Effective Delegation and Supervision

Barbara Cherry, DNSc, MBA, RN, NEA-BC Margaret Elizabeth Strong, MSN, RN, NE-BC Delegation- linking together for better

patient care

"VOlVe WEBSITE Additional resources are available online at: http://evolve.elsevier.com/Cherry/

VIGNETTE Glenda Miller, BSN, RN, is the chatge nurse on a tnedical­surgical floor of a hospital. She has just received report from the 7 PM to 7 AM shift and is about to rnake assignments for the 7 AM to 7 PM shift. The philosophy of the unit is that the registered nurse (RN) coordinates all patient care. Today on this 12-bed unit there are eight patients and 4 empty beds. The nursing staff consists of Ms. Miller, one RN, one licensed practical nurse, one nursing assistant, and one unit secretmy. The following interprofessional team members are available for specific patient care needs: a respiratoty therapist, physical therapist, occupational therapist, speech therapist, medical social worker, nutri­tional support nurse, and chaplain. The patients are medi­cally complex with extensive nursing care needs including psychosocial and emotional support. The patients are described to Ms. Miller as follows:

502: Mr. A. is ventilator dependent with an infection that requires IV antibiotics eve1y 12 hours. He needs to be out of bed in a chair twice a day. He has a stage I sacral decubitus ulcer and a PEG tube with bolus feedings. He is very hard of hearing, tries to speak, and becomes ve1y frustrated and uncooperative.

346

503: Mrs. B., age 77, is on day 2 of 40 days of antibiotics for osteomyelitis. She is dehydrated with a centra /line in her right subclavian and on TPN. She needs to be out of bed and ambulated in the room. She receives a respiratory treatment every 4 hours and needs assistance with am cnre. Her daughter is at her bedside and is ve1y upset that her mother may need to go to a nursing home.

504: Mr. C., age 52, is to be dischmged to a rehabilitation hospital today. Dischatge records need to be prepared for the transfer. The family is at his bedside and is extremely anxious.

507: Mr. D. , age 64, has TPN infusing into a left. sub­clavian catheter and is on multiple antibiotics. He has vancomycin-resistant Enterococcus in his urine and a sta­sis ulcer on his left leg that requires Pulsavac every day.

508: Mr. E., age 72, is a ventilator-dependent patient who will start weaning this AM. He is on continuous tube feedings and IV antibiotics and needs to be assessed for a PICC line. He is to begin ambulation in the hall twice a day per physician's orders. He also needs to have a phatyn­geal speech evaluation scheduled.

509: Mrs. F., age 66, is 3 days after a CVA and unable to move her right extremities. She has an IV infusing via

CHAPTER 19 Effective De ation and Su

V IGNETTE-cont'd /rerfeft arm. Her blood pressure is 170/100. She needs total care with personal hygiene and feeding. The physician just ordered range-of-motion exercises every day. Her husband is at her bedside crying continually and asking, "What am I going to do now?"

510: Mr. G., age 52, has been off the ventilator for the past 24 hours and is doing ve1y well. He continues on respiratory treatments every 4 hours. His TPN is being decreased, and his PEG feedings are increasing. He has glucose monitoring ordered eve1y 4 hours, an indwelling urinmy catheter to gravity drainage, and IV antibiotics every 12 hours. He needs to be out of bed, ambulating in the hall with assistance. If he stays off the ventilator, he will be discharged in 5 days. The family needs to find a nursing !lome for him; however, the family has not visited Mr. G. since his admission 18 days ago.

511: Mr. H., age 49, is a new admission that will be coming from ICU sometime during the shift.

I' EY TERMS ---Acwuntabili ty: In the context of delegation, account­

ability means bearing responsibility for both the action and inaction of the nurse and those to whom he or she delegates tasks (National Council 1)f Stale Boards of Nursing [NCSBN], 2005) .

Assignment: The distribution of work that each staff member is responsible for during a given work period; when making assignments, the RN supervi­sor directs a staff member to do something that he or she is authorized to do and is within tbe staff mem­ber's scope of practice and/or job description (Amer­ican Nurses Association [ANA] and NCSBN, 2006).

Competency: The ability of an individual to perform defined behaviors proficiently by demonstrating the appropriate knowledge, skills, attitudes, and profes­sional judgment required for a specific role or setting.

LEARNING OUTCOMES After studying this chapter, the reader will be able to: l. Evaluate the effect of changes in the current

health care system on nurse staffing patterns and responsibilities.

2. Outline six topic areas that the professional nurse should consider when making delegation decisions.

Tn addition to the tasks mentioned, routine activities of taking vital signs, giving scheduled medications, updat­ing care plans, and answering call lights must be assigned. When reviewing the tasks to be accomplished, Ms. Miller must consider several issues to make safe and effective assignment and delegation decisions.

Questions to Consider While Reading This Chapter: l. Which of the above tasks must the RN perform as

required by your state's nurse practice act? 2. Which of the above tasks can be delegated to the

nursing assistant? 3. How can the training, skills, and competencies of the

licensed practical nurse (LPN) or licensed vocational nurse (L VN) and nursing assistant be determined?

4. How can other members of the interprofessional health care team contribute most effectively to meet patients' needs?

Delegation: Transferring to a competent staff member the authority and responsibility to perform a selected nursing t~sk that the staff member would not nor­mally be allowed to perform; the RN retains account­ability for the delegated task (ANA and NCSBN, 2006).

Unlicensed assistive personnel (UAP): An unli­censed individual who is tra ined to function in an assistive role to the RN by performing patient care activities as delegated by the nurse; may include nursing assistants, clinical assistants, orderlies, health aides, or other titles designated within the work setting.

