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Andrea Raines and Karen Hardin
“I attribute my success to this: I never gave nor took any excuse.”- Florence Nightingale
The Role of The Nurse Leader Part 2
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Introduction
Delegation in Nursing
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Define terminology important to the art of delegation
a. Delegation
According to a joint statement by the American Nurses Association (ANA) and the National Council for State Boards of Nursing (NCSBN) (2019), delegation is allowing the delegatee to complete or perform a certain nursing activity, skill, or procedure, which is normally outside of the normal scope for the delegate and is not routinely practiced. Registered Nurses (RN) use delegation as a tool to ensure the completion of all tasks related to patient care. Ensuring each patient receives competent care through the use of the nursing assistant, allows the RN to prioritize and safely assign each task. Delegation allows the independently practicing nurse, to be accountable for the quality of care provided to the patient (Lanier & Morris, 2017) and is a skill of critical competency, essential for nursing. This chapter will discuss the role of the Registered Nurse when delegating to Licensed Practical Nurses, Vocational Nurses, and Assistive Personnel.
b. Delegated Responsibility
Any nursing skill, activity, or procedure that is transferred from the RN to the delegatee becomes delegated responsibility (NCSBON & ANA, 2019). The employer holds specific responsibilities related to delegation such as the following: Identification of the nurse leader who is responsible for the oversight of responsibilities which are delegated for the facility. This nurse leader will work with a committee to determine the responsibilities which may be delegated, as well as the circumstances for delegation within each facility. Policies and procedures should be developed followed by clear communication to all licensed nurses regarding which responsibilities can be delegated. The employer/nurse leader is then responsible for ensuring that all delegates demonstrate knowledge and competency regarding delegated responsibilities. (NCSBON & ANA, 2019). The licensed nurse is responsible for determining when and what should be delegated in the practice setting. Clear communication with the delegatee regarding the delegated responsibility should follow. The licensed nurse must be available to answer questions and offer guidance as needed while understanding the possibility of performing the task him/herself might be necessary depending on the circumstances. Follow-up between the delegator and delegatee is required after task completion. Any feedback regarding competence or issues should be reported to the nurse leader especially related to judgment and decision making (NCSBN & ANA, 2019). The Delegatee should only accept the responsibilities for which appropriate training has been received. The delegatee must feel comfortable performing the delegated responsibility given the healthcare setting and or patient condition. Competency must be maintained regarding employer-approved delegated responsibilities and clear communication between the delegatee and licensed nurse should be maintained. Once accepted by the delegatee, the delegated responsibility becomes accountable to the delegatee once accepted.
c. Supervision
Supervision of the delegatee includes monitoring the delegated activity, following up after the activity, and evaluating the outcomes. The licensed nurse should be ready to intervene and provide any follow-up education as deemed necessary. Accuracy of documentation is the responsibility of the licensed nurse.
Three A’s
- Authority- The state Practice Act, the National Council of State Boards of Nursing (NCSBN), and the Organizational policies and procedures of the institution all grant the registered nurse the authority and responsibility to supervise delegated tasks.
- Assignment- Distribution of work involving care, activities, and procedures within the scope of practice for the delegatee
- Accountability- to be answerable for choices, decisions, and actions that are measured against a standard
Who is the…
- Delegator- one who delegates a nursing responsibility. A delegator may be APRN, RN, LPN (NCSBN & ANA, 2019).
- Delegatee- one who is delegated a nursing responsibility by either an APRN, RN, or LPN, is competent to perform it, and verbally accepts the responsibility (NCSBN & ANA, 2019).
The principles for delegation
- The process of delegation can be challenging for new graduate nurses. A thorough review of the laws and rules related to the delegation of tasks should be completed by the newer nurse. The laws and rules of delegation vary within each state. Many states consider delegation to be an independent function in the scope of practice for RNs (Lanier & Morris, 2017).
- Laws- all guidelines set by the state practice act and ANA/NCSBN are in place for the safety of the patient.
- RN responsibilities- determine patient needs and when to delegate; ensure availability to delegates, and evaluate outcomes of and maintain accountability for delegated responsibility (NCSBN & ANA, 2019).
- ANA standards- see the National Guidelines for Nursing Delegation.
- State Board of Nursing standards- laws established by the state which must be upheld.
