3. Issues Affecting Staffing Patterns
Reduced reimbursement from Medicare, Medicaid, and
private insurance companies
Prospective payment system
Growing uninsured population
Rapid advances in medical technology
Nursing shortage
4. Changes in Staffing Patterns
Decline in the number and utilization of registered nurses
(RNs) and an increase in the employment of nursing
assistive personnel (NAP)
Increased utilization of NAP forces the RN to delegate more
nursing tasks.
Roles and responsibilities of care providers (RNs, licensed
practical nurses/licensed vocational nurses [LPNs/LVNs],
NAP) are significantly overlapping
5. Economic Necessity
Need competent, appropriately supervised NAP and
LPNs/LVNs in patient care
RNs’ confidence with delegation and supervision skills is
essential
RNs must understand legal responsibility related to
delegation and supervision
7. Definition
Transfer of responsibility for the performance of an activity
from one individual to another while accountability for the
outcome is retained
RN transfers responsibility and authority for the
performance of an activity but remains accountable for
overall nursing care
Management strategy used to ensure the accomplishment of
cost-effective patient care
8. Two-Way Process
RN delegator is responsible for the following:
The act of delegation
Supervising the performance of the delegated task
Assessment and follow-up evaluation
Any intervention or corrective action that may be
required to ensure safe and effective care
9. Two-Way Process
The delegatee (LPN/LVN, NAP) is accountable for the
following:
His or her own actions
Accepting delegation within the parameters of his or
her training and education
Communicating the appropriate information to the
delegator
Completing the task
11. No Definitive List
No definitive list of what can and cannot be delegated
Varies among states, organizations, and specific situations
Assessment, evaluation, and nursing judgment cannot be
delegated.
12. No Definitive List
RNs will have to seek guidance and integrate information
from
State Nursing Practice Acts
Patient needs
Job descriptions
Employee competency
Policies and procedures
Clinical situation
Professional standards of nursing practice
13. State Nursing Practice Acts
State Nursing Practice Acts
Will provide guidance for legal delegation
Delegation criteria may not be clearly spelled out or may
be presented in various parts of the Act
State board of nursing also may offer guidance
RN should understand the legal scope of practice for an
LPN/LVN
Practice by NAP is generally governed by the health care
organization’s standards
14. Patient Needs
RN is required to perform a patient assessment and to
know the level of care required
Generally, the more stable the patient, the more likely
delegation is to be safe
Many tasks that can be delegated may be intertwined with
a nursing responsibility
15. Job Descriptions
Delineates the tasks, duties, and responsibilities required as
a condition of employment
Generally comply with state laws and the health care
organization’s standards of care
RN should be aware of the job training required to function
as described in the job description
In all cases, legal requirements related to delegation
supersede any organizational policy or job description
16. Competencies
Staff member must have the skills and knowledge necessary
to perform a task before it is delegated
Competencies confirm that the individual has demonstrated
specific knowledge and skills
Regulatory and accrediting agencies, such as The Joint
Commission, require written documentation of staff
competencies
RNs should be knowledgeable about the documented
competencies of staff members whom they supervise
17. Competencies
Examples of competencies for an ambulatory care clinic:
Medication management
Telephone triage
Infection control
Glucose testing
Reporting abuse and neglect
18. Organizational Policies and Procedures
The specific skill and supervision requirements for various
tasks are designated in written policies and procedures
Ensure that the delegatee is trained in and understands
the organization’s general standards of care (e.g.,
infection control)
19. Clinical Situation
Does the NAP/LPN/LVN realistically have time to perform
the task?
Is the staff member familiar with characteristics of the
patient population?
How complex is the task?
Does the individual have the resources (supplies,
equipment) to perform the task?
Is the RN able to provide an adequate level of supervision?
