Delegation

DelegationKarilyn Bufka

This presentation will focus on delegation, something we are all familiar with. With cost containment becoming more of an issue for hospitals, delegation has become common practice. Understanding delegation and knowing how to properly perform it will help to decrease the concerns and anxiety that may come with. We will explore these concerns and look at recommendations. At the end of the presentation I will provide resources to help you further improve your delegation skills.1Learning ObjectivesBe able to define delegation.Know who is accountable for delegated tasks.List the Five Rights of Delegation.Understand why delegation is important.Understand who makes the rules and regulations regarding delegation.Understand the concerns about delegation.Integrate nursing theory and theories from other disciplines with delegation.

Please review the learning objectives listed on the slide. I wont go through them all, but please refer back periodically and make sure you are obtaining the information presented here.2What is Delegation?Delegation is the process for a nurse to direct another person to perform nursing tasks and activities. (ANA & NCSBN, n.d.)

It is important to define delegation so we are all on the same page. Delegation, as defined by the American Nurses Association and the National Council of State Boards of Nursing (n.d)., is the process for a nurse to direct another person to perform nursing tasks and activities. As nurses, this is something we do on a daily basis. The cartoon displayed may not be directly related to nursing, but it would be very easy to make it apply. Changing the active directory administration with patient assignment and changing the helpdesk technicians to unlicensed assistive personnel (UAPs) shows how delegation can help nurses balance their assignment on a day to day basis. Without delegating tasks, nurses would suffer under the workload required by a full patient assignment, especially when nurse to patient ratios are increased. This can create frustration and burnout, which only adds to the nursing shortage we continue to hear about.3Who is responsible?Tasks are delegated, but nurses retain accountability!

When nurses delegate tasks to others, it is very important to understand that the accountability of the task is retained by the nurse. This means that you are responsible for the outcome of the task. If the task was not completed, you are also responsible. This is one of the reasons why nurses may be uneasy about delegating. If you are not present during the task and an adverse outcome occurs, you may be held responsible in the event of a lawsuit. Because of this, it is very important to understand the rules and regulations of delegation, the five rights of delegation, and how to properly delegate. By following these rules and guidelines, nurses can be more confident that they will not be held liable if a lawsuit does occur.4Who determines delegation rules and regulations?Each state has different regulations for delegating tasks

In Michigan:Occupational Regulation Sections of the Michigan Public Health Code Michigan Board of Nursings Administration Rules (MNA, 2010).

Who is responsible for knowing the rules and regulations?

Delegation is different in each state. In Michigan, delegation rules are defined by the Michigan Board of Nursings Administration and the Michigan Public Health Code. If you are a traveling nurse or work in another state, it is your responsibility to learn the rules and regulations of delegation there. Individual facilities within a state may also have their own policies on delegation. As nurses, we must be aware of these policies and ensure we comply. Differing policies and regulations within the United States creates confusion and could lead to errors by nurses. I believe this is one area that could be improved upon. Having the same rules and regulations within each state would help clear up some of the confusion.5Why is delegation important?Increasing number of consumers requiring healthcare

Increasingly complex therapy for consumers

Higher nurse to patient ratios

Cost containment for institutions

Delegation has become a very important part of healthcare. We are all aware of the increasing age of the population in the United States and with that comes an increase in the number of people requiring healthcare services. This can lead to increased nurse to patient ratios and puts more of a burden on nurses if they are required to perform total care of all patients. As well as an increase in the number of healthcare consumers, the acuity of patients is also increasing. The strains of the recent economic downturn have left many Americans without health insurance and less income. Delaying routine trips to the doctor and trying to get well at home can lead to increased severity of illnesses and longer recovery times. Speaking of the economic downturn, funding for many institutions have decreased and requirements for reimbursement may have also changed. With less money to spend, institutions can look to delegation to free up nurses to perform more complex tasks and use UAP to perform basic patient care to help decrease costs.6Five Rights of DelegationRight taskRight circumstancesRight personRight directions and communicationRight supervision and evaluation

(NCSBN, 1997)

Much like medication administration, delegation has its own five rights. They are simple enough to understand, but each is very important. First, ensuring the right task means assessing if the task is appropriate for the patient and the person you delegate to. Right circumstance means the complexity of the task is appropriate for the person performing the task and the patient needs have been assessed. Right person means both the right patient and the right UAP or perhaps a volunteer. Right directions and communication is ensuring the UAP has received all of the information needed to perform the task and has been given the opportunity to ask questions to ensure they know what is required of them. The nurse needs to perform the right supervision for the specific task and evaluate the task after completed. If nurses follow these five rights, they can be more comfortable that they have properly performed delegation.7Preparation for DelegationAssess and plan

Communicate

Surveillance and supervision

Evaluation and Feedback

(ANA & NCSBN, n.d.)

