Element 2: Organisational requirements For employers and managers of nurses and midwives Delegation and Supervision for Victorian Nurses and Midwives

Regulatory requirements The Nursing and Midwifery Board of Australia (NMBA) undertakes functions as set by the Health Practitioner Regulation National Law. NMBA sets the registration standards as well as professional codes, standards and guidelines that underpin safe and competent practice. The NMBA’s requirements of nurses and midwives relating to delegation and supervision are outlined in its publication ‘A national framework for the development of decision-making tools for nursing and midwifery practice’.

Delegation and supervision guidelines for Victorian nurses and midwives In order to become registered, nurses and/or midwives must meet the National Board’s mandatory registration standards. To be effective, nurses and midwives need to have a clear understanding of the requirements. Released in 2014, the guide seeks to reinforce the NMBA publications around decision making, by making practical recommendations and outlining a framework.

Delegation and supervision guidelines for Victorian nurses and midwives The guide was developed following consultancy with key stakeholders, discussions with Victorian nurses/midwives and an international literature review. Makes a number of recommendations, assuming a shared responsibility between: o individuals, o employers, o education providers, o professional bodies, and the o Department of Health and Human Services.

Accountability when delegating Delegation and supervision is, and always has been, a core responsibility of Registered Nurses and Midwives The Registered Nurse or Midwife remains accountable for monitoring and evaluating the effect of any care that has been delegated

Accountability when accepting a delegation Can include EN’s, unlicensed healthcare workers, junior RN/RM’s, other workers: A staff member who accepts a delegation is accountable for their actions or decisions A staff member should not accept a delegation if it is beyond their training and competency, and/or if they are not confident undertaking the delegation

Principles of Delegation Delegation is an exercise in professional judgement by the RN/RM. It involves the transfer of authority to a competent person to perform a specific activity in a specific context. Considerations when delegating include: Patient health status (stability and complexity) Complexity of the delegated activity Context of care Level of knowledge, confidence, skill and experience of the person to whom the task has been delegated The expected outcomes of the delegated task How outcomes will be monitored and communicated Legislative requirements

The Five Rights of Delegation 1.Right Activity 2.Right Circumstances 3.Right Person 4.Right Communication 5.Right Supervision and Evaluation Acknowledgement: National Council of State Boards of Nursing, 2005

Right Activity The right activity that, in the professional judgement of the RN/RM: Can be safely delegated to another staff member who has the level of knowledge and competency to perform the task, and Is appropriate for the needs of the specific health consumer The activity being delegated needs to be within the scope of practice of the enrolled nurse or role boundaries unlicensed healthcare worker accepting the delegation

Right Circumstances Consideration of appropriate and right circumstances include: The appropriate patient or patient group (based on the severity and complexity of their condition) The resources available including skill mix, staff availability and capacity for supervision, and other relevant factors including monitoring and communication of progress

Right Person The right person is delegating the right activity to the right person with the right skills and knowledge to assist the right patient: The delegating RN/RM can only delegate care that they themselves are competent to perform The nurse/HA accepting the delegation needs to have the appropriate training and knowledge and competence to provide the required care The Patient whose care is delegated must not require complex observations, decision making, critical thinking or nursing judgement

Right Communication The right communication is clear, concise description of the activity to be undertaken, including the objective and expected outcomes. The delegating RN/RM should ensure that the enrolled nurse or unlicensed healthcare worker clearly understands: What activities are being delegated Who and when to ask for assistance or report concerns How concerns should be reported The enrolled nurse or unlicensed healthcare worker must inform the delegating RN/RM if they have not been trained to perform an activity or if they are uncertain of any aspect of the delegation

Right Supervision and Evaluation The right supervision and evaluation refers to appropriate monitoring, evaluation, intervention as needed, and feedback. The delegating RN/RM retains accountability for ensuring that: the delegated activities are performed to the required standard, monitoring and evaluating the impact and outcome of delegated care is undertaken, direct or indirect supervision is available as required, the enrolled nurse or unlicensed healthcare worker performing the delegated activity has the necessary support and guidance.

Supervision The NMBA identifies 3 types of supervision within nursing/midwifery practice; specifically managerial supervision, professional supervision and clinically focused supervision. Clinically focused supervision Clinically focused supervision specifically relates to supervision of delegated nursing and/or midwifery tasks and activities, including: providing education, guidance and support for individuals who are performing the delegated activity directing the individual’s performance monitoring and evaluating outcomes, especially the consumer’s response to the activity

Supervision The level of supervision should be appropriate to the degree of risk of the activity Direct Supervision Is when the supervisor is present and personally observes, works with, guides and directs the person being supervised Indirect Supervision Is when the supervising RN/RM is on site and easily contactable and available for reasonable access but does not directly observe the activity

Responsibilities when delegating The professional’s responsibilities include: teaching (although this may be undertaken by another competent person, and teaching alone is not delegation) competence assessment providing guidance, assistance, support and clinically focussed supervision ensuring that the person to whom the delegation is being made understands their accountability and is willing to accept the delegation evaluation of outcomes reflection on practice.

