1. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Effective Delegation and
Supervision
Insert Chapter 18 opening illustration

2. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Key Concepts
• Staffing patterns in the current health care
system
• Principles of delegation and supervision
• Safe delegation practices
• Delegation vs. assignment

3. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Effective Delegation and
Supervision
• Accomplish patient care safely
• Effectively use a variety of skilled and
nonskilled workers
• Provide essential skills for the RN in any
practice role or setting

4. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Issues Affecting Staffing
Patterns
• Balanced Budget Act of 1997
• Managed care
• Prospective payment system
• Nursing shortage

5. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Changes in Staffing Patterns
• Decline in the number and utilization of RNs
• Increased utilization of unlicensed assistive
personnel (UAP)
• Overlapping of care providers’ roles

6. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Economic Necessity
• Place for competent, appropriately supervised
UAPs and licensed practical nurses/licensed
vocational nurses (LPNs/LVNs ) in patient care
• RNs’ confidence with delegation and supervision
skills is essential

7. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Delegation
• Management strategy to accomplish cost-
effective health care
• Transfer of responsibility and authority for the
performance of an activity
• RN remains accountable for outcomes
• Two-way process between RN and delegatee

8. Mosby items and derived items copyright © 2002 by Mosby, Inc.
RN Delegator Responsibilities
• The act of delegation
• Supervising the performance of the delegated
task
• Assessment and follow-up evaluation
• Any intervention or corrective actions required to
ensure safe and effective care

9. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Delegatee Responsibilities
• Monitoring his or her own actions
• Accepting delegation within the parameters of
training and education
• Communicating appropriate information to
delegator
• Completing the task

10. Mosby items and derived items copyright © 2002 by Mosby, Inc.
What Can Be Delegated?
• No definitive list
• Varies:
– From state to state
– From organization to organization
– From situation to situation
• Assessment, evaluation, and nursing
judgment cannot be delegated

11. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Delegation Guidance
• State nursing practice acts
• Patient needs
• Job descriptions
• Competencies of employees
• Policies and procedures
• Clinical situation
• Professional standards of nursing practice

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State Nursing Practice Acts
• Provide guidance for legal delegation
• Criteria may be presented in various parts of the
act
• State Board of Nursing can offer guidance
• Know legal scope of practice for LPN/LVN
• UAP practice generally governed by the health
care organization

13. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Patient Needs
• RN must perform patient assessment
• Stable patients generally mean a safer
delegation opportunity
• Tasks that can be delegated may be
intertwined with a nursing responsibility

14. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Job Descriptions
• Detail tasks and responsibilities required as a
condition of employment
• Comply with state laws and organization’s
standards of care
• Training should be related to the job description
• Legal requirements supersede organizational
policies

15. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Competencies
• Confirm the staff member’s specific knowledge
and skills
• Written competency documentation required
by regulatory and accrediting agencies
• RN should be knowledgeable of staff
members’ competencies

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Organizational Policies and
Procedures
• Designate specific skill level and supervision
requirements for tasks
• Designate general standards of care such as
infection control

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Clinical Situation
• Time to perform the task
• Familiarity with characteristics of the population
• Complexity of the task
• Resources to perform the task
• Adequate supervision available

18. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Professional Standards of
Nursing Practice
• Agreed-upon levels of nursing practice
competence determined by American Nurses
Association (ANA) and specialty nursing
organizations

19. Mosby items and derived items copyright © 2002 by Mosby, Inc.
ANA’s Delegation Standard
• When delegating, the RN will consider:
– Assessment of the patient condition
– Capabilities of the nursing and assistive staff
– Complexity of the task to be delegated
– Amount of clinical supervision needed
– Staff workload

20. Mosby items and derived items copyright © 2002 by Mosby, Inc.
ANA’s Delegation Standard—
cont’d
• What can be delegated:
– Feeding, drinking, positioning, ambulating,
grooming, toileting, dressing, and socializing
– Collecting, reporting, and documenting data related
to these activities
– Maintaining a clean, safe, and efficient environment
– Housekeeping, transporting, and record keeping
– Stocking and maintaining supplies

