What happens when a nurse over delegates

Delegation is an important tool for team cohesion and training in any work setting. It can be a critical time management tool for nurses. But how can nurses delegate most effectively?

Nurses have a variety of duties and, in many cases, a large number of patients in their care. Because patient care requires many time-consuming tasks, delegation is a vital tool to helping nurses spend their time in the most productive ways possible. Registered nurses have the ability to delegate tasks to several different kinds of healthcare professionals, including licensed nurses and nursing assistants, though the precise duties of each role vary from state to state.

Delegation is different from assignment in a few key ways. When you assign a task, that task must fall within the scope of the assignee’s job description, and the education and training required by that job must confer the skills required for completion of the task. When you delegate a task, however, that task is allowed to fall outside the purview of the delegatee’s role, provided delegating the task doesn’t violate hospital policy and that the delegatee has obtained additional education that covers the task in question.

Another important distinction is that the assignee is accountable for the result of the task. However, when you delegate a nursing task, you bear ultimate responsibility for the task’s outcome and must be on hand in a supervisory capacity.

Delegation can save considerable time. In the short term, it can give you the ability to better perform your duties and free you up to focus on other challenges. In the long term, it builds valuable skills in those you delegate to, making it easier to delegate to them in the future.

How to Master Delegation in Nursing

5 R’s of Nursing Delegation

The easiest way to make sure you’re delegating properly is to follow the 5 R’s.

Right Task

While delegation can be a good tool for teaching someone new skills, patient care and safety always comes first. When delegating nursing tasks, make sure you have a high degree of confidence that the task can be completed correctly and safely. The task must fall within the purview of the delegatee’s job role or, if it does not, must fall within hospital procedure. Day-to-day tasks are typically safe to delegate, while more complex tasks should be handled only by those with the proper experience and training.

Right Circumstance

It’s also necessary to be aware of the patient’s current state and to only delegate tasks when the patient is in stable condition. Avoid delegating a task when a patient’s condition is prone to fluctuation or when the patient is in critical condition, as this places the patient in unnecessary danger. In addition, be aware that delegating a task doesn’t mean that the delegatee replaces you in the task; as a skilled nurse, you must be on hand to observe, instruct, and step in if something goes wrong.

Right Person

Don’t delegate tasks to delegatees who have not demonstrated the ability to handle those tasks. Verify that your delegatees have the skills and knowledge required to handle the task safely and correctly.

Right Directions/Communication

Clear, precise communication is important to any kind of delegation; unclear communication can directly impact a patient’s well-being. Your instructions must be clear and understandable so your delegatee can easily follow them. Answer any questions and instruct as necessary during the procedure. Expectations must also be communicated, and the results of the procedure must be conveyed to the proper people as well, according to hospital policy.

Right Supervision/Evaluation

Remember, although you are delegating the task to someone else, you are ultimately responsible for the outcome of that task. Stay on hand to supervise your delegatee and make sure that the patient outcome is a good one. Make corrections and modifications as necessary, and evaluate your delegatee’s work. Provide feedback to allow individuals to improve their skills in the future.

Nursing Delegation Tips and Strategies

Leverage Your Team

Delegation can develop team cohesion and effectiveness, which requires you to know who’s on your team, what their strengths and weaknesses are, and what each is qualified to do. As the 5 R’s say, assigning the right people to the right tasks is crucial to good delegation. In addition, a great way to build skills in your team is to assign tasks to people who have the aptitude but little experience, provided you’re on hand to supervise and instruct.

Respect Your Team

Practicing appreciation and respect throughout the delegation process not only helps learning, it’s also great for team-building. Get your team members involved in the delegation process by discussing your plans with them and soliciting feedback. When you provide or respond to feedback, always do so in a respectful and considerate way. When people complete tasks for you, make sure you thank them.

Observe Job Responsibilities and Qualifications

Delegate tasks only to people who are qualified to perform them and who are allowed to perform them by hospital policy. Failing to follow hospital policy can have significant ramifications for you, your delegatee, and the patient. You must also strive to avoid favoritism and delegate tasks in a fair manner; being too hard on a particular team member can create tension within the team and can also have significant patient care consequences.

Expand Your Nursing Skills

Delegation can be difficult at first, but developing your leadership skills can help you master nursing delegation. Rivier University offers online nursing degrees at the bachelor’s, master’s and doctoral levels that are designed for working nurses to build their skills and achieve their career goals.

