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.