased numbers of caregivers related positively to reduced patient distress, fewer problems with symptom management, fewer falls and increased likelihood that patients manage self-care effectively. The researchers concluded that "good outcomes can be achieved with a combination of professional and non-professional staff."17
Favorable patient outcomes and staff satisfaction do not flow automatically from delegation. Effective delegation requires constant vigilance and refined critical thinking. When you reflect on your delegation practices, use the Five Rights of Delegation8 as your own checklist to evaluate and continuously improve your delegation skill:
• The Right Task
• The Right Circumstances
• The Right Person (Delegator and RN-extender)
• The Right Direction/Communication
• The Right Supervision
1. National Council of State Boards of Nursing. (1995). Delegation: Concept and decision-making process, National Council position paper, 1995. Chicago: Author.
2. Case, B. (1998). Competence development: Critical thinking, clinical judgment and technical ability. In K. Kelly-Thomas (Ed.), Clinical and nursing staff development: Current competence, future focus (pp. 244). Philadelphia: J.B. Lippincott.
3. Croke, E. (2003). Nurses, negligence and malpractice. American Journal of Nursing, 103(9), 54-64.
4. Illinois law and practice. (2003, June). Employment, Chapter 5 Liability for Injuries to Third Persons A. Acts of Omissions of Employee section 251.
5. Case, B. (2004). Critical thinking: Working effectively with LPNs and UAP. San Diego: rn.com.
6. Unruh, L. (2003). The effect of LPN reduction on RN patient load. The Journal of Nursing Administration, 33(4), 201-208.
7. Anthony, M., Standing, T., & Hertz, J. (2000). Factors influencing outcomes after delegation to unlicensed assistive personnel. The Journal of Nursing Administration, 30(10), 474-481.
8. National Council of State Boards of Nursing. (1997). Delegation decision-making grid. Chicago: Author.
9. Zimmerman, P.G. (1997). Delegating to unlicensed assistive personnel, Nursing 97, 5, 71.
10. Blanchard, K., & Waghorn, T. (1997). Mission impossible. New York: McGraw-Hill.
11. Aiken, L., et al. (2003). Educational levels of hospital nurses and surgical patient mortality. JAMA, 290, 1617-1623.
12. Aiken, L., et al. (2002a). Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. JAMA, 288, 1987-1993.
13. Needleman, J., et al. (2002). Nurse-staffing levels and the quality of care in hospitals. New England Journal of Medicine, 346, 1715-1722.
14. Clarke, S., & Aiken, L. (2003). Failure to rescue: Measuring nurses' contributions to hospital performance. American Journal of Nursing, 103, 42-47.
15. Aiken, L., Clarke, S., & Sloane, D. (2002b). Hospital staffing, organization and quality of care: Cross-national findings. International Journal of Quality in Health Care, 14, 5-13.
16. Cho, S., et al. (2003). The effects of nurse staffing on adverse events, morbidity, mortality and medical costs. Nursing Research, 52, 71-79.
17. Potter, P. et al. (2003). Identifying nurse staffing and patient outcome relationships: A guide for change in care delivery. Nursing Economics, 21(4),158-166.
Blegen, M., & Vaughn, T. (1998). A multisite study of nurse staffing and patient outcomes. Nursing Economics, 16(4), 96, 197-203.
Case, B. (2000). Preceptor workbook: Advanced practice nurse. Chicago: Loyola University of Chicago, the Marcella Neihoff School of Nursing.
Clarke, S., Sloane, D., & Aiken, L. (2002). The effects of hospital staffing and organizational climate on needlestick injuries to nurses. American Journal of Public Health, 92, 115-119.
Fisher, M. (1999). Do your nurses delegate effectively? Nursing Management, 5, 23-25.
Hansten, R., & Jackson, M. (2004). Clinical delegation skills (3rd ed.). Sudbury, MA: Jones & Bartlett Publishers.
Jackson, M., Ignatavicius, D., & Case, B. (2004). Conversations in clinical judgment and critical thinking. Pensacola, FL: Pohl Publishing.
Parsons, L. (1998). Delegation skills and nurse job satisfaction, Nursing Economics, 6(1), 18-26.
Bette Case is an independent consultant and partner with Clinical Care Solutions Inc., Chicago.
Protecting Against Charges of Negligence
From 1998 to 2001, the number of malpractice payments made by nurses increased from 253 to 413.3 One contributing factor identified was delegation. Specifically, "delegation of some tasks may be considered negligence according to a given facility's standards of care or a state's nurse practice act."3 Protect yourself from negligence by knowing and acting on your facility's standards of care and your state's nurse practice act.
JCAHO Criteria for Making Assignments
[From NC.2.1.2] Assigning responsibility to nursing staff members for providing nursing care to patients is based on the following elements:
1. Complexity of patient care: How involved is the required care?
2. Dynamics of the patient's status: How often does the patient's condition change?
3. Complexity of the assessment: What is required to completely assess the patient's condition?
4. Technology involved: Is the patient being monitored for complex or life-threatening problems? Is complex technology involved?
5. Degree of supervision: What level of supervision is required by the nursing personnel based on their skill and competence?
6. Availability of supervision: Is the appropriate nursing supervision available to provide the degree of supervision determined in No. 5?
7. Infection control and safety precautions: To what degree are Universal Precautions enforced. Are staff competent to carry out emergency, infection control and safety procedures?
Guidelines for Giving Feedback
• Focus on changeable things.
• Make descriptive statements. Describe what you observed, then compare what you saw with the standard for performance.
• Make specific statements. Give concrete details. Offer specific positive as well as corrective statements.
• Be specific about not only what was good, or unacceptable, but also exactly why it was (i.e., what the effect of the action was). For example, "That was good timing to ambulate your patient right after breakfast. It probably helped her to have a bowel movement."
• Give immediate feedback, which is much more effective than delayed. If you must wait to give feedback, be sure to specifically identify the incident to which you are referring.
• Choose appropriate times. Give feedback in private. If you must intervene in front of patients or others, say as little as necessary to make the situation safe. Harsh words can damage rapport not only between you and the staff member, but also can damage the trust patients must be able to place in this person.
• Choose one issue to work on at a time. Do not overwhelm the individual with information or counseling.
• When giving corrective feedback, identify exactly what needs to be improved. Refer to the performance standard and, if appropriate, the rationale. Demonstrate if indicated. Obtain a commitment to improve.
• Tell staff members you will give them prompt feedback when you see improvement.
• .Congratulate staff members on their efforts when they successfully improve their work. Recognize their efforts and recognize partial correction when you notice it, encouraging them to continue to improve.
Source: Case, B. (2000). Preceptor workbook: Advanced practice nurse. Used with permission of Loyola University of Chicago, the Marcella Neihoff School of Nursing.