In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of assignment, delegation, and supervision in order to:

• Identify tasks for delegation based on client needs
• Ensure appropriate education, skills, and experience of personnel performing delegated tasks
• Assign and supervise care provided by others (e.g., LPN/VN, assistive personnel, other RNs)
• Communicate tasks to be completed and report client concerns immediately
• Organize the workload to manage time effectively
• Utilize the five rights of delegation (e.g., right task, right circumstances, right person, right direction or communication, right supervision or feedback)
• Evaluate delegated tasks to ensure correct completion of activity
• Evaluate the ability of staff members to perform assigned tasks for the position (e.g., job description, scope of practice, training, experience)
• Evaluate the effectiveness of staff members' time management skills

The assignment of care to others, including nursing assistants, licensed practical nurses, and other registered nurses, is perhaps one of the most important daily decisions that nurses make.

Proper and appropriate assignments facilitate quality care. Improper and inappropriate assignments can lead to poor quality of care, disappointing outcomes of care, the jeopardization of client safety, and even legal consequences.

For example, when a registered nurse delegates aspects of patient care to a licensed practical nurse that are outside of the scope of practice of the licensed practical nurse, the client is in potential physical and/or psychological jeopardy because this delegated task, which is outside of the scope of practice for this licensed practical nurse, is something that this nurse was not prepared and educated to perform. This practice is also illegal and it is considered practicing outside of one's scope of practice when, and if, this licensed practical nurse accepts this assignment. All levels of nursing staff should refused to accept any assignment that is outside of their scope of practice.

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Delegation, simply defined, is the transfer of the nurse's responsibility for the performance of a task to another nursing staff member while retaining accountability for the outcome. Responsibility can be delegated. Accountability cannot be delegated. The delegating registered nurse remains accountable for all client care despite the fact that some of these aspects of care can, and are, delegated to others.

Appropriate decisions relating to the successful assignment of care are accurately based on the needs of the patient, the skills of the staff, the staffs' position description or job descriptions, the employing facility's policies and procedures, and legal aspects of care such as the states' legal scopes of practice for nurses, nursing assistants and other members of the nursing team.

The "Five Rights of Delegation" that must be used when assigning care to others are:

• The "right" person
• The "right" task
• The "right" circumstances
• The "right" directions and communication and
• The "right" supervision and evaluation

In other words, the right person must be assigned to the right tasks and jobs under the right circumstances. The nurse who assigns the tasks and jobs must then communicate with and direct the person doing the task or job. The nurse supervises the person and determines whether or not the job was done in the correct, appropriate, safe and competent manner.

The "Right Task" and The "Right Person": Identifying Tasks for Delegation Based on Client Needs

The client is the center of care. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care, among other things such as the scopes of practice and the policies and procedures within the particular healthcare facility.

Some client needs are relatively predictable; and other patient needs are unpredictable as based on the changing status of the client. Some needs require high levels of professional judgment and skill; and other patient needs are somewhat routinized and without the need for high levels of professional judgment and skill. Some client needs are acute, ever changing and/or rarely encountered; and other patient needs are chronic, relatively stable, more predictable, and more frequently encountered.

Based on these characteristics and the total client needs for the group of clients that the registered nurse is responsible and accountable for, the registered nurse determines and analyzes all of the health care needs for a group of clients; the registered nurse delegates care that matches the skills of the person that the nurse is delegating to.

For example, a new admission who is highly unstable should be assigned to a registered nurse; the care of a stable chronically ill patient who is relatively stable and more predictable than a serious ill and unstable acute client can be delegated to the licensed practical nurse; and assistance with the activities of daily living and basic hygiene and comfort care can be assigned and delegated to an unlicensed assistive staff member like a nursing assistant or a patient care technician. Lastly, the care of a client with chest tubes and chest drainage can be delegated to either another registered nurse or a licensed practical nurse, therefore, the registered nurse who is delegating must insure that the nurse is competent to perform this complex task, to monitor the client's response to this treatment, and to insure that the equipment is functioning properly.

Ensuring the Appropriate Education, Skills, and Experience of Personnel Performing Delegated Tasks

The staff members' levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for. Some staff members may possess greater expertise than others. Some, such as new graduates, may not possess the same levels of knowledge, past experiences, skills, abilities, and competencies that more experienced staff members possess. Some may even be more competent in some aspects of client care than other aspects of client care. For example, a licensed practical nurse on the medical surgical floor may have more knowledge, skills, abilities, and competencies than a registered nurse in terms of chest tube maintenance and care because they may have, perhaps, had years of prior experience in an intensive care area of another healthcare facility before coming to your nursing care facility.

Delegation should be done according to the differentiated practice for each of the staff members. A patient care technician, a certified nursing assistant, a licensed practical nurse, an associate degree registered nurse and a bachelor's degree registered nurse should not be delegated to the same aspects of nursing care. Based on the basic entry educational preparation differences among these members of the nursing team, care should be assigned according to the level of education of the particular team member.

