13
Delegation of Nursing Tasks
• Define delegation.
• Identify the five rights of delegation.
• Review the circumstances where delegation is appropriate.
• Identify tasks appropriate for delegation.
• Discuss the role of unlicensed personnel in the delivery of health care.
• Identify the role of the nurse in the delegation of health care.
• Review the legal ramifications of delegation of care.
Key Terms
accountability acknowledgment and assumption of responsibility for actions, decisions, and policies within the scope of the role or employment position and encompassing the obligation to report, explain, and be answerable for resulting consequences
assignment delegation of work to a selected group of patient care givers. The downward or lateral transfer of the responsibility of an activity from one individual to another while retaining accountability for the outcome
delegation transferring the authority to perform a selected nursing task in a selected situation to a competent individual
direct patient care activities activities such as hygienic care, feeding patients, taking vital signs, and so on that are performed on the patient
indirect patient care activities routine activities of the patient unit that deal with the day-to-day functioning of the unit, such as restocking supplies
supervision active process of directing, guiding, and influencing the outcome of an individual’s performance of an activity
unlicensed assistive personnel individuals who are not licensed by the state but are trained to assist nurses by performing patient care tasks as allowed by the organization. There are many job titles for such employees, such as nursing assistant (NA), patient care associate (PCA), and unlicensed assistive personnel (UAP)
Delegation
Delegation is defined as the “transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome. Example: the nurse, in delegating an activity to an unlicensed individual, transfers the responsibility for the performance of the activity, but retains professional accountability for the overall care” (American Nurses Association [ANA], 1992). It is the entrusting of a selected nursing task to an individual who is qualified, competent, and able to perform such a task.
The following principles provide guidance and inform the registered nurse’s (RN’s) decision making about delegation:
• The nursing profession determines the scope and standards of nursing practice.
• The RN takes responsibility and accountability for the provision of nursing practice.
• The RN directs care and determines the appropriate use of resources when providing care.
• The RN may delegate tasks or elements of care, but does not delegate the nursing process itself.
• The RN considers facility/agency policies and procedures and the knowledge and skills, training, diversity awareness, and experience of any individual to whom the RN may delegate elements of care.
• The decision to delegate is based upon the RN’s judgment concerning the care complexity of the patient, the availability and competence of the individual accepting the delegation, and the type and intensity of supervision required.
• The RN acknowledges that delegation involves the relational concept of mutual respect.
• Nurse leaders are accountable for establishing systems to assess, monitor, verify, and communicate ongoing competence requirements in areas related to delegation.
• The organization/agency is accountable to provide sufficient resources to enable appropriate delegation.
• The organization/agency is accountable for ensuring that the RN has access to documented competency information for staff to whom the RN is delegating tasks.
• Organizational/agency policies on delegation are developed with the active participation of registered nurses (ANA and National Council of State Boards of Nursing [NCSBN], 2008).
The majority of health care institutions have care delivery systems that include various levels of caregivers. The acuity of patients within hospitals has increased during the past 10 years, and many hospitals have moved from total patient care, primary care, and other care delivery systems that require an all–registered nurse staff. To meet the needs of the higher-acuity patients, nurses must delegate aspects of care to nonregistered nurse team members. Delegation changes as the health care environment changes. Since the advent of the nursing shortage, unlicensed assistive personnel (UAP) have been used to help fill the workforce gaps. The role of these assistive personnel is set by the institution that employs them and defines their practice. They may be called noncredentialed assistive personnel, as well as unlicensed assistive personnel (UAP). Individuals hired into these jobs are trained and evaluated by the facility. They may use a variety of titles, such as nursing assistant (NA), patient care associate (PCA), nursing technician, unit technician, and others (Carroll, 1998). They cannot practice nursing, and they must be directed, supervised, and evaluated by a registered nurse, who is ultimately responsible for all patient care (see Box 13-1 for the nurse’s responsibility in delegation). One form of licensed personnel, the licensed practical nurse (LPN), is used by many facilities. The LPN works under the direction and supervision of the registered nurse. Licensed personnel work according to the state board regulations (see Chapter 11), but the job descriptions will vary from institution to institution. Various patient care roles are listed in Table 13-1.