Supervision: The active process of directing, guiding, and influencing the outcome of an individual's per­formance of an activity or task (ANA, 2005).

3. List nine essential requirements for safe and effec­tive delegation.

4. Incorporate principles of delegation and supervision in professional nursing practice to ensure safe and legal patient care.

UNIT 3 Leadersh i

The delivery of patient care is the fundamental goal of eve1y health care organization. To accomplish this goal cost-effectively, teams of diverse professionals and assis­tnnts nre used to deliver care. Bemuse the RN is most often responsible for coordinating care provided by the various team me111bers, he or she must clearly understand and be able to effectively use the nuuwgelllent processes ofdelegation and supervision to ensure high-quality, safe

DELEGATION AND SUPERVISION IN THE HEALTH CARE SYSTEM Several factors influence staffi ng patterns and the provi­sion of patient care in today's health care system. First, reduced reimbursement from Medicare, Medicaid, and private insurance companies has led to cost -cutting mea­sttres. Second, the growing uninsured population is forc­ing health care organizations to provide care in the most cost-efficient manner possible. Third, the strong focus on safety and qmdity is requiring healtb care systems to make rapid changes for continual improvement. Fourth, advances in medical technology are causing a sharp increase in the cost of providing care. Finally, the nursing shortage combined with an increase in patient acuity and complex treatments contribute to health care environ­ments struggling to address multiple complex priorities with dwindling resources. Using UAP, such as nursing assistants and patient care technicians, is one strategy to increase cost-effectiveness of providing patient care.

As the usc ofUAP increases, the RN is forced to del­egate more tasks to a person who does not have clearly defined parameters for education, training, job respon­sibilities, and role limitations. Therefore, it is up to the RN to know the laws and regulations that govern nursing practice. It is also important that the RN work closely with nonclinical administrators and managers to make su re they understand the assessment and deci­sion-making activi ties that must be performed by the RN according to state law.

There is a growing concern that the roles and respon­sibiliti es of care providers, including RNs, LPNs or LVNs, and UAP, are significantly overlapping. In some practice settings, LPNs or L VNs are functioning as man­agers and supervisors and are performing more complex

ent in Nursi

patient care. This chapter hi 11/ights issues thatf 1.1/l .(, . li-enee stnff'mg pnttems a11d delegation and supervisio p1·ocesses. The chnpt ' I' nl o discusses the RN's role tilt~ responsibility i11 delegnting to and sup rvising stn}fmem. bers, in h1ding rutlicens:d ass~.sf'ive perso/1/!el (UAP) nnrl LPNs or LVNs, and ll pr0111dcs us iful gwdclines for establislling n safe and e[feL·tive delegation nnd s11perv;. sian practice.

and invasive procedures. In some states, U AP are trained to perform complex procedures, such as venipunctures and catheter insertions. This trend has prompted many nurses, nursing organizations, and state boards of nurs­ing to reexamine the scope of nursing practice and the nurses' delegation and supervis ion responsibilities.

The issue of health care errors and the RN's essential role in keeping patients safe was brought to the nation's attention through the Institute of Medicine's (IOM) report Keeping Patients Safe: Transforming the Work Environll1ellt of Nurses. This report effectively high­lights how nurses improve patient outcomes th l'Ough the ongoing monitoring of patients' health status, coor­dinating care, educating paliellls and fam ilies, provid­ing essential therapeutic care, and intercepting health care errors before they can adversely affect patients (10M, 2004). RNs must learn to delegate nursing tasks safely and effectively so that they will be ava il able to deliver these most important aspects of professional nu rsing care.

In support of the role of UAP in delivering patient care, the Joint Statement on Delegation (ANA and NCSBN, 2006) states, "There is a need and a place for competent, appropriately supervised, unlicensed assis­tive personnel in the delivery of affordable, quality health care" (p. 2). As health care facilities continue to seek more cost-effective ways to provide care, RNs must lea rn new ways of managing care and delegating tasks.

Because RNs are becoming increasingly responsible for delegation and supervision in today's health care system, it is imperative that they have confidence in their delegation skills and understand the legal respon­sibility that they assume when delegating to and super­vising licensed personnel and UAP. RNs should know what aspects of nursing and health care can be delegated

CHAPTER 19 Effective Dele ation and Su

,111

d what level of supervision is required to ensure that the patient receives safe, competent, and effective care.

WHAT IS DELEGATION? - -pelegation is a legal and management concept that involves assessment, planning, intervention, and evalu­ation. Delegation as defined by the American Nurses Association (ANA, 2005) is "the transfer of respon­sibility for the performance of an <1ctivity from one individual to another while retaining accountability for the outcome" (p. 4). Although RNs can transfer the responsibility and authority for the performance of an activity, they remain accountable for the overall nursing care. When delegating tasks, the nurse should understand the delegatee's competencies, commu­nicate succinctly, offer clear guidelines in advance, monitor progress, and remain accountable for the final outcomes of care.

Delegation is a two-way process in which the RN requests that a qualified staff member perform a specific task. When delegating, the RN delegator is accountable for the following:

The act of delegation Supervising the performance of the delegated task Assessment and follow-up evaluation

Professional standards of nursing

Any intervention or corrective actions that may be required to ensure safe and effective care

The delegatee is accountable for the following: His or her own actions Accepting delegation within the parameters of his or her training and education Communicating the appropriate information to the delegator Completing the task

Delegation is a mzmagement strategy that when used appropriately can ensure the accomplishment of safe and effective patient care.