Also, staff members differ in terms of their knowledge, skills, abilities and competencies. A staff member who has just graduated as a certified nursing assistant and a newly graduated registered nurse cannot be expected to perform patient care tasks at the same level of proficiency, skill and competency as an experienced nursing assistant or registered nurse. It takes time for new graduates to refine the skills that they learned in school.

Validated and documented competencies must also be considered prior to assignment of patient care. No aspect of care can be assigned or delegated to another nursing staff member unless this staff member has documented evidence that they are deemed competent by a registered nurse to do so. For example, a newly hired certified nursing assistant cannot perform bed baths until a supervising registered nurse has observed this certified nursing assistant provide a bed bath and has decided that they are now competent to do this task without direct supervision.

All healthcare facilities and agencies must assess and validate competency before total care or any aspect of care is performed by an individual without the direct supervision of another, regardless of their years of experience. Competency checklists are used to document the competency of the staff; they must be referred to as assignments are made. Care can be delegated to another only when that person is deemed competent to perform the role or task and this competency is documented.

Scopes of practice are also considered prior to the assignment of care. All states have scopes of practice for advanced nurse practitioners, registered nurses, licensed practical nurses and unlicensed assistive personnel like nursing assistants and patient care technicians.

Assigning and Supervising the Care Provided by Others

The job of the registered nurse is far from done after client care has been delegated to members of the nursing team. The delegated care must be followed up on and the staff members have to be supervised as they deliver care. The registered nurse remains responsible for and accountable for the quality, appropriateness, completeness, and timeliness of all of the care that is delivered.

The supervision of the care provided by others includes the monitoring the care, coaching and supporting the staff member who is providing the care, assisting the staff member with priority setting and time management skills, as indicated, educating the staff member about the proper provision of care, as indicated by a knowledge or skills deficit, and also praising and positively reinforcing the staff for a job well done.

Remember, the delegating registered nurse is still responsible and accountable for all of the client care that is delegated to others.

Communicating Tasks to be Completed and Report Client Concerns Immediately

Registered nurses who assign, delegate and/or provide nursing care to clients and groups of clients must report all significant changes that occur in terms of the client and their condition. For example, a significant change in a client's laboratory values requires that the registered nurse report this to the nurse's supervisor and doctor.

They must also communicate and document all tasks that were completed and the client's responses to this treatment. As the old adage says, "If it wasn't documented, it wasn't done."

Organizing the Workload to Manage Time Effectively

Time is finite and often the needs of the client are virtually infinite. Time management, organization, and priority setting skills, therefore, are essential to the complete and effective provision of care to an individual client and to a group of clients.

Priorities of care, as previously discussed, are established using a number of methods and frameworks including the ABCs, Maslow's Hierarchy of Needs and the ABCs/MAAUAR method of priority setting.

Some time management techniques, in addition to priority setting, that you may want to consider using to insure that you manage your workload and time effectively include:

• Clarifying your assignment as necessary
• Planning your work in an orderly and systematic manner knowing that priorities and clients' status change frequently
• Avoiding all unnecessary interruptions
• Learning how to say no to others when they ask you for help and you have priority patient needs that would not be addressed if you helped another

Utilizing the Five Rights of Delegation

As previously discussed, all delegation may be based on the "Five Rights of Delegation" which are:

• The "right" person
• The "right" task
• The "right" circumstances
• The "right" directions and communication
• The "right" supervision and evaluation

Evaluating Delegated Tasks to Ensure the Correct Completion of the Activity or Activities

In addition to the supervision of delegated tasks in terms of quality, appropriateness, and timeliness, the registered nurse who has delegated tasks must insure that the assigned activities have been correctly completed.

When assignments are made, the registered nurse must insure that the staff member will have ample time during the shift to complete the assignment and, then, the registered nurse must monitor and measure the staff members' progress toward the completion of assigned tasks throughout the duration of the shift.

This monitoring must be done in an ongoing and continuous manner and not at the end of the shift when it is too late to make corrections.

Evaluating the Ability of Staff Members to Perform the Assigned Tasks for the Position

As previously discussed, staff members should have documented competency for all tasks that are assigned to them. All nursing team members have the responsibility, however, to refuse an assignment if they believe that they cannot do it properly. When this occurs, the registered nurse should either teach the staff member how to perform the task and then document their competency in terms of this assigned task or assign the task to another nursing team member who has documented competency and is sure that they can perform the task in a correct manner.