Before delegation takes place, nurses must first assess the situation and plan based on the patient needs and the resources available. Staffing must be able to accommodate delegation, and this is part of the institutions responsibility with delegation. They need to ensure that an appropriate mix of staff is available to handle delegation of tasks. Second, the nurse must communicate with the person they are delegating the task to. Proper communication is essential to ensure the task is completed in the right fashion. Directions must be included and any patient specific issues should be addressed at this time. Third, the nurse must perform surveillance and supervision of the task. Each task will require a different amount of supervision and each person being delegated to may require different levels. Last, the nurse must evaluate the delegated task and ensure it was completed correctly. Feedback should be provided to the delegatee. If they did not do something correctly, teaching them the correct way will help patient care flow more smoothly in the future.8What do studies show?Bittner, N. P., & Gravlin, G. (2009)Qualitative, descriptive studyNurses were given a survey regarding delegation, UAPs (unlicensed assistive personnel), and the following:Tasks DelegatedKnowledge Expectations of UAPsRelationships with UAPsRole UncertaintyCommunication BarriersOmitted CareSystem Support Conclusions: Chief nursing officers and nurse leaders were given information on why delegation often fails, which can be used to improve outcomes in the institution

There have been several studies performed on delegation and the issues around it. The study that was posted prior to this presentation by Bittner and Gravlin titled Critical thinking, delegation, and missed care in practice is highly relevant. The authors gave nurses a survey regarding delegation and reviewed the results. They found that nurses expected UAPs to report significant findings and follow up tasks, both of which are not within the scope of practice for UAPs. This is a significant concern because these nurses may not have been providing the correct supervision and review of the tasks delegated, which is part of the five rights of delegation discussed previously. They also found that newly licensed nurses had trouble discerning what tasks they could delegate to UAPs and what tasks they should complete on their own. UAPs often have several patients who are assigned to different nurses. It was reported that several nurses were delegating to one UAP without the knowledge of the UAPs other assignments. This creates a concern as UAPs can become overloaded with tasks and may not be able to complete them all.

The authors concluded that the survey provides chief nursing officers and nurse leaders information on why delegation often fails. As stated by the authors, ineffective delegation of nursing care, resulting in poor patient outcomes, could yield a direct impact on quality measure, satisfaction, and reimbursement for the institution. (Bittner & Gravlin, 2009). This sums up the importance of delegation for management and why improving delegation skills should be a priority for all institutions. 9What do studies show?Hasson, F., Hugh, M. P., & Keeney, S. (2013). Delegating and supervising unregistered professionals: The student nurse experienceTwo phases, one qualitative, the other quantitativeA face-to-face interview and a questionnaireFindings:78% of students thought their education was inadequate to properly perform delegationStudents often stated they performed tasks a UAP could perform due to resistance from UAP and negative perceptions from staffStudents felt their lack of education resulted in underuse of UAP, ineffective delegation, and inhibited them from learning the professional nursing roleConclusions: Newly licensed nurses may not be properly prepared to delegate tasks to UAP, an important factor for administrators and leaders to be aware of

This study focused on student nurses and their experiences and education regarding delegation. It was performed in the United Kingdom and delegation is part of their training standards. Student nurses were given a face to face interview in the first phase and a questionnaire was given in the second. Results were then statistically analyzed. The findings were quite interesting and somewhat surprising and are listed on the slide. Overall, the study shows that delegation is not being effectively taught in nursing programs. New graduates therefore may not feel at all comfortable with delegation. This is a major concern for management if new grads are hired in the institution. This does not mean new grads should not be hired, but for management to provide additional training and supervision to these employees to ensure delegation is performed properly and effectively. 10What do studies show?Saccomano, S. J., & Pinto-Zipp, G. (2011). Registered nurse leadership style and confidence in delegation.A quantitative study Nurses in a magnet status hospital were given a surveyFindings:Leadership style did not have any correlation with confidence in delegating tasks to UAPRNs with a least a BSN and less clinical experience exhibited higher confidence in delegating tasks than those with an ADN and the same amount of clinical experienceClinical experience increased confidence in those with an ADNConclusion: Education leaders need to identify a strategy to improve confidence in delegating tasks to UAPs and work with institutions to help create programs for new graduates

In this study, Saccomano and Pinto-Zipp gave a survey to nurses to analyze delegation. They believed that leadership style would impact delegation, but they were not able to support this hypothesis through their findings. However, they did find that associate degree nurses had lower confidence in delegation initially than did their BSN counterparts with the same amount of clinical experience. This is important to consider in the hiring process when delegation is a crucial part of the position in consideration.