There are two types of nursing activities that may be delegated: direct and indirect patient care activities. Direct patient care activities include assisting with feeding, grooming, hygienic care, taking vital signs, ambulation, electrocardiogram tracing, and measuring blood sugar levels. Indirect patient care activities are those routinely done to support the functioning of the patient care unit. Such activities include the restocking of supplies, the transport of patients, and clerical activities.
TABLE 13-1
Patient Care Team Members and Their Roles
Registered nurses (RNs)
• Determine the scope of nursing practice.
• Are responsible and accountable for the provision of nursing services.
• Supervise and determine the appropriate use of any UAP involved in patient care.
• Define and supervise the education, training, and use of any unlicensed assistive personnel (UAP).
Licensed Vocational Nurse/Licensed Practical Nurse (LVN/LPN)
• Complete a 1-year to 18-month educational program.
• Provide basic patient care that includes, but is not limited to, taking vital signs, changing dressings, performing phlebotomy, and assisting with activities of daily living, under the supervision of the RN.
UAP
• Work under the direct supervision of an RN to implement the delegated aspects of nursing care.
• Assist the RN in providing patient care.
• Enable the RN to provide nursing care for the patient.
• May include but are not limited to the following titles:
• Patient care assistant
• Nurse’s aide
• Technician
• Multi-skilled worker
• Practice partner
• Nursing assistant
• Nurse extender
• Orderly
• Support personnel
• Practice partner
American Association of Critical-Care Nurses. (2004). http://www.aacn.org/wd/practice/docs/aacndelegationhandbook.pdf
The Five Rights of Delegation
The National Council of State Boards of Nursing (1997) has defined the Five Rights of Delegation, as follows:
1. Right task.
2. Right circumstance.
3. Right person.
4. Right direction/communication.
5. Right supervision.
To assist you in reviewing these five rights, Box 13-2 will help you to determine if you are following these rights in your delegation (ANA and NCSBN, 2008).
Right Task
State boards of nursing regulate nursing practice within each state. It is important for you to know the nurse practice act of the state in which you are practicing and to be aware of the delegation regulation within your state. In addition, most hospitals have policies that very carefully describe what nursing tasks can be delegated to whom; there are differing standards of delegation depending on the type of health care facility in which you practice. Many long-term care facilities assign LPNs as charge nurses, with RNs supervising that care. In ambulatory care settings, medical assistants play a major role in the delivery of care. Just because your institution uses patient care technicians to measure all vital signs and blood sugar levels and to make blood draws, it does not mean that all facilities can or do use such personnel. It is vital to know your institution’s standard on delegation and the specific job descriptions and competencies of each level of personnel with whom you will be working. A sample hospital policy on delegation is shown in Figure 13-1. The scope of practice will vary from state to state, so this will vary across the country.
Generally, appropriate tasks for consideration in delegation decision making include those:
• That frequently reoccur in the daily care of a client or group of clients.
• That do not require the UAP to exercise nursing judgment.
• That do not require complex and/or multi-dimensional application of the nursing process.
• For which the results are predictable and the potential risk is minimal.
• That use a standard and unchanging procedure.
(The Five Rights of Delegation. www.ncsbn.org/fiverights.pdf.)
Right Circumstance
The right circumstance refers to the workplace. The circumstance is the context in which the delegation takes place. As stated earlier, an LPN will be performing different tasks under different circumstances. In a long-term facility, it is not unusual to have an LPN as “charge nurse” with an RN covering multiple units for supervision. However, it would be unusual to have an LPN assigned as a “charge nurse” in an acute care facility with a high acuity of patients. There may be differences in extreme circumstances, such as disasters, but in such a situation, the right communication/direction needs to occur.
Right Person
The requirement of the right person means that you must know the competency level, job description, individual level of skill, and standard of education of the individual to whom you are delegating. Job descriptions will give you a broad view of what an individual is expected to do, but you must know the individual’s capabilities, experience, attitude, and skills. A novice nurse will not have the competency that a nurse with 10 years of experience, a professional certification, and a clinical ladder position will have. It is also necessary to have knowledge of the individual strengths and weaknesses of each team member. A team member who just lost her mother to breast cancer may not be the best person to delegate to perform tasks for a patient with breast cancer.
