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On a busy evening, Shannon, a registered nurse, is assigned to care for eight hospital patients. Because her unit is short-staffed, Jordan, an unlicensed assistive personnel (UAP), has floated from another department to help out. Although she has worked with Jordan before, Shannon still feels uneasy delegating tasks to him and wishes more nurses were working on this night. Your concerns are valid. Delegation errors are a primary factor in malpractice lawsuits against nurses. Many nurses are confused about when and how to delegate, and some aren’t clear on state laws and facility policies that pertain to delegation. “Why do I have to delegate?” Step-by-step decision process Decision #1: Do state rules and regulations support delegation? Decision #2: Do my state and facility permit me to delegate this task? Determine if state law and facility policies permit you to delegate the specific task. Does the task lie within the scope of RN practice in your state? Remember—nurses must be licensed and able to perform any task they delegate. Also, the task must be one that your facility designates as delegatable and that UAP can perform. A delegatable task is one that doesn’t require nursing judgment. Typically, it’s repetitive—for instance, measuring urine output and vital signs. Don’t delegate tasks that require specialized knowledge or complex observations, such as monitoring a patient with chest pain. Even experienced UAP aren’t educationally prepared or licensed to perform such complex tasks. Even if a task is delegatable, UAP aren’t permitted to perform it independently. When delegating a task, you must do so in a specific situation. For instance, Shannon’s hospital may permit Jordan and other UAP to ambulate patients—but only Shannon can decide whether Jordan should ambulate a particular patient at a particular time. As a general rule, don’t delegate the assessment, planning, and evaluation steps of the nursing process. Most nurse practice acts specifically prohibit nurses from delegating initial patient assessments, discharge planning, health education, care planning, triage, and interpretation of assessment data. UAP, licensed practical nurses (LPNs), and licensed vocational nurses (LVNs) can collect patient data, but only the registered nurse can interpret data. Jordan might report to Shannon that Mr. Wareham’s urine output for the past 2 hours measures 20 cc. But he shouldn’t interpret what this means—for instance, by stating that the patient’s output is “low” or that Mr. Wareham “doesn’t look good.” Only the nurse can interpret assessment data. Decision #3: Have I assessed the patient and evaluated current needs? Nurses are expected to foresee possible harm to patients. This means Shannon must assess patients before delegating tasks—or at least be confident a task has a predictable outcome. If a high-risk stroke patient requires feeding, Shannon must assess him first to know if he can safely swallow. Jordan can’t make that evaluation, and Shannon shouldn’t depend on Jordan’s judgment. Decision #4: Have I assessed the UAP’s abilities? Beyond these basics, how would Shannon know if Jordan is competent? She could recall her experience working with him. She could ask co-workers, including the nurses and educators who trained him. If she can’t get relevant information from them, she should ask Jordan the following key questions before assigning him the task: • Have you been trained to do this task? • Have you ever performed this task with a patient? • Have you ever done this task unsupervised? • How confident are you about performing this task accurately? • What problems have you encountered with this task in the past? Based on the answers to these questions, Shannon may decide to delegate, not to delegate, or to provide direct supervision while Jordan performs the task. Ask the same questions before delegating a task to an LPN or LVN. Obtain copies of the LPN or LVN scope of practice and job descriptions. Base your decision on what the LPN or LVN is legally permitted to do—not on what that employee has “always done around here.” Don’t delegate tasks outside the LPN’s or LVN’s practice scope. In an unpublished case, an RN delegated care of an unstable neonate to an LPN. The RN didn’t specify how often to check the blood glucose level and did not reassess the patient, on the grounds that the LPN “has worked here longer than I have.” The neonate suffered permanent neurologic damage, and the family received a large, undisclosed award. Bottom line—LPNs should accept only those assignments they’re qualified, prepared, and licensed to perform. Decision #5: Is adequate RN supervision available? Decision #6: Would a reasonable, prudent nurse delegate the task in this situation? • She can ask an experienced colleague for advice. • She can practice delegation using the decision tree with written or simulated case studies. • She can request a peer review of her delegation decisions. • She can contact the facility’s risk manager for answers to specific legal questions. Decision #7: Have I communicated clearly to the UAP? Even if you’ve worked with a particular UAP for a long time, avoid the urge to mind-read or make assumptions about what the worker understands. If you rely on the judgment of a UAP—even an experienced one—you could be placing yourself in legal jeopardy. Be diligent in communicating and following up on delegated tasks. Give UAP constructive feedback. At the end of shift, Shannon might tell Jordan, “Thanks for your help tonight. I’m especially glad you gave me those frequent vital signs on Mr. Downey. Next time, let’s concentrate on shortening our wait time for transports off the unit.” When UAP make mistakes, keep your communications positive to maintain a good working relationship. Remember—UAP are valuable resources. The UAP who “knows” a unit is an asset. Retaining competent UAP benefits all stakeholders. By the end of decision #7, you may be exhausted and wish you could just perform the task yourself. Resist this urge. Instead, push yourself to keep delegating. Remember—delegating gets easier with experience. If you’re still having difficulty, ask your colleagues for feedback on your delegation decisions. Who’s responsible for mistakes UAP make? Affirmations to ease your anxiety • I’m familiar with state and facility delegation guidelines. • I know what types of delegation are legal. My colleagues and I support each other within these norms. • I know how to determine whether a UAP is prepared to perform a task. • I can let go of tasks I’ve always done. I can learn new skills and eventually enjoy them. • I will gain confidence in delegating as I gain experience. • I feel comfortable requesting peer review for my delegation decisions and will modify my decision making as needed. Write down these affirmations and place them on a mirror, screensaver, or pocket card. Setting an achievable goal Selected references Croke E. Nurses, negligence, and malpractice: an analysis based on more than 250 cases against nurses. Am J Nurs. 2003;103:54-64. Gosfield A, Reinertsen J. The 100,000 Lives Campaign: crystallizing standards of care for hospitals. Health Aff. 2005;24:1560-1570. Hansten R, Jackson M. Clinical Delegation Skills: A Handbook for Professional Practice. 2nd ed. Sudbury, Mass: Jones and Bartlett; 2004. Mahlmeister L, Koniak-Griffin D. Professional accountability and legal liability for the team leader and charge nurse. J Obstet Gynecol Neonatal Nurs. 1999:28(3):300-309. Pamela S. Anderson, RN, BSN, CCRN, is a Staff Nurse in the intensive care unit at Ball Memorial Hospital in Muncie, Ind. and a graduate student in the Nurse Practitioner program at Ball State University in Muncie. Renee Samples Twibell, RN, DNS, is Associate Professor at the School of Nursing at Ball State University; she is also a Nurse Researcher and a Staff Nurse in the progressive care unit at Ball Memorial Hospital. Debra Siela, RN, DNSc, CCNS, APRN,BC, CCRN, RRT, is Assistant Professor at the School of Nursing at Ball State University; she is also an ICU Clinical Nurse Specialist at Ball Memorial Hospital.
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