Overall, you can see from these three studies that nurse managers and leaders need to be aware of the downfalls of delegation and not assume that their nursing staff is confident and competent when it comes to delegation. Additional resources and guidance should be given to all new hires and supervision of these employees should be elevated to ensure proper delegation and therefore improvement in patient safety and satisfaction. 11What are the concerns?Newly licensed nurses have not learned the skills to delegate.Education programs lack effective teaching in delegation and supervision of UAPs.Skills needed to delegate effectively have not been developed.Many nurses dont want to delegate due to accountability issues and concerns.

Based on the importance of delegation and the studies, I have summarized some of the concerns. First, new graduates may not have had experience with delegation. This can be due to a lack of teaching in their education program. From the studies, BSN and ADN graduates may have a confidence level difference when it comes to delegation. Even nurses with years of experience may not have developed the skills necessary to delegate tasks. For example, a RN with 10 years of experience in a physician's office that has transitioned to an acute care role may not have had to delegate in her previous employment. Even though she has been a nurse for an extended period of time, she may be even less confident than some new grads. Nurses may also have a fear of delegation due to retaining accountability for the task, even though they are not performing it. This can lead to legal risks that some nurses may not be willing to take.

I want to bring your attention to the cartoon on this slide. The caption reads You dont have to do everything! Even Batman had Robin. I believe this sums up delegation with nurses. We may not quite be superheroes, but we need assistance to complete our tasks on a daily basis or patient care may suffer. Even though it can be difficult, we must delegate. That is why learning to properly delegate is so important.12Root Cause AnalysisImproper, Inefficient, or Lack of DelegationIncreased number of healthcare consumersInsufficient delegation skillsFear of DelegationIncreased nurse to patient ratiosIncreased acuityAccountabilityMalpractice LawsuitsLack of training in education programsManagement unaware/unsupportiveDecreased RevenueStaffing shortagesIncreased patient demands

A root cause analysis is given to help understand the reasons for problems that occur with delegation. I will not spend much time here, as this is just a summary of the points that are given through the presentation. Please take a moment to think if you could add anything here that you have found in your own practice.13Implications and ConsequencesNursing Implications

Patient Implications

Hospital Implications

Delegation issues have several implications for nursing. As you can see, understanding the five rights of delegation and following them with each task is important for patient safety and completion of tasks. Nurses should also continue their education on delegation after graduating from nursing school as studies have shown that nurses do not feel comfortable with delegation after graduation. Ensuring the person you delegate to is properly trained and comfortable with the task is also an important implication. Correctly understanding and performing delegation can help decrease negative consequences from malpractice lawsuits.

Patients, although not directly involved with delegation, have implications from it as well. Their basic needs are often tasks that are delegated by nurses to UAPs. If supervision by nurses does not take place, these simple yet important tasks may not be completed.

Patient satisfaction from these delegated tasks is directly connected to hospital implications. If patient care suffers due to improper or lack of delegation and patient satisfaction scores decrease, hospital reimbursement may also decrease. This is increasingly important to recognize and correct promptly to ensure the viability of the hospital.14How does nursing theory relate to delegation?Virginia Hendersons philosophy based on 14 basic needs of the patient.Needs include:Eat and drink adequatelyEliminate body wastesMove and maintain a desirable positionAvoid dangers in the environment and avoid injuring others Henderson believed that if the patient isnot able to perform the needs on their own, nurses are to assist them.(Chitty & Black, 2011)

Virginia Henderson is a well known nursing theorist who developed her philosophy based on 14 basic needs of patient care that are relevant to each patient we see. They are: breathe normally, eat and drink adequately, eliminate body wastes, move and maintain a desirable position, sleep and rest, select suitable clothes dress and undress, maintain body temperature within normal range by adjusting clothing and modifying the environment, keep the body clean and well groomed and protect the skin, avoid dangers in the environment and avoid injuring others, communicate with others in expressing emotions, needs, fears, or opinions, worship according to ones faith, work in such a way that there is a sense of accomplishment, play or participate in various forms of recreation, learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities.