The Right Direction/Communication
The right direction/communication is required of nurses as they delegate tasks to staff members. It is not enough to assign a task to a staff member; the staff member must know what is expected of them. “You will take Ms. Smith’s temperature every hour starting at 8 AM, and report the temperature back to me immediately.” If you tell the staff member to take the temperature every hour, they may not know when to start and may report a sudden increase in temperature to you because they have not been trained to determine when an independent nursing action is needed. Your directions must follow the 4 Cs: be clear, concise, correct, and complete. A clear communication is one that is understood by the listener. If you say, “Can you get Mrs. Jones,” what are you asking? For that patient to be transported back to the unit from a test? For the staff member to assume full care for Mrs. Jones? Or to answer Mrs. Jones’s bell? Tell the staff member exactly what you want done. A concise communication is one in which the right amount of communication has been given. If you are asking a PCA to take a patient’s temperature, they do not need to know the physiological response to an increased temperature. It confuses the communication and wastes time. Tell the associate what they need to know. A correct communication is one that is accurate. You may have two patients named Edward Norton on your unit. It is not enough to tell the LPN to give Mr. Norton his pain medication. Which Mr. Norton are you referring to? Last, a complete communication leaves no questions on the part of the delegate. Do not assume that just because you asked a PCA to take a patient’s temperature that they will know to report it to you.
Communication is a two-way activity, and it is important to create an environment where staff members feel free to say that they are not comfortable doing a task, for instance because they have not done it for a long time.
Right Supervision
The nurse remains accountable for the total care delivered to the patients on the unit. The right supervision includes “the provision of guidance, direction, oversight, evaluation and follow-up by the licensed nurse for accomplishment of a nursing task delegated to nursing assistive personnel” (NCSBN, 2005). While you will not directly perform the tasks delegated, you will be responsible for determining patient progress and outcomes of the care delivered, as well as evaluating and improving staff performance. This requires you to be able to communicate effectively to support team performance.
Acceptance of Delegated Assignment
In accepting a delegated assignment, the following decision-making algorithm is appropriate (State of New Jersey, 1999):
• Is the act consistent with your defined scope of practice?
• Is the activity authorized by a valid order and in accordance with established institutional/agency or provider protocols, policies, and procedures?
• Is the act supported by research data from nursing literature/or research from a health-related field? Has a national nursing organization issued a position statement on this practice? (See Chapter 19.)
• Do you possess the knowledge and clinical competence to perform the act safely?
• Is the act to be performed within acceptable “standards of care” that would be provided under similar circumstances by reasonable, prudent nurses with similar education and clinical skills?
• Are you prepared to assume accountability for the provision of safe care?
This model will assist you if you have a question about nursing practice or the delegation of work to you.
Delegation Factors
To recap, what to delegate will depend on a number of factors (adapted from Heidenthal & Marthaler, 2005):
• Your state’s nurse practice act.
• Job descriptions.
• Staff competencies.
• Clinical situation.
• Professional standards.
• Patient needs.
What activities can usually be delegated? The following is a list of potential activities that may be delegated.
Direct Patient Care Activities
Vital signs
• Take and record blood pressure, respirations, temperature, and pulse rate.
• Obtain daily weight.
• Apply leads and connect to cardiac monitor.
Intake and output
• Measure and record intake and output.
• Collect specimens.
Activities of daily living
• Perform total or partial bed bath.
• Perform perineal care.
• Shave.
• Wash hair.
• Perform mouth care.
• Change linen and assist with making occupied bed.
Nutrition
• Feed patient.
• Calculate and record calorie count.
Skin care
• Perform back care.
• Prepare skin for procedure.
• Perform skin prep for operative procedure.
Activity and mobility
• Assist in ambulating patient.
• Perform passive and active range of motion.
• Position.
• Turn and reposition patient.
• Assist with transfers.
Respiratory support
• Set up oxygen.
• Assist patient with using an incentive spirometer.
• Assist patient with coughing and deep breathing exercises.
Procedures
• Set up patient room (suction canisters, cables for continuous cardiac monitoring, tubing for chest tubes).