WHAT SHOULD AND SHOULD NOT BE DELEGATED? Unfortunately there is no easy answer as to what can and cannot be delegated. The answer varies, depending on the (1) nursing practice acts and other applicable state laws, (2) patient needs, (3) job descriptions and competencies of staff members, ( 4) policies and procedures of the health care organization, (S )k linical situation, and (6) profes­sional standards of n~u·sing practice. To establish a safe, effective delegation practice, the RN must seek guidance and integrate information regarding each of these areas as discussed in the following paragraphs (Figure 19-1).

Job descriptions and competencies

Organizational policies and procedures

FIGURE 19-1 Solv ing the Delegation Puzzle.

UNIT 3 Leadershi

State Nurse Practice Acts Each state's nurse practice act provides the legal author­ity for nursing practice, including delegation. However, each state's nurse practice act expresses delegation cri­teria differently, and the criteria often are not clearly spelled out in the act, or they may be presented in vari­ous parts of the act. It is absolutely essential that every RN be familiar with his or her state nurse practice act and know the delegation criteria contained within the act. Johnson (1996) has identified 10 essential elements related to delegation criteria in nurse practice acts, as follows:

1. Definition of delegation 2. Items that cannot be delegated 3. Items that cannot be routinely delegated 4. Guidelines for the RN about what can be

delegated 5. Description of professional nursing practice 6. Descr iption of LPN or LVN and nursing assistive

personnel rol es 7. Degree of supervision required 8. Guidelines for decreasing the risks associated

with delegation 9. Warnings about inappropriate delegation

10. Restricted use of the word nurse to licensed nurses only

Although not every state's nurse practice act con­tains all 10 elements, the RN can use this list to assist in understanding delegation criteria in his or her own nurse practice act and apply the information to enhance delegation activities. Box 19-1 presents policies com­mon to m any nurse practice acts.

If the nurse practice act does not provide clear direction regarding delegation, the state board of nursi ng m ay be able to offer guidance. The board of nursing may have developed definitions, rulings, advi­sory opinions, or interpretations of the law to provide guidance regarding delegation activities . Many state boards of nursing may also have practical tools avail­able, such as delega tion decision trees or delegation checklists. Figure 19-2 is a delegation decision tree recommended by the NCSBN and provides an excel­lent framework for the four steps in the delegation process-assessment and planning, communication, surveillance and supervision, and evaluation and feedback.

Most states also have a practice act to govern practice by LPNs or L VNs. Because the practice ofLPNs or L VNs

ent in Nursin

BOX 1 9-1 POLICIES COMMON TO MANy STATE NURSE PRACTICE ACTS

• Only nursing tasks can be delegated, not nursing practice.

• The RN must perform the patient assessment to determine what can be delegated.

• The LPN or LVN and UAP do not practice professional nurs1ng.

• The RN can delegate only what is within the scope of nursing practice.

• The LPN or LVN works under the direction and super­vision of the RN .

• The RN delegates based on the knowledge and skill of the person selected to perform the delegated ta sks.

• The RN determines the competency of the person to whom he or she delegates.

• The RN cannot delegate an activity that requires the RN 's professional skill and knowledge.

• The RN is accountable and responsible for the del­egated task.

• The RN must evaluate patient outcomes resulting from the delegated activity.

• Health care facilities can develop specific delegation protocols, provided they meet the state board del­egation guidelines.

• Delegation requires critical thinking by the RN.

From Johnson SH: Teach ing nursing delegation: analyzing nurse practice acts, J Cantin Educ Nurs 27(2):52-58, 1996

varies significantly from state to state, RNs should know the LPN or L VN practice act in the state in which they practice and understand the LPN or LVN's legal scope of practice. State law generally does not define practice by UAP, although such practice should be governed by the health care organization's policies.

Patient Needs When deciding to delegate, the RN must remember that tasks can be delegated, but nursing practice can­not. The functions of assessment, evaluation, and nurs­ing judgment cannot be delegated. Generally the more stable the patient, the more likely delegation is to be safe. However, it also is important to remember many tasks that can be delegated may also carry with them a nursing responsibility. Taking vital signs on a physi­ologically stable patient after a CVA could be delegated

CHAPTER 19 Effective Del ation and Su

If not in the licensed nurse 's scope of practice, then cannot delegate to the

Are there laws and rules in place that ~

nursing assistive personnel (NAP). Authority to delegate varies; so

support the delegation? licensed nurses must check the

! YES jurisdiction's statutes and regulations.

Is the task within the scope of the

I NO delegating nurse? Do not delegate.

~YES

Has there been assessment of the client ~ Assess client needs and then proceed needs? to a consideration of delegation.

~ YES

Is the delegating nurse competent to make GJ-) Do not delegate. until the nutse delegation decisions? can provide and document additional

education, then reconsider delegation; ~ YES otherwi~g do not delegi!t~.

Is the task consistent with the recommended criteria for delegation to nursing asslstive personnel (NAP)? Must meet all of the following criteria:

• Is within the NAP range of functions • Frequently recurs in the daily care of a client or group of

' clients • Is performed according to an established sequence of

~Do not delegate. steps • Involves little or no modification from one client-care

situation to another • May be performed with a predictable outcome • Does not inherently involve ongoing assessment, .

interpretation, or decision making which cannot be logically separated from the procedure(s) itself

• Does not endanger a client's life or well-being

~ YES

Does the nursing assistive personnel have the Do not delegate until evidence of appropriate knowledge, skills and abilities (KSA) to

~ education and validation of

accept the delegation? competency available , then reconsider delegation; otherwise do not

Does the ability of the NAP match the care needs of delegate. the client?