21. Mosby items and derived items copyright © 2002 by Mosby, Inc.
ANA’s Delegation Standard—
cont’d
• What cannot be delegated:
– Initial nursing assessment
– 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

22. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Safe Delegation Practices
• Establish a foundation of knowledge
• Assess patient before delegation
• Know delegatee’s knowledge and skill level
• Know the task to be delegated
• Comply with skill requirements in written policies
and procedures

23. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Safe Delegation Practices—
cont’d
• Explain task and outcomes
• Expect responsible action
• Assess and supervise job performance
• Provide for positive outcomes
• Evaluate and follow-up

24. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Safe Delegation Practices—
cont’d
• Know specific standards of nursing practice
• Be involved in LPN/LVN and UAP training
programs
• Help develop LPN/LVN and UAP job
descriptions
• Always evaluate the delegated action
• Never ignore poor performance

25. Mosby items and derived items copyright © 2002 by Mosby, Inc.
High-Risk Delegation
• Task should be performed only by an RN
• Task could involve substantial risk for the patient
• Delegatee has not had the necessary training
• RN fails to provide adequate supervision
• RN fails to evaluate the delegated action

26. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Delegation and the
Nursing Process
• Assess the patient and plan the care
• Identify tasks that someone else can perform
• Implement the plan of care
• Assign and supervise task performance
• Evaluate performance and client response

27. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Five Rights of Delegation
• Right task
• Right circumstances
• Right person
• Right direction and communication
• Right supervision and evaluation

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Supervision
• Active process of directing, guiding, and
influencing a worker’s performance
• On-site supervision
– Physically present or immediately available
• Off-site supervision
– Available through written and verbal communication
– Increased use of telecommunications technology is
raising supervision questions

29. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Components of Supervision
• Initial direction
• Periodic inspection
• Levels of supervision
– Unsupervised
– Initial direction and periodic inspection
– Continuous

30. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Supervising
• Make frequent rounds, observe, and
communicate
• Provide the appropriate level of supervision
• Be available for questions/unexpected
problems
• Supervise in a positive, supportive manner

31. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Supervising—cont’d
• Intervene immediately if the task is not being
performed safely and appropriately
• Never ignore poor performance—document
and report
• Use mistakes as learning opportunities

32. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Assigning vs. Delegating
• Assignment
– Transfer of responsibility and accountability is
downward or lateral
– Activities designated are consistent with job position
and qualifications
– Staff member assumes responsibility and is
accountable

33. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Assignment Considerations
• UAP assignments are functions and tasks, not
patients or groups of patients
• LPN/LVN may be assigned specific clients for
whom to perform care
• RN remains responsible for nursing practice
activities

34. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Assignment Considerations—
cont’d
• Patient’s psychologic status
• Patient’s physiologic status
• Complexity of care
• Infection control or cross-contamination
• Level of supervision required
• Staff development opportunities

35. Mosby items and derived items copyright © 2002 by Mosby, Inc.
The Transdisciplinary Team
• Teams valuable in meeting patient care needs
• Team members should know scope of practice
and training of other team members
• Team members may report to the RN
• Team members may report to supervisors in
their individual disciplines and work
collaboratively with the RN

36. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Barriers to Effective Delegation
• Fear of being disliked
• Fear of losing control
• Fear of taking risks
• Fear of making mistakes
• Lack of confidence
• Lack of knowledge

37. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Effective Delegation and
Supervision Skills
• Communicate effectively
• Create an environment of trust and cooperation
• Create an environment of teaching and learning
• Promote patient satisfaction
• Provide feedback and follow-up

38. Mosby items and derived items copyright © 2002 by Mosby, Inc.
Appropriate Feedback
• Provide honest feedback about performance
• Praise good performance
• Address poor performance
– Immediately stop inappropriate, unsafe, or
incompetent performance
– Document and report
– Request additional training or other action