The Five Rights of Delegation… Image from: Essentialsofcorrectionalnursing.com |
Five rights of delegation
The establishment of a clear delegation plan with executed delegated tasks promotes safe care (Wagner, 2018). Utilization of the five rights of delegation is the first step in the promotion of safe delegation practices.
1. Right task
Does the activity fall within the delegatee job description? Is it included in the established policies and procedures of the facility?
2. Right circumstance
Is the condition of the patient stable? If the patient condition changes during the performance of the delegated responsibility, the delegatee must immediately report/communicate the change to the licensed nurse for a reassessment of the patient.
3. Right person
Not only is the employer or leadership responsible for ensuring the delegates possess the appropriate skill set, but the licensed nurse must ensure the delegatee is capable of completing the delegated responsibility.
4. Right direction/communication
The assignment must be clear and concise. It should include the procedure, time, and completion of the task with two-way communication occurring to close the feedback loop.
5. Right supervision and evaluation
Supervision of the delegated activity should occur by the Registered Nurse.
Benefits of good delegation
- To nurse leaders- allowing more time to complete managerial responsibilities. Allows building trust and confidence in staff.
- To the organization/agency- a unit with smooth delegation allows for a more cohesive staff. This in turn allows the staff to meet the organizational goals of the hospital and increasing employee satisfaction
- To the manager- allowing more time to complete managerial responsibilities. Allows building trust and confidence in staff.
- To the delegator or delegate- improved patient safety.
Are You An Effective Delegator? By JrcasasImage from: https://medium.com/walmartglobaltech/are-you-an-effective-delegator-find-out-now-bb27e60f138 |
Ineffective delegation
- Organizational culture- decreases meeting the organizational goals
- Lack of resources can cause ineffective delegation to occur
- An insecure delegator is someone who lacks training in delegation or does not feel comfortable delegating or prefers to complete the tasks themselves.
- An unwilling delegatee- someone who is not willing to accept the task which is delegated to them.
- Under delegation- when the nurse takes on too much responsibility themselves and does not delegate tasks as appropriate.
- Over delegation- a problem that can cause dissension among staff by putting a burden on the unit.
Tasks that may be delegated
A clear explanation of tasks that must be delegated is listed in the documents listed below. The student should click on the link below to access the joint statement from the American Nurses Association statement and National Council Board of Nursing statement. The joint statement provides a clear review of the guidelines for task delegation. Each licensed nurse must have access to the established laws and guidelines within their practicing state. Access to the laws of the South Carolina Nurse Practice Act is provided below.
ANA and NCSBN have created a joint statement regarding delegation: Please review the statement by accessing this link: https://www.ncsbn.org/NGND-PosPaper_06.pdf
State BON statement: Each state BON provides a position statement regarding the legal rules and guidelines for nursing. The SCBON Nurse Practice Act offers the legal practice guidelines for nursing delegation to unlicensed assistive personnel. Please review Section 40-33-42: Delegation of tasks to unlicensed assistive personnel using the following link: https://www.scstatehouse.gov/code/t40c033.php
Supervision
The role of supervision is not to inspect the completed work by the LPN/UAP but to assist in the development of the individual completing the task (Hughes, 2018). Nurses should have a clear understanding of the differences between the responsibilities outlined in the LPN/UAP job description and delegated tasks. This knowledge helps to build rapport between the nurse and LPN/UAP. Having a good rapport with assistive personnel promotes safe care. Safe delegation practices equal safe care (Wagner, 2018). The RN is responsible for ensuring the delegatee has a clear understanding of the assigned task. If help is needed then the RN is responsible for providing instruction for task completion.
SMART objectives
Supervised delegation of a task is writing a Specific Measurable Achievable Realistic and Timely (SMART) objective. When delegating an activity, the registered nurse must make sure the assignment is clear. The task should be measurable, meaning the nurse should know whether or not the delegatee accomplishes the task within the specific time frame.
Understand the delegate job description
Institutional and state differences in the job description for unlicensed personnel should be reviewed and understood by the registered nurse. Again, the joint statement by the BON and ANA should be reviewed as well as the state nurse practice act and the facility policies (Burke, 2020).