• Orient patient to room environment.
• Obtain necessary supplies for sterile procedure.
• Perform postmortem care.
Indirect Patient Care Activities
Cleaning
• Clean equipment in use and stored equipment.
• Clean environment, including counter tops and desk tops.
• Clean and defrost food refrigerators.
• Clean patient care area after transfer or discharge.
• Clean patient care area after procedures are completed.
• Empty waste baskets in patient rooms and unit.
• Empty linen hampers.
• Remove meal trays.
• Clean supply carts.
• Clean and restock procedure rooms.
• Make unoccupied beds.
Errands
• Deliver meal trays.
• Obtain and deliver supplies.
• Obtain and deliver equipment.
• Obtain and deliver blood products.
• Check laboratory specimens for appropriate labeling.
• Deliver specimens to clinical laboratory.
Clerical tasks
• Place pages.
• Place and answer phone calls.
• Assemble, disassemble, and maintain patient charts.
• Transcribe physician and nursing patient care orders.
• Schedule diagnostic tests and procedures.
• Order necessary office supplies and forms.
• Sort and deliver mail.
• Keep unit log books up to date with patient admissions, transfers, and discharges.
• Maintain awareness of nursing bed assignments.
Stocking and maintenance
• Stock patient bedside supplies.
• Stock unit supplies.
• Stock utility rooms.
• Stock treatment, examination, and procedure rooms.
• Stock nourishments and kitchen supplies.
• Check electrical equipment for inspections due dates.
• Stock linen cart.
Activities That May Not Be Delegated
Nursing activities that may not be delegated include the following:
• Formulating a nursing diagnosis.
• Identifying nursing care goals and developing the nursing plan of care in conjunction with the patient and/or family.
• Updating the patient’s plan of care.
• Providing patient education to patient and/or family.
• Evaluating a patient’s progress, or lack thereof, toward achieving desired goals and outcomes.
• Discussing patient issues with physician.
• Communicating with physicians or implementing orders from physician.
• Documenting the patient’s assessment or response to therapeutic interventions in the patient’s plan of care.
• Administering medications.
• Providing direct nursing care.
Adapted from American Association of Critical-Care Nurses (2004).
Obstacles to Delegation
There are obstacles to delegation. Nurses who have worked with primary care models for much of their professional life may have difficulty in giving up aspects of nursing care. It is important to keep in mind that “effective teams focus on integrative work processes while working toward a common goal” (Anthony, Standing, & Hertz, 2000).
Barriers to delegation can arise not only on the part of the delegator, the RN, but also on the part of the delegatee, the UAP, and the situation/environment.
Characteristics that create barriers in the delegator.
• Preference for operating by oneself.
• Demand that everyone know all the details.
• “I can do it better myself” fallacy.
• Lack of experience in the job or in delegating.
• Insecurity.
• Fear of being disliked.
• Refusal to allow mistakes.
• Lack of confidence in subordinates.
• Perfectionism, leading to excess control.
• Lack of organizational skill in balancing workloads.
• Failure to delegate authority commensurate with responsibility.
• Uncertainty over tasks and inability to explain.
• Disinclination to develop subordinates.
• Failure to establish effective controls and to follow up.
Characteristics that create barriers in the delegate.
• Lack of experience.
• Lack of competence.
• Avoidance of responsibility.
• Overdependence.
• Disorganization.
• Overload of work.
• Immersion in trivia.
Characteristics that create barriers related to the situation/environment.
• One-person-show policy.
• No toleration of mistakes.
• Criticality of decisions.
• Urgency, leaving no time to explain (crisis management).
• Understaffing.
Adapted from American Association of Critical-Care Nurses (2004).
Levels of Clinical Experience
The use of effective delegation has been related to levels of clinical experience (Benner & Benner, 1984, cited in Carroll, 2006).
The novice nurse has limited experience with tasks and needs rules to guide actions.
The advanced beginner has enough experience to recognize patterns in work but continues to need help in setting priorities; relies on rules and protocols.
The competent nurse has been practicing 2 to 3 years; can prioritize and cope with various contingencies; requires assistance working through various situations not yet experienced.