! YES Do not proceed without evaluation of need for policy, procedures

Are there agency policies, procedures and/or -~

and/or protocol or determination protocols in place for this task/activity? that it is in the best interest of the

t YES client to proceed to delegation.

Is appropriate supervision available? NO Do not delegate.

t YES

Proceed with delegation.

FIGURE 19-2 Decision Tree for Del egating to Nursing Ass istive Personnel. (From the Joint Statement on Delegation, Appendix B. National Counci l of State Boards of Nursing. Used with permission from the American Nurses Association and the National Counci l of State Boards of Nursing, 2006.)

I

UNIT3 ement in Nursi •

to the UAP, but the task presents an opportunity for the RN to assess the patient's cognitive functioning. In the vignette presented at the opening of this chap­ter, Ms. Miller should not delegate any care for the newly admitted patient until the nursing assessment is complete.

Job Descriptions and Competencies The RN who is delegating has the responsibility of knowing the background, skill level, training received, and job requirements of each person to whom tasks are delegated. The job description provides important information about what a staff member is allowed to do and delineates the specific tasks, duties, and responsi­bilities required of the person as a condition of employ­ment. Job descriptions generally comply with state laws and the health care organization's standards of care. However, in all cases, legal requirements related to del­egation supersede any organizational requirement or policy.

The RN should be aware of what type of educa­tion and training the person received to function as described in the job description and, when possible, be involved in training programs. The RN should also know what kind of orientation is provided to new employees. In the opening vignette, the LPN's job description most likely would include duties such as "perform dressing changes" and "administer oral medications," but Ms. Miller also should know the LPN's knowledge and skill level for the population of patients on the unit.

In addition to requiring job descriptions for care pro­viders, health care organizations also require employees to demonstrate that they are competent to perform cer­tain technical procedures and to apply specific knowl­edge to safely care for patients. Written documentation of those skills and knowledge for which the employee has demonstrated competency is maintained in the employee's personnel file. Most health care organiza­tions require employees to undergo annual competency training for aspects of care unique to the population of patients generally being cared for in the nursing unit. Box 19-2 provides an example of annual competen­cies to be demonstrated by nurses in a family practice ambulatory care clinic. Various regulatory and accred­iting agencies, such as The Joint Commission (TJC) require written documentation of staff competencies. It is important for the RN to be aware of the documented

BOX 1 9-2 ANNUAL COMPETENCIES TO BE DEMONSTRATED BY RNS AND LVNS IN A FAMILy PRACTICE AMBULATORY CARE CLINIC

• Safety rules and regulations • HIPAA policies and procedures • Patient safety goals • Infection control • Telephone triage • Glucose testing • Patient education and health literacy • Medication management • Reporting abuse and neglect • Documentation in the medical record • Handling emergencies in the outpatient setting

HIPAA, Health Insurance Portability and Accountability Act

competencies for all staff members whom he or she supervises.

Organizational Policies and Procedures When delegating, the RN should comply with the spe­cific skill requirements designated in the organization's written policies and procedures, which usually describe the supervision required for a specific task and how problems or incidents should be reported and docu­mented. Again it is important for the nurse to remem­ber that the legal requirements related to delegation supercede any organizational requirement or policy. The RN should also know the organization's general standards of care, such as infection control, and ensure that the delegatee has the necessary knowledge and skills to comply with the standards. In the opening vignette, Ms. Miller should be aware of the hospital's policy regarding the orientation process. All clinical staff members should have received training about the unit's infection control, emergency, and safety procedures.

Clinical Situation Each delegation opportunity presents the RN with a vari­ety of considerations, including the delegatee's current workload and the complexity of the task in relationship to the patient. Does the staff member realistically have time to accomplish the task? Is the staff member familiar with characteristics of the patient population (i.e., pedi­atrics or geriatrics) and with the task to be performed?

CHAPTER 19 Effective De ation and Su

Is the RN able to provide tl1e appropriate level of supervision? Lher considerations in lude the availabil­itY of resources uch as supplies and equipmen t.

professional Standards of Nursing Practice professional standards of nursing practice, as estab­lished by professional nursing organizations, exist to guide the RN in providing patient care. According to the ANA (2010), "The Standards of Professional Nurs­ing Practice are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently. The standards are subject to change with the dynamics of the nursing profession, as new patterns of professional practice are developed and accepted by the nursing profession and the public" (p. 2). To practice safe del­egation, the RN should be familiar with the standards of practice outlined in ANA's Nursing: Scope and Stan­dards of Practice (2010) and with the standards for any specialty area in which the RN practices. See Appen­dix A on the Evolve website (http://evolve.elsevier.com/ Cherry/) for a list of most of the specialty nursing organizations in the United States.

As an accepted standard of care, the RN should use professional judgment to determine activities that are appropriate to delegate based on the concept of pro­viding safe and effective patient care and protecting the public. In delegation, the RN considers the following:

Assessment of the patient condition o Capabilities of the nursing and assistive staff o Complexity of the task to be delegated o Amount of clinical oversight (supervision) the

RN will be able to provide Staff worldoad

The RN cannot delegate activities that include the core of the nursing process and require specialized knowl­edge, judgment, and/or skill (ANA, 2005) including:

Initial nursing assessment and any subsequent assessment that requires professional nursing knowledge, judgment, and skill Determination of nursing diagnoses, establish­ment of nursing care goals, development of the nursing plan of care, and evaluation of the patient's progress with the nursing plan of care

o Any nursing intervention that requires profes­sional knowledge, judgment, and skill. Box 19-3 presents a list of questions to assist the nurse in making delegation decisions.