With an increased nurse to patient ratio, nurses may not always be able to complete these tasks. Delegating to UAPs that are able to properly care for the patient can help ensure the patients needs are met in a timely manner and allows the nurse to focus on more critical tasks in patient care. It is important to remember that each of the 14 basic needs are required for the patient and need to be addressed daily. Nurses with higher patient loads will not be able to perform them all and they need to keep this in mind if they are unwilling to delegate. We must always do what is best for the patient.15How do other disciplines theories apply to delegation?Social Development TheoryThe process of organizing human energies and activities at higher levels to achieve greater results. (Jacobs & Cleveland, 1999).Two aspects:LearningApplicationSociety develops due to pressures from human contact and pressures from the environmentOutcome: Developments that improve efficiency and effectiveness of human activities

How does this apply to delegation?

Delegation not only applies with nursing theory, but it can apply to theories from other fields as well. The theory of social development from the humanities field is a good example. This theory contains two aspects, learning and application. Learning helps to build awareness of issues and human consciousness whereas application helps to expand social organization. The theory states that society has developed, and will continue to do so, based on the pressures from human contact and also from the pressures exerted from the environment, such as natural disasters. Ultimately, the learning experiences help to create developments in physical skills, social systems, and information. Together these developments improve efficiency and effectiveness of human activities.

How does this apply to delegation? Going back to Virginia Hendersons theory of the basic needs tells us we need to complete certain tasks for our patients, a pressure from human contact if you will. To help ease this pressure, we have developed a system to improve our efficiency, delegation. It makes day to day care of patients in the hospitals more effective. It is a very simple concept, but it does directly apply to delegation.16Recommendations for Quality & Safety ImprovementsQSEN (Quality and Safety Education for Nurses)

Competency Areas:

Patient Centered CareTeamwork & CollaborationEvidence Based PracticeQuality ImprovementSafetyInformatics(QSEN Institute, 2011)

How can they help with delegation?

Quality and Safety Education for Nurses (QSEN) provides information for proposed skills and education for pre-licensure and graduate nurses in several different competency areas. The areas are patient-centered care, teamwork & collaboration, evidence based practice, quality improvement, safety, and informatics. QSEN helps develop strategies that will help future nurses build their education in these areas.

In 2011, QSEN developed a strategy that would help build delegation skills for nurses. It included an activity that would help build confidence and focuses on the importance of teamwork and collaboration in delegation. They provided a tool for nursing students in their last semester to complete and a rubric for clinical instructors for evaluation.

I think that this activity could be useful for employers to implement for all new hires while on orientation. Nurses with different backgrounds and levels of confidence could also benefit, not just new graduates. Utilizing tools that are already available would be cost effective and help nurses succeed in properly delegating tasks. 17Recommendations for Quality & Safety Improvements, cont.American Nurses Association Standards of Professional Performance

Ethics

Education

Quality of Practice

Communication

The American Nurses Association Standards of Professional Performance is something we are all very familiar with as we have discussed them several times in our studies. In regards to delegation, we will focus on a select few.

Ethical decision making is a concern for all nurses with their patients. When we delegate tasks to UAPs, we must be sure that they are properly trained and can effectively carry out the task. If we were unsure if the task was within their scope of practice and still delegated the task, we would be putting our patient at risk and not following the ANA standard to practice ethically (ANA, 2010). It is also important for nurses to speak up and voice their concerns if they feel the UAPs are not properly trained during the orientation process. We need to be the voice to help protect our patients.

As nurses, we need to continue our education on a day to day basis. This is important with delegation as we need to seek out resources, whether they be mentors at work or printed research, to further our understanding and confidence with delegation. Seeking out formal and independent learning experiences is a direct recommendation by the ANA (2010) when it comes to the standard of education.

Nurses should work to help improve the quality of practice where they work on a day to day basis. This includes making recommendations and developing and implementing new policies, procedures, and guidelines (ANA, 2010). For example, if nurses recognize that UAPs are not being properly taught how to perform Foley catheter care on orientation, they can work with management to improve the education UAPs receive. This in turn will help nurses feel more confident in delegating this task to the UAPs, freeing them up to perform more complex tasks.

Communication is, I believe, one of the most important standards when it comes to delegation. Communicating with UAPs is one of the five rights of delegation and one of the recommended preparations for delegation. It is imperative that the task being delegated is properly communicated to the UAP and the UAP is comfortable and able to communicate back with the nurse in order for the task to be completed in an appropriate manner. Inefficient communication can lead to detrimental impacts on patient safety and satisfaction. Nurses should perform a self-evaluation of their communication skills frequently.