The proficient nurse has enough experience to see the “big picture” rather than a series of individual accidents/actions; decision making is more efficient and accurate; is able to prioritize and plan even more challenging patient care.
The expert no longer relies on rules to understand a situation or to act appropriately; focuses quickly on viable solutions; is able to lead a team efficiently; can organize others’ work and supervise them effectively.
So, it is important to know the nurses with whom you are working on any given day, so that you can also use their level of expertise in the planning of your delegation. The following guidelines may help RNs delegate more effectively:
• Be aware of your internal barriers to delegation.
• Delegate to the most appropriate person, carefully considering these factors:
• Patient acuity.
• The activity to be performed.
• The support person’s job description.
• Competencies of the individual who will complete the task.
• Communicate clearly. How one communicates a task can determine how successfully it will be completed. Ineffective communication is the most commonly cited reason delegated activities are not completed as expected.
(American Association of Critical-Care Nurses [AACN], 2004).
Koloroutis et al. (2007) described three scenarios that can be used as a means of determining the most appropriate method of delegation to become part of the staffing assignments of a unit. These scenarios are unit based, pairing, and partnering.
Unit-Based Scenarios
In the unit-based scenario, assistive personnel, such as the ward secretary and nursing assistant, serve the unit. The nursing assistant works off a task list usually found in the job description, and has minimal direction from, or interaction with the RNs. An example of the unit-based scenario is assigning a nursing assistant to take all the vital signs or bathe all the patients. But another nurse may ask the nursing assistant to help with picking up medications from pharmacy, while another nurse asks the NA to assist with feeding a patient.
Pairing
In a pairing scenario one RN works with an LPN and/or an NA for the shift. However, the RN and LPN and/or assistant are not intentionally scheduled to work the same shift each day. Delegation usually increases with pairing. In this scenario, the RN and the LPN or NA are able to discuss how care is to be prioritized and how it is to be done, and identify expected individualized outcomes for the shift
Partnering
In partnering, one RN and one LPN and/or NA are consistently scheduled to work together, making a commitment to maintain healthy interpersonal relationships, trust each other, and advance each other’s knowledge
Priority Setting
Proper delegation also requires priority setting. One of the most difficult challenges facing both the nurse and the nurse manager is the prioritization of care delivered to the patients on a unit. The priorities change rapidly and the nurse manager should be aware of the unit needs at all times. To manage your priorities and to control the activity of the workplace around you, Carrick et al. (2007) suggest the three I’s:
1. Identify your priorities.
2. Interact differently with others.
3. Initiate action.
To identify your priorities, list your entire job-related responsibilities on a piece of paper. Then classify the top priorities, and create a “to-do” list that you can work from during the day. Remember, this list will change as the day progresses, but keep updating it and rank your priorities as they change. This list serves as a reference for the actions of the day.
To interact differently with others, Carrick et al. (2007) recommend the following four tactics to maintain control over your time, energy, and priorities.
• Identify a time when you can handle an issue: You cannot refuse a task or patient request, but you will be able to say when you will be available to do the task. Reassuring a person that you will complete the task and giving a timeline, help to control requests and interruptions that compete for your time.
• Ask questions before taking on an assignment: Before you take on any assignment, you need to understand the scope, the intended outcome, and the deadlines.
• Ask for help when you need it: Quickly do a reality check of your time, prioritize alternatives, and then meet with the person who can help you make the right decision or complete the assignment. When asking for help, be realistic about the expectation of the other person, and be open to alternative decision making.
• Use delegation to manage your responsibilities: You cannot do it all! When delegating, be sure to explain the scope, expectations, roles, responsibilities, and authority for the task. Always be available as a resource.
To initiate action, you need to set realistic goals. To set realistic goals, be SMART: the goals need to be specific, measurable, attainable, relevant, and time bound.
As a nurse manager, you have a responsibility to control time, set appropriate priorities, and act on the priorities. In setting priorities, you will always need to keep in mind the following question: “Of all of the important things that I need to do right now, which is the most important for the patient(s)?” Is it urgent? Or just important?
Summary
Delegation is one of the most challenging activities of the new manager. There is more nursing care needed than nurses to provide that care. In addition, not all care needed for a patient requires a professional nurse. Nurses must work within an interdisciplinary team and with individuals of varying capabilities and talents.