Responsibilities when accepting a delegation The recipient’s responsibilities include: negotiate, in good faith, the teaching, competence assessment and level of clinically focussed supervision needed notify in a timely manner if unable to perform the activity for an ethical or other reason be aware of the extent of the delegation and the associated monitoring and reporting requirements seek support and direct clinically focussed supervision until confident of own ability to perform the activity perform the activity safely participate in evaluation of the delegation.

Decision making tree Is it the right activity? Has there been a RN/RM assessment of patient care need? Are there organisational guidelines that support the delegation? Can the task be routinely performed without complex observations, decision making or clinical judgement? Is it the right circumstance? Does the RN/RM have the skills and knowledge to safely delegate? Does the skill-mix in your ward/unit/environment enable you to undertake appropriate supervision? Is it the right person? Is the task within the scope of practice of the enrolled nurse or role parameters of the health assistant? Does the enrolled nurse or health assistant have the appropriate knowledge, skills and competency to perform the delegated tasks? Is it the right communication? Does the enrolled nurse or health assistant understand and accept the delegated task; know when and who to ask for assistance, and who to report to? Is it the right supervision and evaluation? Is there ongoing monitoring and evaluation of the outcomes of care by the supervising RN/RM? YES Do not delegate Delegation is appropriate NO

Strengthening delegation and supervision within your team The guideline outlines a framework to support to enhance nursing/midwifery delegation and supervision. Framework based on recommendations on skill and knowledge development, alongside the development of tools and activities to support safe and effective practices. All parties play a role. As a manager and/or employer of nurses/midwives, you play a vital role in setting expectations and enabling best-practice within your team.

Framework Element 1: Regulatory Element 1: Regulatory Element 2: Organisational Element 2: Organisational Element 3: Individual Element 3: Individual Decision making consistent with stated delegator/delegatee requirements Policy and procedure Capability framework Roles and responsibilities Policy and procedure Capability framework Roles and responsibilities Leadership and management Communication and team interaction Leadership and management Communication and team interaction Checklist tool Flow chart/summary card Checklist tool Flow chart/summary card Position descriptions Role clarity statements and activities Competency and credentialling processes Organisational and unit-level direction and leadership Position descriptions Role clarity statements and activities Competency and credentialling processes Organisational and unit-level direction and leadership Interpersonal skill development training package and activities Supporting activities Frequently asked questions resource Comprehensive learning packages (covering all three key elements) Partnering with education providers – pre-registration preparation Partnering with nursing and midwifery leaders Supporting activities Frequently asked questions resource Comprehensive learning packages (covering all three key elements) Partnering with education providers – pre-registration preparation Partnering with nursing and midwifery leaders Required skills and knowledge Recommended tools and activities

Check-list of possible actions Team leadership: Consider obtaining a baseline, by asking your staff about their current delegation and supervision skills. Ensure you are aware of and understand the key regulatory, organisational and individual factors that influence safe and effective delegation and supervision. Ensure that the communication model utilised within your team supports safe and effective delegation. Consider attending (and supporting member of your team wishing to attend) educational programs with a focus on critical thinking, effective communication and team engagement.

Check-list of possible actions Recruiting and rostering your team: Safe and effective delegation and supervision occurs when there is an appropriate skill-mix within the team. When recruiting new staff ensure that you are mindful of the skills, competency and roles required to complement your existing team to allow appropriate delegation and supervision to occur. Ensure that you roster your team in a way that provides an appropriate skill-mix across all shifts, enabling safe and effective delegation and supervision to occur. Nurses and midwives delegate more effectively when there is established trust and role clarity within the team. Enhance role clarity for team members, and support staff to have appropriate delegation and supervision strategies for unknown staff (e.g. casual or new staff).

Check-list of possible actions Role Clarity: Ensure that the position descriptions for nurses, midwives and assistive staff within your team are clear and informative. Ensure that registered nurses/midwives within your team have access to and knowledge of the approved duty list and competency levels achieved by any unlicensed assistive worker. If your team lacks clarity on the roles within the team, facilitate consultation and discussion with team members to build a clear and shared understanding of: o each of the roles within the team o the skills and competencies each role is expected to demonstrate

Check-list of possible actions Local governance: Ensure any local policies align with the organisational policy relating to safe and effective delegation and supervision of nursing/midwifery tasks and activities. Education: Ensure that all members of your team receive ongoing education on delegation and supervision Ensure that your team has access to any educational learning tools utilised by your organisation addressing effective and safe delegation and supervision.

Check-list of possible actions Awareness: Consider utilising tools and promotional material to raise awareness of delegation and supervision requirements within your team. Consider encouraging your team to use a point-of-care tool to support effective delegation and supervision.

More information available: Nursing in Victoria Nursing & Midwifery Board of Australia Statements/Codes-Guidelines.aspx#dmf Statements/Codes-Guidelines.aspx#dmf Full reference list included in the guideline. Questions and discussion