DEVELOPING SAFE DELEGATION PRACTICES For the RN to make safe, effective delegation decisions and develop a sound delegation practice, he or she must have a strong foundation of knowledge related to the legal criteria and standards of practice govern­ing delegation decisions. In addition to having a good understanding of what should and should not be del­egated based on the previous discussion, the RN also must know the patient, the staff members to whom he or she is delegating, and the tasks to be performed. The RN must provide for effective outcomes by clearly communicating expectations, supporting and appro­priately supervising the delegatee, evaluating the out­comes, and reassessing the patient after the delegated task is completed. Following is a brief discussion about these essential requirements for safe and effective delegation.

Know the Patient A nursing assessm~1t must be completed before delega­tion-know the level of care required by the patient, considering the clinical, physiologic, emotional, cogni­tive, and spiritual status. Is the patient's condition con­sidered stable? Generally the more stable the patient, the more likely delegation is to be safe. What is the potential for change in the patient's condition as a result of the delegated task? If there is moderate to high risk that the task will result in a change in the patient's condition, delegation should not be considered. Can the patient's safety be maintained with delegated care? The answer to this question must be a firm "yes" for delegation to be considered.

Know the Staff Member Before the task is delegated, the delegatee must have the skills and knowledge necessary to perform the task, as evidenced by the person's job description, training program, and documented competencies. Experience and past job performance should also be considerations. Is the staff member knowledgeable and trained to perform the task? Does the staff mem­ber perform the task routinely? Select the right person for the right task. It is very helpful for the RN to be involved in development of job descriptions, training programs, and competency documentation for staff members.

UNIT 3 Leadershi ement in Nursin

BOX 1 9-3 QUESTIONS TO GUIDE DELEGATION DECISION MAKING

A. State nurse practice act 1. 1s the task within the RN's scope of practice? 2. Does the nurse practice act address delegation of

the tas k? 3. Does the task to be delegated require the exercising

of nursing judgment? 4. Is the RN delegator willing to accept accountability

for the performance of the delegated task? B. Job description and competencies

1. Does the RN delegator understand the nature of the tas k and have the knowledge, skills, and compe­tency required to perform the task?

2. Does the delegatee have the appropriate education, training, skills, and experience to perform the task?

3. Is there documented or demonstrated evidence that the delegatee is competent to perform the task?

4. Does the delegatee perform the task on a routine basis 7

5. Is the delegatee familiar with the patient population? C. Organizational policies and procedures

1. What skill level and level of supervision are required for the task as stated in the organization's policy/pro­cedure manual?

2. What is the policy or procedure for documenting tasks and reporting results, observations, problems, or unusual incidents?

3. Does the delegatee have the necessary knowledge and skills to comply with general standards of care, such as infection control?

Know the Task(s) to Be Delegated The RN delegator must be competent and skilled in performing any task he or she is considering delegat­ing, and the task must be in the RN 's scope of practice. Routine, standardized tasks that are performed accord­ing to a standard and unchanging procedure and have predictable outcomes are the safest to delegate. These routine tasks are most likely to have been documented in the staff member's competencies and may require fewer directions and less supervision. Complex tasks or activities that pose a high risk for patient complications or unpredictable outcomes should be examined closely before delegation is considered.

Explain the Task and Expected Outcomes The RN should explain the delegated. task, what must be done, and the expected outcomes. If necessary,

D. Clinical situation and task 1. Is adequate supervision by the delegator available? 2. Are adequate resources available, including supplies

and equipment, to the delegatee? 3. What is the delegatee's current workload? Does

the person realistically have time to perform the task?

4. How complex is the task? Does it frequently recur in the daily care of patients? Does it follow a standard and unchanging procedure?

E. Patient needs 1. Has the nursing assessment and plan of care been

completed by the RN? 2. What is the patient's clinical, physiologic, emotional,

cognitive, and spiritual status? 3. Is the patient's condition considered stable? 4. What is the potential for change in the patient's con­

dition as a result of the delegated task? 5. Can the patient's safety be maintained with del­

egated care? F. Professional standards of nursing practice

1. What specific standards of nursing practice apply to the specific situation?

2. Does the delegated task include health counseling, teaching, or other activities that require specialized nursing knowledge, skill, or Judgment?

outline the task in writing. Failure to effectively com­municate what is expected may result in unsatisfactory performance, errors, and possible harm to the patient. Directions should be provided clearly and concisely. Demonstration and return demonstration by the del­egatee or other in-service education may be required. The delegated task is acceptable only when the staff member understands the task and is adequately pre­pared to carry it out.

Expect Responsible Action from the Delegatee When the staff member accepts and understands the task, he or she should then be allowed to perform the task. The staff member becomes responsible for his or her own actions and is obligated to complete the task as mutually agreed. The RN should provide appropriate

'

CHAPTER 19 Effective Delegation and Supervision 355

supervision, but should not intervene in task perfor­mance unless assistance is requested or an unsafe situa­tion is recognized. Interfering with the delegatee's task will negate his or her responsibility and obligation. The RN should expect responsible actions, give authority,

8nd retain accountability.

Assess and Supervise Job Performance Supervising job performance provides a mechanism for feedback and control. Job performance is assessed by making frequent rounds, observing, and communicat­ing (ask about progress, and determine whether there are any questions or concerns). Determine the appro­priate level of supervision. The RN should be available to the delegatee if there are any questions or unexpected problems. Supervise in a positive and supportive man­ner to reassure the staff member that his or her work is important and appreciated. Intervene immediately if the task is not being performed in a safe and appropriate manner. Poor performance must be documented and reported to the nurse manager. Never ignore poor per­formance. When a mistake is made, use it as a learning opportunity for all staff involved.