Delegation skills are developed by the new nurse over time. It involves an awareness of the total patient care needs for the patients assigned, as well as a thorough knowledge of the capabilities and competencies of staff members. Delegation is a process that results in safe and efficient patient care if it is used appropriately. It is a critical step in the delivery of nursing care.
In summary, the Four Delegation Steps identified by the National Council of State Boards of Nursing and The American Nurses Association will serve as a guideline for effective delegation: Step One – Assessment and Planning; Step Two – Communication; Step Three – Surveillance and Supervision; Step Four – Evaluation and Feedback (https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf [pp. 7-9]).
Clinical CornerDelegation and the New Nurse
A wide range of emotions is expressed when nurses share their stories about how they learned, or if they had formal education specific to nursing delegation. Experiences vary in degree and sentiment, and very often, reactions tend to run the gamut; some are explosive “It was trial by fire!” most are questionable “I don’t remember learning about that!” and all were learning experiences on what to do or what not to do in the future. Often, the responses are reflective of how the nurse was “formed.” Educational background, years of experience, and formal versus extemporaneous education factor into the equation.
Clinical staff are directly impacted by these experiences. It can make or break a positive orientation/on-boarding process, develop or degrade teamwork and collaboration, and it can even be a factor if a newly hired nurse or other hospital worker decides to rethink their decision on whether to stay at the institution or even to leave the field altogether. Therefore, it is critical for faculty and staff development specialists to create solid curriculum to implement a variety of learning modalities aside from the dry, and sometimes tedious, lecture, by mixing it up with simulations, discussions, anecdotes, role-playing, and the like. The goal of the education of nurses in the art of delegation is to develop skilled, professional clinical leaders who are excellent communicators, efficient, and conscientious, and who achieve positive patient care experiences and desired outcomes.
Delegation keeps costs down, builds effective and solid teams across health care disciplines, and involves education and collaboration. It relies on an enormous team effort and mandates clear, coordinated communication skills. It is an expected nursing competency and as nurses become proficient in delegation, it allows them to make sound judgments about patients and coordinate optimal patient care (Currie, 2008).
Reflecting on my past early experiences as a new nurse “delegator,” I decided to ask my current class of registered nurse (RN) to Bachelor of Science in Nursing (BSN) students the following questions:
• What do you remember about the subject of delegation?
• Were you taught this subject in nursing school?
• Did you have a degree of mastery or comfort with this skill?
Would you share your nursing delegation initiation story with me?
I share with you these stories, and of course, mine.
Personal Reflection #1 Kimberly
“I went to nursing school at a community college. I graduated in 1997 with an Associate Degree in nursing. We were not taught how to delegate in school at all! When I started on the floor, we had a 4- to 6-week orientation. During that orientation, my preceptors showed me how to assign certain tasks to the tech. They were the ones who instructed me on what could and could not be assigned to the techs, and what had to be done by me as the nurse. They also made it clear that whatever I assigned to the tech, I was still ultimately responsible. Then one day I came in to work to find out that I was in charge. My delegation education at this level was baptism by fire. I was put in charge with no training, and part of the responsibility was to complete the assignment for the floor, as well as assign admissions as they came up. Oh, and if you screw it up, everyone will be miserable for the shift!”
Reflection #2 Deborah
“When I attended nursing school 32 years ago, we were never formally taught nursing delegation or peer delegation. We learned how to delegate from our nursing instructors. My nursing clinical rotations consisted of 8 hours of direct patient care followed by post-evaluations. Upon graduation, we knew how to function on the floor.
Today, as a preceptor for new RNs in Labor & Delivery, I think that the new graduates are not well prepared in the role of delegation. Prioritization skills are lacking and they are more focused on ‘tasks’ rather than the bigger picture or the ‘whole picture.’ I lead by example and support them in every way to make them feel comfortable and not to feel intimidated. I am currently orienting a patient care assistant (PCA) and use the same techniques as mentioned above.”