Does the delegate need clarification, help, or review of the process to be delegated
It is the responsibility of the RN to ensure the Unlicensed Assistive Personnel has a clear understanding of the task. If this is a task that is new to the UAP, then the nurse is responsible for providing education to the UAP to ensure accuracy and patient safety.
https://www.flickr.com/photos/library-company-of-philadelphia/12237390594/World War I-era poster depicts woman in foreground wearing white nurse uniform. Woman raises right hand to her heart. Shadowy figures in background carry guns with bayonets. Poster urges viewers to “enroll at the nearest recruiting station of the Womans Committee of the Council of National Defense.” Published by New York: John H. Eggers Co., artist: Milton Bancroft, ca. 1917- ca. 1919.Accession Number: P-2284-188 |
Exercises
Instructions for Class Exercises: The following are exercises that may be completed by the student as practice in class or on their own.
Delegation Exercise: Delegating Assignments
Karen is a Registered Nurse (RN) in charge of a patient assignment. There are 10 clients on a medical-surgical unit in an acute care setting. Total staffing includes 2 RNs, 1 LPN, and 1 UAP on the unit.
10 patient beds:
3 patients are post-op:
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- Bilateral Mastectomy: tearful, no visitors, refuses to ambulate, refuses to look at the bandage
- Open Splenectomy: 3 days post-op, anxious for dc, employed as a stoneworker where he lifts heavy rocks daily and is anxious to return to work
- Abdominal Hysterectomy: 3 days post-op with subsequent dehiscence of wound 12 hours post-op., the wound is being packed with NS gauze 3 times daily.
1 patient with Pneumonia: resolving pneumonia being discharged back to the nursing home later this evening requiring turning, feeding, and bathing.
1 patient with asthma: having respiratory difficulty, receiving an Aminophylline drip
1 patient with hypertension and resolved stroke; discharge information and teaching complete. Ready to roll out when transportation arrives
1 newly admitted female with anemia and possible GI Bleed has not been assessed and will be receiving a transfusion of packed red blood cells ASAP.
1 type II diabetic who has met with the diabetic educator but requires reinforced education regarding insulin administration.
1 diabetic foot ulcer with last BG reading of 400mg/dl with food continually brought by the family from outside fast food. Dr. needs to be called for new insulin order.
- Which duties cannot be delegated, therefore the RN must complete? Provide rationale.
- Which clients or tasks should be delegated to the LPN? Provide rationale.
- Which tasks should be delegated to the UAP? Provide rationale.
- What is the RNs responsibility before the end of the shift about the delegated activities? Provide rationale.
NCLEX style practice questions
The measurement and documentation of vital signs occur in the acute care setting based on provider orders for the patient. 5 south is a renal unit that is currently fully staffed for the shift. Who does the charge delegate the task of taking and documenting vital signs?
- Registered Nurse
- Licensed Practice Nurse
- Certified Nursing Assistant
- Volunteer
Which one of these tasks can be safely delegated to a Licensed practical nurse (LPN)?
- Dressing change of a decubitus
- Assess the function of a newly created Ileostomy
- Teach ostomy care to a client and their family members
- Change the plan of care for a client after a sudden increase in blood pressure
You are acting as a preceptor for a newly graduated RN during her 2nd week of orientation. You would assign the new RN, under your supervision, to provide care to which patients?
- A 56 y/o with lung cancer who has just returned from recovery after a left lower lobectomy.
- A 63 y/o hip replacement 2 days post-op needing staples removed.
- A 38 y/o with moderate persistent asthma awaiting discharge.
- A 49 y/o just admitted with a new diagnosis of esophageal cancer.
Answers to NCLEX Questions with Rationale
- All 3 nursing personnel, RN, LPN, & UAP, are qualified to take vital signs. However, in a fully staffed situation, the charge nurse understands the UAP can assist the nurse by completing the task of Measurement and documentation of vital signs.
- In these questions, the task of assessment, teaching, and plan of care evaluation, are all roles and duties of the registered nurse.
- The patient with lung cancer is not a good match for a new graduate RN due to the increased need for monitoring and assessment post-op (acuity of the patient). The patient needing staples removed is a good match for a new graduate RN because it is a skill she has recently learned (less acuity of the patient). The patient with asthma is awaiting discharge, therefore they should be stable (less acuity of the patient). The new diagnosis of esophageal cancer would not be a good fit for the new graduate RN because of the increased need for education, swallow risk, mental health, and wellness, etc. (acuity of the patient).