Evaluate and Follow Up Once the task is complete, evaluate the staff mem­ber's performance and reassess the patient to ensure that the expected outcomes were achieved. Follow up with any interventions that may be required based on the patient's care outcomes or the delegatee's job per­formance. Appropriate evaluation and follow-up will ensure a positive outcome for both patient and staff member. Box 19-4 presents some important steps to remember after the decision to delegate has been made.

Understand High-Risk Delegation The RN often expresses concern about legal liability­"putting my license on the line"-when delegating to unlicensed staff members. How does the RN know whether he or she might be at risk when delegating? The RN may be at risk if the following occurs (ANA, 1996):

Delegated task can be performed only by the RN according to law, organizational policies and procedures, or professional standards of nursing practice. Delegated task could involve risk or harm to a patient.

BOX 1 9-4 FROM DECIDING TO DELEGATE TO ACTUAL DELEGATION: STEPS TO REMEMBER

A. Communicate effectively. 1. The delegatee accepts the delegation and account­

ability for carrying out the task correctly . 2. The RN delegator provides clear directions to

the delegatee, including what specific task is to be performed, for whom the task is to be done, when the task is to be done, how the task is to be performed, what data are to be collected, and any patient-specific instructions.

3. The RN delegator clearly communicates expected outcomes and timellnes for r·eporting results .

B. Provide appropriate supervision. 1. Monitor performance to ensure compliance with

established standards of practice and organiza­tional policies and procedures.

2. Obtain and provide feedback. 3. Intervene if necessary. 4. Ensure proper documentation.

C. Evaluate andfeassess. 1. Reassess the patient. 2. Evaluate the performance of the task and the del­

egatee's experience. 3. Rea~?ess and adjust the overall plan of care as

needed.

• RN knowingly delegates a task to a person who has not had the appropriate training or orientation. RN fails to adequately supervise the delegated activity and does not evaluate the delegated action by reassessing the patient.

One method to avoid high-risk delegation and sim­plify the delegation process is referred to as the Five Rights of delegation (ANA and NCSBN, 2006):

1. The right task: Delegated tasks must conform to the established guidelines.

2. The right circumstances: Delegate tasks that do not require independent nursing judgment.

3. The right person: Delegate to someone who is qualified and competent.

4. The right direction and communication: Give clear explanation about the task and expected out­comes, and indicate when the delegatee should report back to the RN.

UNIT 3 Leadershi

5. The right supervision and evaluation: Invite feed­back to assess how the process is working and how to improve the process. Also evaluate the patient's outcomes and results of the tasks.

RNs can prevent being placed into unsafe, risky del­egation situations by adhering to the safe delegation prac­tices recommended in this chapter. See Case Study 19-1 demonstrating excellence in delegation practice in a home health care setting.

SUPERVISION Supervision is defined by the ANA (2005) as "the active process of directing, guiding and influencing the out­come of an individual's performance of a task" (p. 4). Supervision may be categorized as on-site, in which the nurse is physically present or immediately avail­able while the activity is being performed, or off-site,

in which the nurse has the ability to provide directio through various means of written, verbal, and ele ll

C-tronic communication (ANA, 2005). On-site supervj_ sion generally occurs in the acute care or ambuiator care settings where the RN is immediately availab]:. Off-site supervision may occur in home health care practice, community settings, and long-term care facilities.

Hansten and Jackson (2009) have identified levels of supervision based on the task delegated and the educa­tion, experience, competency, and working relationship of the people involved:

Unsupervised: One RN is working with another RN in a collegial relationship, and neither RN is in the position of supervising the other. Each RN is responsible and accountable for his or her own prac­tice. However, the RN in a supervisory or manage­ment position (e.g., team leader, charge nurse, nurse

CASE STUDY 19-1 EXCELLENCE IN DELEGATION PRACTICE :.

Amy Laurence, RN, works for a home health care agency. Ms. Laurence manages a caseload of 35 patients and makes between 8 and 10 skilled nursing visits a day. Several of Ms. Laurence's patients need assistance with activities of daily living, such as personal hygiene and mobility. Ms. Laurence assigns these tasks to the home health aides (HHAs) that she has worked with over the past 6 months. From her ongoing evaluation of patient outcomes and supervision of these aides, she knows they are skilled and proficient in performing their assigned tasks.

Five of Ms. Laurence's patients are newly diagnosed with diabetes and need extensive assistance with moni­toring blood glucose levels and administering insulin. The home health care agency where Ms. Laurence works has recently adopted a diabetic delegation policy. This policy allows HHAs that have been specifically trained and certi­fied to perform glucose testing and give insulin from pre­filled, labeled syringes. Ms. Laurence actively participates in the training classes to certify HHAs in diabetic care.

In caring for her patients with diabetes, Ms. Lau­rence does extensive diabetic teaching with each of her patients and sees them weekly to assess their learning, monitor their physiologic status, evaluate and adjust their individualized plans of care, and provide ongoing educa­tion and support as needed. During the weekly visits, Ms. Laurence fills and labels the exact number of insulin syringes with the correct doses of insulin to last the week.

Ms. Laurence is then able to delegate the daily insulin administration and glucose monitoring to the HHAs certi­fied in diabetic care. During the initial delegation process, Ms. Laurence makes supervisory visits to each patient's home to ensure that the HHA is performing the tasks cor­rectly and has been carrying them out according to the patient's plan of care . To provide appropriate supervision of these delegated tasks, Ms. Laurence plans her weekly skilled nursing visits to coincide with the HHA's daily visit. During these visits, Ms. Laurence observes each HHA perform the glucose testing and insulin administration and reinforces any specific training needed. Following these supervisory visits, Ms. Laurence is confident that the HHAs are competent to perform the delegated tasks.