Reflection #3 Michelle
“Let me share with you my operating room experience today. I needed to turn our room around quickly, but of course, safely. We had the same surgeon following himself; therefore, I needed to manage my time wisely. I helped the surgical tech open all of the instrumentation so she would not feel as if I had put it all on her. Really, I should have been seeing the patient, going over her history, obtaining the meds needed for the case, and putting some of the information in the computer. But because I myself was a tech at one time, I knew how it felt to be left on your own and open up an entire room by yourself.
After helping the tech, I went to see my patient. It took me about 15 minutes as she had a long history. When I brought my patient to the room, the tech was gone and had not communicated to me where she was going. There should always be two people in a room with a patient in case of a code, or other emergency. The tech felt it was unfair that she did not get a break and I did. I told her that she could have said something, I would have given her more time for lunch to make up for a break; communication is key. Safety first: she was not being responsible in leaving the room and not letting me know where she was. I work hard and do lead by example.”
Reflection #4 Donna
“As a new RN working nights on an orthopedic unit, I remember feeling that I had to do it all. I was afraid to ask for help from the nursing assistants because I felt intimidated by their veteran status and I was not at all confident in my new role. I didn’t have a good sense of what the big picture was, how it impacted my patients, my team, and my ability to be a better nurse. I remember many times leaving late from work because I couldn’t complete all my work in a timely manner. Charting was always put off until the bitter end; and when it came time to remember what needed to be charted, that became another brutal memory game.”
Reflection #5 Kathleen
“As a relatively new RN, I was partnered with a licensed practical nurse (LPN) for an assignment of 10 patients. I was told I needed to hang all IV meds (intravenous medication) because they needed to be mixed and that is not in the scope of an LPN. Looking back now, I was unclear of the scope of LPN practice and the job description for what I could expect from her.
These were all my patients and my responsibility. The situations were difficult as I was unclear what I could delegate to the LPN; she was happy to keep busy with her patients and remind me she could not administer certain meds.
I found myself unprepared to delegate, not even sure what that looked or sounded like and therefore cared for the full patient load myself (at least this was my perception). Delegating to this LPN also seemed difficult to me as she was an older nurse who had been there much longer than me.
Delegation to unlicensed care providers, such as a nursing assistant and unit clerk was also something I struggled with. In this case, I had been a nursing assistant in another hospital before becoming a nurse. I think this helped me know ‘what nursing assistants do‘ so I did not have that issue, but the nursing assistants were very experienced, and again, older than me. This was sometimes a barrier for me as a new young nurse. The nursing assistants did not always like a new and young person telling them what to do. However, I did have the opportunity to work with some amazing nursing assistants where this was not an issue and I learned plenty from them as well.
To say what I have learned since, one very important point my very experienced nurse manager taught me was to communicate with the person you are delegating to within the framework of the patient. Instead of asking the nursing assistant, ‘Could you please do me a favor and take Mr. Smith to the bathroom,’ we need to say, ‘Our patient Mr. Smith needs to use the bathroom. Will you assist him as I am beginning a dressing change for our patient Mrs. Johnson.’ She taught me that this language is more respectful and builds the staff as a team with the care of the patient in the center. The care I am requesting is to meet the patient’s need, not purely my need. One other lesson learned is to be well aware of job descriptions and scope of practice for those with licenses.”
Common themes come to the surface with these reflections. Often, the RN with the delegation dilemma is a new RN, with limited (if any) experience. A certain baseline level of discomfort exists and causes anxiety. Initially, the nurse views delegation as a “to-do” list of tasks that need to be completed during a certain prescribed time. Most of the delegation decisions are based on job descriptions: patient care associate, RN, other ancillary help. Rarely does a new delegator use their nursing judgment and take into consideration each person’s strengths and weaknesses, who is suited to the various subtitles, etc. Delegation is a process. The nurse assesses if, when, or where assistance is needed. She/he then selects the appropriate person. The assistance is carried out under that “umbrella” supervision, and lastly, the delegation process is evaluated and feedback is shared. The nurse prioritizes the patients’ needs, considers their condition, differentiates between nursing versus non-nursing tasks, and selects tasks to be delegated. The nurse then chooses the appropriate member of the team to assume the task. Nurses need to know the skill level of each team member to match the assignment appropriately (Curtis & Nicholl, 2004).