CHAPTER 9 D ELEGATION OF CLIENT CARE

OBJECTIVES Define delegation and unlicensed assistive personnel. Define delegation and unlicensed assistive personnel. Identify the rights of delegation and the implications of each. Identify the rights of delegation and the implications of each. Understand the legal implications of making assignments to other healthcare personnel. Understand the legal implications of making assignments to other healthcare personnel. Discuss the process of delegation and the coordination of assignments. Discuss the process of delegation and the coordination of assignments.

Objectives Differentiate delegation from work allocation. Differentiate delegation from work allocation. Outline how delegation benefits the patient, staff and the organization. Outline how delegation benefits the patient, staff and the organization. Valuate the need for delegation using the Seven Components of the Delegation Decision-Making Grid, NCSBN & Five Factors for Determining if Client Care Activity Should be Delegated, AACN. Examine the criteria for safe delegation. Examine the criteria for safe delegation.

OBJECTIVES Discuss the task related and relationship- oriented concerns of delegating. Identify and discuss barriers to delegation. Identify the basic rights of individuals in the workplace. Differentiate direct and indirect client care activities. Describe ways to facilitate performance of tasks by the delegatee.

OBJECTIVES Compare delegation in professional practice as it relates to responsibility, accountability and authority. Compare delegation in professional practice as it relates to responsibility, accountability and authority. Illustrate critical thinking when making assignments and delegating tasks. Illustrate critical thinking when making assignments and delegating tasks. Illustrate how to communicate assignments and delegated tasks and recognize barriers to successful delegation. Illustrate how to communicate assignments and delegated tasks and recognize barriers to successful delegation. Differentiate the models of care delivery - Functional, Team, Total Client Care

OBJECTIVES Apply delegation concepts, and critical thinking to client scenarios and NCLEX- style questions. Apply delegation concepts, and critical thinking to client scenarios and NCLEX- style questions. Illustrate critical thinking when making assignments and delegating tasks. Illustrate critical thinking when making assignments and delegating tasks. Illustrate how to communicate assignments and delegated tasks and recognize barriers to successful delegation. Illustrate how to communicate assignments and delegated tasks and recognize barriers to successful delegation. Apply delegation concepts, and critical thinking to client scenarios and NCLEX- style questions. Apply delegation concepts, and critical thinking to client scenarios and NCLEX- style questions.

DEFINITION The reassigning of responsibility for the performance of a job from one person to another. (ANA, 1996) The reassigning of responsibility for the performance of a job from one person to another. (ANA, 1996)

Concepts of Delegation The responsibility of the task is transferred. The responsibility of the task is transferred. Accountability remains with the delegator. Accountability remains with the delegator. Delegation may be direct or indirect. Delegation may be direct or indirect.

Direct Delegation Usually verbal direction Usually verbal direction RN decides which staff member is capable of performing a specific task RN decides which staff member is capable of performing a specific task

Indirect Delegation Contained in an approved listing of tasks established by an institution Permitted tasks may vary from institution to institution

CONSIDERATIONS Whether the client's condition is stable and predictable; The nature and complexity of the nursing task; The risk to the client if the task is done inappropriately or incorrectly; The necessary knowledge, skills and abilities needed to perform the task;

Considerations Cont. The competency of the unlicensed assistive person; Whether the outcome anticipated is stable and predictable; The number of unlicensed assistive personnel that can safely be supervised by the licensed nurse.

The Five Rights of Delegation Right task Right circumstances Right person Right direction/communication Right supervision/evaluation

Right Task What can the nurse not delegate? Initial nursing assessment and follow-up assessments if nursing judgment is indicated Decisions and judgments about client outcomes Determination and approval of a client plan of care Interventions that require professional nursing knowledge, decisions, or skills Decisions and judgments necessary for the evaluation of client care Note: Nurse cannot delegate own accountability for patient outcome.

Right Circumstance Relate to patient condition To delegate task, outcome must be reasonable, predictable, and the task must not require ongoing assessment or critical decision making

Right Person RN accountable and responsible for meeting patient needs Delegated care (to UAP) should be for stable patients Competencies: basic nursing skills that include standard reoccurring procedures Appropriate assignment: predictable outcomes Abilities: Performs care for routine procedures---feeding, bathing, routine VSs, transferring patient

Communicate expectations Evaluate whether or not instructions are understood 4 Cs of Communication ◦ Is it Clear? ◦ Is it Concise? ◦ Is it Correct? ◦ Is it complete? Right Direction & Communication

Right Supervision and Evaluation Monitoring ◦ Guidance ◦ Direction Feedback

Red Flags Complexity of nursing activity Unidentified client needs Missing requisite knowledge and skills Insufficient opportunity to train Insufficient opportunity to monitor

Assigning Tasks The RN may assign a more skilled individual to perform a task The RN may assign a more skilled individual to perform a task The RN may not assign an individual to perform an activity outside of a job description or the scope of practice The RN may not assign an individual to perform an activity outside of a job description or the scope of practice Consider the following situation… Consider the following situation…

Mr. Ross was admitted to the neurological unit from the Neuro ICU. She suffered a grade II subarachnoid hemorrhage 2 weeks ago and has a left hemiparesis. She has difficulty with swallowing and receives tube feedings through a PEG tube; however, she has been advanced to a pureed diet. She needs assistance with personal care, toileting, and feeding. A PT comes BID to get her up for gait training; otherwise, the physician wants her in a chair as much as possible. Mr. Ross was admitted to the neurological unit from the Neuro ICU. She suffered a grade II subarachnoid hemorrhage 2 weeks ago and has a left hemiparesis. She has difficulty with swallowing and receives tube feedings through a PEG tube; however, she has been advanced to a pureed diet. She needs assistance with personal care, toileting, and feeding. A PT comes BID to get her up for gait training; otherwise, the physician wants her in a chair as much as possible.