20. Professional Standards of Nursing Practice
Professional standards of nursing practice
Agreed-upon levels of nursing practice as determined by the
American Nurses Association (ANA) and specialty nursing
organizations
ANA’s standard states that in delegation, the RN will consider the
following:
Assessment of the patient condition
Capabilities of the nursing and assistive staff
Complexity of the task to be delegated
Amount of clinical oversight (supervision) the RN will be
able to provide
Staff workload
21. Professional Standards of Nursing Practice
ANA has delineated activities that can be delegated by
the nurse
Functions that are technical and assistive in
nature and can be taught (e.g., feeding,
ambulating a stable patient)
Activities that provide amenities to the patient
(e.g., making beds, cleaning the environment)
22. Professional Standards of Nursing Practice
ANA has delineated activities that the RN cannot delegate:
Initial nursing assessment and any subsequent assessment
that requires nursing knowledge, judgment, and skill
Determination of nursing diagnoses
Establishment of nursing care goals
Development of nursing plan of care
Evaluation of patient’s progress
Health counseling or teaching
Activities that require specialized nursing knowledge, skill,
or judgment
24. Establish a Foundation of Knowledge
Establish a foundation of knowledge
Know delegation criteria delineated in the state’s Nursing
Practice Act
http://www.state.tn.us/sos/rules/1000/1000-01.pdf
Know specific skill requirements designated in written
policies, procedures, and standards of care
Know delegatee’s scope of practice, competencies, and job
description
Know professional standards for nursing practice and
specific recommendations on delegation
25. Know the Patient
Assess the patient before delegation
What is the potential for change in the patient’s condition
as a result of the delegated task?
Can the patient’s safety be maintained with delegated care?
26. Know the Staff Member
Does the staff member have the skills and knowledge
necessary to perform the task?
Does the staff member perform the task on a routine
basis?
Be involved in training programs and the development of
job descriptions for NAP and LPNs/LVNs
27. Know the Task to Be Delegated
RN delegator must be competent and skilled in performing
the task
Task must be in the RN’s scope of practice
Routine, standardized tasks are the safest to delegate
Complex tasks or activities that convey high risk for patient
complications or unpredictable outcomes must be carefully
considered
28. Explain Task and Outcomes
Failure to effectively communicate may result in
unsatisfactory performance, errors, or patient harm
Clearly explain the task, what must be done, and the
expected outcomes
Demonstration and return demonstration may be
required
29. Expect Responsible Action
Delegatee becomes responsible for his or her own actions
RN should supervise appropriately
RN should not intervene unless assistance is requested,
or an unsafe situation is recognized
30. Assess and Supervise Job Performance
Assess and supervise job performance:
Make frequent rounds, observe, and communicate
Provide the appropriate level of supervision
Be available for questions or unexpected problems
Supervise in a positive and supportive manner
Intervene immediately if the task is not being performed safely
and appropriately
Never ignore poor performance—Document and report
Use mistakes as learning opportunities
31. Provide for Positive Outcomes
Ongoing communication and support are vital
Necessary resources to perform the tasks should be available
32. Evaluate and Follow Up
Evaluate and follow up:
Always evaluate the delegated action by reassessing the
patient
Evaluate the staff member’s performance
Follow up with any interventions that may be required
Review and document the skills that were learned
33. Characteristics of High-Risk Delegation
Delegated task can be performed only by the RN
according to law, organizational policies, or professional
standards of nursing practice
Delegated task could involve substantial risk or harm to a
patient
RN knowingly delegates a task to an individual who does
not have appropriate training
RN fails to provide adequate supervision
RN does not evaluate the delegated action by reassessing
the patient
34. Delegation and the Nursing Process
Components of the delegation process become familiar
when compared with the nursing process
Assess the patient and plan the care, then identify tasks that
someone else can perform
Implement the plan of care, and assign and supervise task
performance
Evaluate the delegatee’s performance, planned outcomes,
and client response
35. “Five Rights of Delegation”
Right task: Delegated tasks must conform to established
guidelines
Right circumstances: Delegated tasks do not require independent
nursing judgment
Right person: One who is qualified and competent
Right direction and communication: Clear explanation about the
task and outcomes and when the delegatee should report back to
the RN
Right supervision and evaluation: Feedback to assess and
improve the process; evaluate patient outcomes
37. Definition
The active process of directing, guiding, and influencing
the outcome of a worker’s performance
On-site supervision—The nurse is physically present or is
immediately available while the activity is being
performed
Off-site supervision—The nurse has the ability to provide
direction through various means of written and verbal
communication
38. Definition
Distinction between on-site and off-site supervision has
become unclear with the use of telecommunications
technologies
ANA has established operational guidelines for
supervision related to telecommunication technologies
Who is in control of the activity?