In this case, Ms. Laurence is following all of the criteria essential for safe delegation in her state. She is adher­ing to the agency's policy, which also is in line with the state board of nursing rules for delegation in a home health care setting. She has actively participated in the training programs for the HHAs and provided clear direc­tion during the initial delegation process. Ms. Laurence provides ongoing patient assessment, care evaluation, and supervision of the HHAs. In performing appropriate delegation, Ms. Laurence is able to focus her energy on skilled nursing services, such as providing patient educa­tion, assessing and monitoring patients' physiologic con­dition, and coordinating the care for the interprofessional home health care team.

CHAPTER 19 Effective Dele ation and Su

manager), as defined by the health care organization, will be in a position to supervise other RNs. Initial direction and/or periodic inspection: The RN supervises a licensed or unlicensed caregiver, knows the person's training and competencies, and has developed a working relationship with the staff member. For example, the RN has been working with the nursing assistant for 6 months and is comfortable in giving initial directions for a delegated task and following up with the assistant once during the shift.

. Continuous supervision: The RN has determined that the delegatee will need frequent to continual support and assistance. This level of supervision is required when the working relationship is new, the task is complex, or the delegatee is inexperienced or has not demonstrated an acceptable level of competence. It is absolutely essential that the RN understands and

provides the appropriate level of supervision whenever tasks are delegated. Box 19-5 provides a list of online resources for more information about delegation and supervision.

ASSIGNING VERSUS DELEGATING Assigning tasks is not the same as delegating tasks. Assignment, as defined by the ANA, is "the-distribu­tion of work that each staff member is responsible for during a given work period" (2005, p. 4). An assign­ment designates those activities that a staff member is responsible for performing as a condition of employ­ment and is consistent with the staff member's job position and description, legal scope of practice, and training and educational background. The staff mem­ber assumes responsibility and is accountable for com­pleting the assignment.

BOX 1 9-5 HELPFUL ONLINE RESOURCES

American Nurses Association www.nursingworld. org

National Council of State Boards of Nursing www.ncsbn. org

Working with Others: A Position Paper www.ncsbn. org/Working_ with_ Others.pdf

Individual states' board of nurse examiners Manv states provide online access to their nurse

practice act.

Assignment Considerations Assigning groups of patients to various care providers, including UAP and LPNs or LVNs, is not appropri­ate. For example, UAP cannot be assigned to a patient or group of patients, but rather should be assigned to an RN. Typical assignments for UAP include passing trays, assisting patients with activities of daily living, transporting patients, stocking supplies, and complet­ing delegated tasks for the RN. The LPN or LVN may be assigned specific patients for whom to perform care, but the RN remains responsible for all nursing practice activities, including patient assessment, care planning, and patient teaching.

The RN is also respo11sible for assignments made to personnel in the clinical setting. Several factors should be considered when making assignments. • Patient's physiologic status and complexity of care:

Are vital signs unstable? Is the patient's condition changing rapidly? Does the patient have multisys­tem involvement? Does the patient need extensive health education? Does the patient need extensive emotional suf>port? What technology is involved in the care (e.g., cardiac monitor, intravenous pump, patient-controlled analgesia pump)? Patients with more unstable physiologic status or complex care requirements need a higher level of skilled care. Infection control: To what extent are isolation pro­cedures required? Which patients could be adversely affected as a result of cross-contamination? For example, a new patient is admitted with a history of night sweats and chronic cough. The results of a sputum culture are pending. Another patient on the unit was admitted with complications resulting from chemotherapy. The same caregiver should not be assigned to a potentially infectious patient and an immunosuppressed patient. Degree of supervision: What level of supervision, direct or indirect, is required based on staff members' education, experience, skill level, and competence? Is the appropriate supervision available? The on-call RN who works an occasional weekend may require more supervision than the LPN who has worked in the unit full time and has demonstrated competence in caring for the patient population on the unit. Note that the most experienced skilled staff members

should not be exclusively assigned to the most complex, difficult cases. Assignments should be used as a staff development tool. Assigning a less experienced nurse to

UNIT3

a more complex patient, but at the same time increasing the level of supervision, increases that nurse's skill level, competence, and confidence while maintaining safe, effective patient care.

Working with lnterprofessional Health Care Team Members Other health professionals who are members of the interprofessional health care team, including respi­ratory therapists, physical therapists, occupational therapists , speech therapists, nutritionists, medi­cal social workers, and chaplains, are very valuable in helping meet patient care needs. In the vignette, Ms. Miller will need to coordinate the efforts of each of the interprofessional team members available to her unit to accomplish the many and varied tasks needed by the patients for whom she is responsible and accountable.

The RN must be knowledgeable about the scope of practice and training background of the interprofes­sional team members to ensure the very best patient care. The RN also needs to understand how the work is delegated or assigned to the team members and where they fit in the unit's organizational structure. In soi11e organizations, some or all of the interprofes­sional team members report to the RN, and it is the RN who is responsible for assigning and delegating patient care tasks to the team members. In other organizations, the interprofessional team members report to super­visors in their individual disciplines and work collab­oratively with the RN to provide patient care based on their individual legal scope of practice, knowledge, and experience.