Delegation vs Supervision Supervision usually more direct than delegation Requires directly overseeing the work or performance of others Could include reevaluation

Assessment Assess client needs Set client-specific goals Match the personnel with the appropriate skills to care for the client The Nursing Process and Delegation

Planning Mentally identify who is best suited for the task or activity Mentally identify who is best suited for the task or activity Planning prevents later problems Planning prevents later problemsImplementation Assign the appropriate personnel who have the level of expertise necessary to deliver the care or carry out the activities

Evaluation Evaluation Oversee the care or activities Oversee the care or activities Determine if client care needs have been met Determine if client care needs have been met Allow for feedback Allow for feedback

Coordinating Assignments: Methods to Help Organize Care Care plans Clinical (Critical) pathways Computerized information sheets Personalized worksheets

Tips for Organizing Care Plan time around activities that must be performed at a certain time Perform high-priority activities first Cluster activities that may be performed together Consider your peak time when performing optional activities

The Need for Delegation Changes in the Health-Care Environment ◦ Nursing shortage ◦ Health-care reform ◦ Increased need for nursing services ◦ Demographic trends ◦ Use of unlicensed assistive personnel

Unlicensed Assistive Personnel (UAPs) Individuals trained to function in an assistive role to the nurse Perform delegated tasks Under direct supervision of the RN May or may not be certified

Decision -Making Grid Method to evaluate activities being considered for delegation ◦ Level of client acuity ◦ Level of UAP capability ◦ Possibility for injury ◦ Number of times the skill has been performed by the UAP ◦ Level of decision making needed for the activity ◦ Client’s ability for self care

Examples of Tasks Vital signs Skills learned through special training: ◦ Blood drawing ◦ ECGs Measuring intake and output Non-nursing duties

The nurse cannot delegate: Initial nursing and follow-up assessments if nursing judgment is indicated Decisions and judgments about client outcomes Determination and approval of a client plan of care Interventions that require a professional nursing knowledge, decisions, or skills Decisions and judgments necessary for the evaluation of client care

Five Factors for Determining if Client Care Activity Should be Delegated Potential for harm to the patient Complexity of the nursing activity Problem-solving and innovation necessary to complete the task or activity Predictability of outcome Extent of interaction

When should the nurse intervene? A task not completed in a timely manner The implementation of a task/function/activity not meeting expectations Change in a client’s condition Alertness to subtle signs and symptoms (which allows nurse and assistant to be proactive, before a client’s condition deteriorates significantly) Awareness of assistant’s difficulties in completing delegated activities early rather than later Questions asked by the assistant inform the nurse of the assistant's level of understanding and may alert the nurse that the assistant needs additional training

Primary task-related concern: Ability Priorities Efficiency Appropriateness

Relationship-Oriented Concerns Fairness Learning opportunities assignments Compatibility Preferences

Obstacles to Delegating Inadequate experience and education “I can do it better” Lack of skill Confidence in UAP Need to feel indispensable Fear of losing authority Lack of time

Obstacles to accepting delegation Fear of criticism Lack of self-confidence Lack of time

LPN vs RN roles NP PhaseLPNRN AssessGather data ID strengths Gather extensive data; Group & analyze data; ID resources Nsg Dxn/aDraw conclusions;Use judgment; Assign Nsg Dx PlanningContributesShort/long-term goals; Establish Priorities; Collaborate/refer ImplementProvide basic care measures, teaching, documents Manage patient care – perform/ delegate, teaching, referrals, collaborate team members, Document EvaluateEval effects of careEvaluate plans overall effectiveness, analyze new data, modify plan

Delegating to LPN Competencies: Technical skills Appropriate assignment: Stable patient with predictable outcomes Abilities: More complex care than UAP; sterile technique, medication administration…

Models of Care Delivery Major ConceptAdvantagesDisadvantages FunctionalDivision of tasks with clearly defined roles Efficient, economical, productive Fragmented care TeamRN team leader supervises ancillary staff More holisticRN must take time to delegate PrimaryRN maintains 24 hour responsibility for client Emphases on accountability and client satisfaction Extremely costly; primary nurse must be capable of meeting all client needs Total CareOne RN with total responsibility for care Continuity of careCostly; no efficient use of staff

The Five Rights of Delegation Right task Right circumstances Right person Right direction/communication Right supervision/evaluation

In Conclusion, Points to Consider: Delegation is not new Delegation is essential today Organizational skills are a prerequisite for delegation Understanding client needs is essential for appropriate delegation

The RN Needs to: Be knowledgeable in relation to own State Nurse Practice Act Be aware of the capabilities of each staff member Understand/know the tasks that may be delegated Understands the concept of accountability in delegation

RN cannot give responsibility away for assessment, evaluation, and knowledge base needed for nursing judgment RN assignment---the unstable patient with the least predictable outcome.