Part of supervision entails the ongoing evaluation of staff's ability by the registered nurse to perform assigned tasks using direct observations and with indirect observations of patient safety, the quality of the care provided, the appropriateness of care provided, and the timeliness of care provided. For example, the registered nurse can directly observe the performance of the nursing assistant while the client is being transferred from the bed to the chair; and the registered nurse can review the medication administration record to determine if the licensed practical nurse has administered medications in a timely manner which is an example of indirect observation.

The ability of a staff member to perform a specific task is not only based on their competency but it is also based on their:

• Legal scope of practice,
• Documented competency,
• Education and training,
• Past experiences,
• Position description which is also referred to as the job description and
• Healthcare facility specific policies and procedures.

All states throughout our nation have legally legislated scopes of practice for registered professional nurses, licensed practical or vocational nurses, and advanced nursing practice nurses; and they also have legal guidelines related to what an unlicensed, assistive staff member, such as a student nurse technician, patient care aide, patient care technician or nursing assistant, can and cannot legally perform regardless of whether or not the healthcare provider or the delegating nurse believes that they are competent to do.

Although these legal, legislated scopes of practice may vary a little from state to state, they share a lot of commonalities and similarities. For example:

• The scope of practice for the registered nurse will most likely include the legal ability of the registered professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis, planning, implementation and evaluation.

• The scope of practice for the licensed practical or vocational nurse will most likely include the legal ability of this nurse to perform data collection, plan, implement and evaluate care under the direct supervision and guidance of the registered nurse.

• The scope of practice for an advanced practice nurse, such as a nurse practitioner, will most likely include the legal ability of the advanced practice registered professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis, planning, implementation and evaluation in addition to prescribing some medications.

Nurses violate scope of practice statutes, or laws, when they function in roles and aspects of care that are above, beyond and/or not included in their scope of practice. Permanent license revocation may occur when a nurse practices outside of the legally mandated scope of practice. Additionally, licensed nurses who have failed to either reapply for their license or have had it revoked as part of a state disciplinary action cannot and continue to practice nursing are guilty of practicing nursing without a license.

Among the tasks that CANNOT be legally and appropriately delegated to nonprofessional, unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and personal care aides, include assessments, nursing diagnosis, establishing expected outcomes, evaluating care and any and all other tasks and aspects of care including but not limited to those that entail sterile technique, critical thinking, professional judgment and professional knowledge.

Some examples of tasks and aspects of care that can be delegated legally to nonprofessional, unlicensed assistive nursing personnel, provided they are competent in these areas, under the direct supervision of the nurse include:

• Assisting the client with their activities of daily living such as ambulation, dressing, grooming, bathing and hygiene
• Measuring and recording fluid intake and output
• Measuring and recording vital signs, height and weight
• The provision of nonpharmacological comfort and pain relief interventions such as establishing and maintaining an environment conducive to comfort and providing the client with a soothing and therapeutic back rub
• Observation and reporting changes in and the current status of the patient's condition and reactions to care
• The transport of clients and specimens and other errands and tasks such as stocking supplies
• Assistance with transfers, range of motion, feeding, ambulation, and other tasks such as making beds and assisting with bowel and bladder functions

In addition to the legally mandated state scopes of practice, the registered nurse must also insure that the delegated tasks are permissible according to the nursing team members' position description which is also referred to as the job description, and the particular facility's specific policies and procedures relating to client care and who can and who cannot perform certain tasks.

For example, intravenous bolus and push medications may be permissible for only licensed registered nurses in certain areas of the healthcare facility such as the intensive care units; the administration of blood and blood components may be restricted to only registered nurses; and the care of a client who is receiving conscious sedation may be restricted to only a few registered nurses in the particular healthcare facility, according to these job descriptions, policies and procedures.

Evaluating the Effectiveness of Staff Members' Time Management Skills

As previously mentioned, the registered nurse must allot a reasonable amount of time for staff members to complete their assignments when care and tasks are delegated. The staff should be able to complete their assignments within the allocated period of time. When an assignment is not done as expected, the delegating nurse should determine why this has occurred and they must take corrective actions to insure task completion.

One of the things that the delegating nurse will want to consider when an assignment is not completed within the allotted time frame is determining whether or not the staff member is organizing their work and using effective time management skills. If the staff member is not using effective time management skills, the nurse must teach and assist the staff member about better time management and priority setting skills.

RELATED NCLEX-RN MANAGEMENT OF CARE CONTENT:

SEE - Management of Care Practice Test Questions

Alene Burke RN, MSN is a nationally recognized nursing educator. She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. She got her bachelor’s of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. She graduated Summa Cum Laude from Adelphi with a double masters degree in both Nursing Education and Nursing Administration and immediately began the PhD in nursing coursework at the same university. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Association’s task force on competency and education for the nursing team members.

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