The RN is generally responsible for coordinating the efforts of the interprofessional team. In the open­ing vignette, the interprofessional team members do not report directly to Ms. Miller, but to a supervisor in their respective disciplines. However, each team mem­ber is available and willing to work collaboratively with Ms. Miller to meet the needs of the patients on the unit. For example, the respiratory therapist monitors all patients on ventilators and assists in the weaning pro­cess. The medical social worker provides valuable assis­tance to identify family support and assists with nursing home placement for Mr. G. The speech therapist can work on communication techniques with Mr. A., the ventilator-dependent patient who becomes very frus­trated when he tries to speak.

ent in Nursi

BUILDING DELEGATION AND SUPERVISION SKILLS Effective delegation is an underlying quality for the suc­ces. of working with thers efficiently and being able to provide afe, cost-efti ctive care to patients. Delegatin an be very diffi ult, e pecially for the novice nurse. Som:

of the struggles the nurse has are the fear of being dis­liked, losing control, taking risk.s, making mistakes, lack of confidence, and lack of knowledge of the delegation process itself. Because delegation and supervision involve interactions between two people, the RN needs to develop strong interpersonal skills and a supportive work envi­ronment to guarantee an effective delegation situation. Following are management skills RNs need to develop to become proficient at delegation and supervision.

Communicate Effectively Clear communication is the key to successful delega­tion. The first step toward effective communication is for the RN to know exactly what needs to be done and what outcomes are expected. What is the specific task to be done? For whom is the task to be done? When is the task to be done? How is the task to be performed? What is the expected outcome? What feedback is expected? Why does the task need to be done in a certain way?

Maintaining self-control and confidence is an important communication skill. New RNs often have expressed concern about delegating to more seasoned LPNs or LVNs or UAPs. "I have been working here for 12 years, and I do not need you telling me what to do" might be a typical response directed to the new RN. The RN's correct response is to maintain composure and confidence and remain positive. "I really appreciate your experience and knowledge, and I need you to help me by ... [describe the task clearly]."

It also is important to listen carefully to the delega­tee's response. Did the delegatee appear to listen and understand the directions? Did he or she appear to be hesitant to accept the task? Angry? Uninterested? Frus­trated? If a delegation action elicits a negative response from the delegatee, ask for feedback using open-ended, nonthreatening statements, such as, "You seem unsure about performing this task." Always provide an oppor­tunity for the delegatee to ask questions. The positive communication techniques discussed in Chapter 18 provide additional guidelines for the reader to enhance delegation skills.

CHAPTER 19 Effective Del ation and Su

create an Environment of Trust and Cooperation staff members will report problems more quickly if they know that the reaction from the supervisor will be non­threatening and non judgmental. When mistakes occur, the rerson should not be blamed or criticized, but rather the supervisor should look for root causes and system issues, such as inadequate training or an excessive work­load. Encouraging staff members to report and discuss problems is an excellent method of improving patient care and maintaining a helpful, supportive attitude. Just as the RN establishes trust and rapport with patients, he or she should strive for the same type of supportive relationships with staff members.

Provide Feedback and Follow-Up Evaluation The delegation process is not complete until the RN reassesses the patient and adjusts the plan of care as

indicated. The RN also should provide honest feedback to the delegatee about his or her performance. An easy, although often overlooked, delegation skill is to rraise good performance. Often more difficult for the RN, and sometimes ignored, is the duty to address poor job performance.

The RN should tell the staff member about mistakes in a supportive manner- in private-with a focus on "learning from mistakes." However, if the staff member performs in an inappropriate, unsafe, or incompetent manner, the RN must intervene immediately and stop the unsafe activity, document the facts of the perfor­mance, and report to the supervisor. In addition, the RN should request additional training or other appropriate action for the staff member to ensure that patient safety is protected. The RN has a professional resronsibility to intervene appropriately when poor performance is observed.

S UMMABY --------------------~·-------Effective delegation and supervision are essential skills for information to assist the RN with delegation decisions and

the professional nurse in any practice role or setting, espe- also discusses effective delegation and supervision skills, cially with the increased use of UAP to provide health care including communicating effectively, crenting an environ-services. Although there is no definitive list of what can and ment of tr(lst and cooperation, and providing feedback and cannot be delegated, the RN is guided to safe, effective del- follow-up evaluation. These activities and skills provide egation and supervision through an assessment of (1) the the tools the RN needs to provide safe and legal delegation clinical situation; (2) patient needs; (3) the job descrip- in practice. tions and competencies of the assistive and vocational or practical nursing personnel; ( 4) the health care organiza­tion's policies and procedures; (5) nurse practice acts and other regulations and applicable state laws; and (6) profes­sional standards of nursing practice. This chapter presents

REFERENCES American Nurses Association: Registered professional nurses

and unlicensed assistive personnel, ed 2, Washington, DC, 1996, American Nurses Association.

American Nurses Association: Principles for delegation, Silver Spring, MD, 2005, American Nurses Association.

American Nurses Association: Nursing: scope and standards of practice, Washington, DC, 2010, American Nurses Association.

American Nurses Association and National Council of State Boards of Nursing: Joint statement orr delegation, 2006 (website). www .ncsbn.org/J oint_statement.pdf.

VOlVe WEBSITE

Additional resources are available online at: http://evolve.elsevier.com/Cherry/

Hansten Rl, Jackson M: Clinical delegation skills: a handbook for professional practice, cd 4, Sudbury, MA, 2009, Jones and Bartlett.

Institute of Medicine: Keeping patients safe: transforming the work environment of nurses, Washington, DC, 2004, National Academies Press.

Johnson SH: Teaching nursing delegation : analyzing nurse practice acts,] Cantin Educ Nurs 27(2):52- 58, 1996.

National Council of State Boards of Nursing: Working with others: a position paper, 2005 (website). www·.ncsbn.org/ Working_ with_ Others. pdf.