How should controls be instituted?
39. Components of Supervision
Initial direction: instructions provided when the task is
first delegated
Periodic inspection: the decision the RN makes regarding
frequency of monitoring the delegatee’s performance
40. Levels of Supervision
Unsupervised
One RN works with another RN in a collegial
relationship
Neither RN is in the position of supervising the
other
41. Levels of Supervision
Initial direction/periodic inspection
RN is supervising a licensed or unlicensed caregiver
Knows the individual’s training and competencies
Has developed a working relationship with the
individual
42. Levels of Supervision
Continuous supervision
RN has determined that the delegatee will need
very frequent to continual support and assistance
Continuous supervision is required when
The working relationship is new
The task is very complex
The delegatee is inexperienced or has not
demonstrated an acceptable level of competence
44. Definition of Assignment
Distribution of work that each staff member is responsible
for during a given work period
Designates activities consistent with job position and
description, legal scope of practice, and educational
background
The staff member assumes responsibility and is
accountable for completing the assignment.
45. Assignment Considerations
Assigning groups of clients to various care providers,
including NAP and LPNs/LVNs is not appropriate
NAP assignments would include functions and tasks
LPNs/LVNs may be assigned specific clients for which to
perform care, but RNs remain responsible for all nursing
practice activities
46. Assignment Considerations
The RN is responsible for assignments made to nursing
personnel and should consider the following:
Patient’s physiologic status and complexity of care
Infection control or cross-contamination issues
Level of supervision required
Staff development opportunities such as assigning a
less experienced nurse to a more complex patient
with an increased level of supervision
47. Utilizing the Interdisciplinary Health Care
Team
Interdisciplinary team members will be valuable in
meeting patient care needs
RNs should know scope of practice and training
background of team members
48. Utilizing the Interdisciplinary Health Care
Team
RN should know how the work is delegated or assigned to
interdisciplinary team members
Interdisciplinary team members may report to the RN,
who is responsible for assigning and delegating patient
care tasks
Interdisciplinary team members may report to
supervisors in their individual disciplines and may
work in a collaborative manner with the RN to provide
patient care
50. Novice Nurses’ Barriers to Effective Delegation
Fear of being disliked, losing control, taking risks,
making mistakes
Lack of confidence
Lack of knowledge
51. Communicate Effectively
Know exactly what needs to be done and what outcomes
are expected
Maintain self-control and confidence
Listen carefully to the delegatee’s response
Ask for feedback by using open-ended, nonthreatening
statements if the delegation action elicits a negative
response
52. Create an Environment of Trust and Cooperation
Maintain a nonthreatening and nonjudgmental
attitude—Problems will be reported more
quickly
Avoid blaming and criticizing when mistakes
occur—Look for root causes such as inadequate
training or too heavy workload
Encourage staff members to report and discuss
problems
53. Create an Environment of Teaching and Learning
Remember that inadequate training is a common cause
for poor performance in the work setting
Identify staff learning needs and provide educational
programs aimed at building skills and competencies
Be willing to teach and demonstrate how to perform a
task rather than merely telling how it should be done
54. Promote Patient Satisfaction
Clients need and want to know their caregivers’
qualifications
The RN is responsible for describing the health care team to
the client
55. Provide Feedback and Follow Up
Delegation process is not complete until the RN
reassesses the patient and adjusts the plan of care as
indicated
Provide honest feedback to the delegatee about his or her
performance
Praise good performance
Address poor job performance
Stop inappropriate, unsafe, or incompetent performance
immediately; document and report to the nurse manager
or supervisor
Request additional training or other appropriate action to
ensure that patient safety is protected