18Case StudyAmy is a graduate RN working in a critical care unit. There were two call ins for her shift, leaving two nurses to care for seven critically ill patients. A UAP has floated from a med/surg floor to help care for patients. Amy has worked with this UAP once before, but does not know the extent of his ability in the critical care unit. How can Amy decide what tasks she can delegate and which she cannot?

For additional understanding of delegation, I have included a case study. Please review the case study now.19Case StudyQuestions Amy must consider:Do state rules and regulations support delegation?Does my facility allow me to delegate this task?Have I properly assessed my patient to see what their needs are?Have I assessed the UAPs abilities?Am I able to adequately supervise the UAP?Would another reasonable, prudent nurse delegate this task in this situation?Have I communicated clearly with the UAP and allowed them to ask questions?(Anderson, Twibell, & Siela, 2006)

As a new nurse, Amy may not feel as comfortable as more experienced nurses with delegation. Staffing shortages have put Amy in a situation where delegating will be imperative to performing all of the tasks required for all of the patients in a timely manner. The American Nurses Association (2006) has created a delegation decision tree that can be very helpful for new nurses to determine what is appropriate to delegate and what is not. The questions on the tree are listed above. Each time you delegate, you should ask yourself these questions. In doing so, you are protecting yourself, the UAP, your institution, and the patients. 20How can I improve my delegation skills?Michigan Nurses Association Continuing Education Coursehttp://www.minurses.org/files/files/Nursing%20Practice/SS_RNAccountabilityforDelegation.pdf

American Nurse Today Delegating without doubtshttp://www.americannursetoday.com/assets/0/434/436/440/5120/5122/5160/5162/be29a174-c47e-4ddb-a904-30a627589e56.pdf

As nurses, we cannot count on management or our education providers to provide all of the resources for continuing our education and improving our practice. I have given two sources here, but a quick internet search will provide numerous resources on improving your delegation skills.21Discussion QuestionsDo you feel you received enough experience/teaching on delegation in your education experience prior to becoming a RN?Do you delegate in your current practice? If so, do you think management has done enough to properly educate staff on delegation?What are some of the reasons you think nurses are uneasy about delegating tasks?Knowing that you retain accountability for tasks, how do you determine who to delegate to?How do you think the increasing number of healthcare consumers will affect nurses and delegation?

I have included the discussion questions posted prior to the presentation again here for your review. Please take a moment to go over the questions and see if your thoughts have changed now that you have more knowledge on the topic. Thank you for your time and attention, I look forward to your feedback in blackboard.22ReferencesAmerican Nurses Association (2010). Nursing: Scope and standards of practice (2nded.). Silver Spring, Maryland: Author.

American Nurses Association & National Council of State Boards of Nursing (n.d.). Joint statement on delegation. Retrieved from https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf

Anderson, P. S., Twibell, R. S., & Siela, D. (2006). Delegating without doubts. American Nurse Today, November 2006, 54-56. Retrieved from http://www.americannursetoday.com/assets/0/434/436/440/5120/5122/5160/5162/be29a174-c47e-4ddb-a904-30a627589e56.pdf

Bittner, N. P. & Gravlin, G. (2009). Critical thinking, delegation, and missed care in nursing practice. The Journal of Nursing Administration, 39(3), 142-146.

Chitty, K. K. & Black, B. P. (2011). Professional Nursing: Concepts and challenges (6th edition). Maryland Heights, MO: Saunders Elsevier.

23References, cont.Hasson, F., McKenna, H. P., & Keeney, S. (2013). Delegating and supervising unregistered professionals: The student nurse experience. Nurse Education Today, 33, 229.-235.

Jacobs, G. & Cleveland, H. (1999). Social Development Theory. Retrieved from http://www.icpd.org/development_theory/SocialDevTheory.htm

Michigan Nurses Association (2010). RN accountability for delegation decisions. Retrieved from http://www.minurses.org/files/files/Nursing%20Practice/SS_RNAccountabilityforDelegation.pdf

National Council of State Boards of Nursing. (1997). The five rights of delegation. Retrieved from https://www.ncsbn.org/fiverights.pdf

24Reference, cont.QSEN Institute (2011). Delegation: A collaborative, patient-centered approach. Retrieved from http://qsen.org/delegation-a-collaborative-patient-centered-approach/

Saccomano, S. J. & Pinto-Zipp, G. (2011). Registered nurse leadership style and confidence in delegation. Journal of Nursing Management, 19, 522-533. doi: 10.1111/j.1365-2834.2010.01189.x

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