An essential regulatory role for RNs in long-term care is the ability to delegate tasks to licensed practical or vocational nurses, and certified nursing assistants.1 The Board of Nursing Examiners rules and regulations §225.4(6) defines delegation as the act of authorizing unlicensed assistive personnel (UAP) to provide nursing services while retaining accountability for how the unlicensed person performs the task.2
Delegation is a complex skill requiring both academic and clinical instruction. The practice remains an underdeveloped skill among some nurses.3
The Five Rights
The National Council of State Boards of Nursing (NCSBN) has identified "Five Rights of Delegation."4 Briefly, these are:
1. Right Task: A task that is delegable for a specific patient.
2. Right Circumstances: Appropriate patient setting, available resources and other relevant factors considered.
3. Right Person: The right person is delegating the right task to the right person to be performed on the right person.
4. Right Direction/Communication: Clear, concise description of the task, including its objective, limits and expectations provided.
5. Right Supervision: Appropriate monitoring, evaluation, intervention as needed, and feedback.
Each of the Five Rights further identifies specific principles and responsibilities for the nursing service administrator and the staff nurse in developing a program for implementation.
Although one component of delegation is the performance of tasks, effective delegation depends on what is being delegated and the abilities of those who are responsible for delegation.
RNs are often uncertain about whom to delegate, what to delegate and under what circumstances delegation should occur. Williams and Cooksey describe several steps in the process of effective delegation, including:
assessment of patient needs and the UAP's knowledge and skill level;
identification of tasks that may be safely assigned;
prioritization of tasks and a timeframe for completion;
communication with the UAP with encouragement to ask any questions that may arise;
evaluation to review progress toward goals with appropriate feedback; and
revision of the plan as patient needs change.5
The NCSBN identifies several steps nurses should take in making delegation decisions.
Step 1: Assess the situation. Identify the needs of the patient, consult the plan of care, consider the circumstances and setting of care and assure the availability of adequate resources.
Step 2: Plan for specific tasks to be delegated. This includes specifying the nature of each task and the knowledge and skills required to perform it, requiring documentation or demonstration of delegate competence of each task required and determining possible implications for patients and significant others.
Step 3: Assure appropriate accountability. As the delegator, accept accountability for performance of the task and verify that the CNA accepts the delegation and accountability for carrying out the task correctly.
Step 4: Supervise the task. Provide the CNA with clear expectations of how the task or tasks are to be performed; monitor performance of the tasks ensuring compliance with current standards of practice, policies and procedures of the institution; intervene if necessary and ensure proper documentation of the task.
Step 5: Evaluation. During evaluation, the delegation process is re-examined, including patient outcome, status, the staff performance and obtaining and providing feedback to the CNA.
Step 6: Reassessment. During reassessment outcomes are re-evaluated and the overall plan of care may need to be readjusted based on findings.6
Although RNs are responsible for the planning, supervision and evaluation of the CNA's work, some are not comfortable with this responsibility. RNs are often younger and less experienced in a health care setting than the CNAs to whom they must delegate. Some nurses, embarrassed by their discomfort and inability to act in the role of supervisor or manager, choose instead to do the task themselves.7
RN duties that should not be delegated is anything involving ongoing or initial assessments. These require nursing diagnoses, professional judgment and interventions that require the application of professional skill and knowledge, e.g., the administration of medication, admission assessments and the development of care plans.
The workload of the team should also be considered and not be uneven through delegation of duties and tasks.
Growing Nursing Knowledge
The scope of nursing practice and nursing knowledge that has enriched the profession has led to changes in nursing roles and nursing practice.
Nurses now function in a wide variety of roles, including leadership, which will continue to proliferate in the next century.8 RNs need a range of skills to function effectively in today's healthcare environment.
Nurses now must work in collaboration with many different levels of staff, residents and families, physicians and third party stakeholders, and effectively integrate the needs of these groups in their care plan.
Nurses must be able to make decisions in a rapidly changing health care environment and understand the mission and future of the organization to motivate and empower others through a system of shared leadership, which integrate into the day-to-day operations to contribute to team objectives.9
Therefore, educational programs that build on basic RN professional education can help nurses improve and integrate leadership knowledge and skill into their practice base so that they can confidently delegate to CNAs in a safe manner.
Useful educational strategies can include patient case study simulations and role-playing to run-through delegation skills in the classroom. Expert preceptors who are skilled in delegation can be partnered with inexperienced staff to guide them in learning to delegate confidently and supervise CNAs safely and effectively.10
It is imperative nursing home administrators and educators include appropriate content on supervision and delegation in orientation programs, as these skills are requisite in nursing practice settings, particularly in long-term care. It is equally imperative that nursing service administrators provide nurses with the continuing education necessary to develop delegation and supervision strategies if they have not had this content in their basic academic programs.11
References for this article can be accessed here.
Scott J. Saccomano is assistant professor in the department of nursing at Herbert H. Lehman College, Bronx, N.Y.