1. Delegation and Supervision for Victorian Nurses and Midwives
Element 3: An individual’s requirements For nurses, midwives and the assistive workforce

2. 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’.

3. Delegation and supervision guidelines for Victorian nurses and midwives
In order to become registered, nurses and 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.

4. 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:
individuals,
employers,
education providers,
professional bodies, and the
Department of Health and Human Services.

5. 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

6. 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
Unlicensed healthcare workers include roles such as health assistants (nursing), assistants in nursing, health care assistants, personal care attendants, constant patient observers, orderlies, ward attendants.

7. 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

8. The Five Rights of Delegation
Right Activity
Right Circumstances
Right Person
Right Communication
Right Supervision and Evaluation
Acknowledgement: National Council of State Boards of Nursing, 2005

9. 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

10. 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

11. 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/unlicensed healthcare worker 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

12. 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

13. 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 person performing the delegated activity has the necessary support and guidance.

14. Decision making tree Do not delegate Delegation is appropriate
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?
Do not delegate NO
YES
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? NO
YES
Right person
Is the task within the scope of practice or role parameters of the person you are delegating to?
Does the person you are delegating to have the appropriate knowledge, skills and competency to perform the delegated tasks? NO
YES
Right communication
Does the person being delegated to understand and accept the delegated task; know when and who to ask for assistance, and who to report to? NO
YES
Right supervision and evaluation
Is there ongoing monitoring and evaluation of the outcomes of care by the supervising RN/RM? NO
YES
Delegation is appropriate
Acknowledgements:
National Council of State Boards of Nursing, 2005
Nursing Council of New Zealand, 2011

15. 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

16. 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

17. 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.

18. 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.

19. Case Scenarios

20. Introductory video
There are 8 case scenarios included in the package. Each case scenario highlights key elements of delegation.
Whilst some of the scenarios take place in a particular setting and involve a specific role, the learning is applicable across settings and can be applied working with other types of roles and workers.
Working through case scenarios can help link theory to the application to real-life workplace scenarios.
Presenters are able to utilise all scenarios or alternately select a few of the scenarios that are most relevant to the group receiving the education.
Note that the videos all presume that organisational policies are in place to support delegation, to meet the requirements under ‘right activity’.

21. YouTube link: http://www.youtube.com/watch?v=k0qH1GGq4LA
Introductory video
YouTube link:

22. Case scenario 1: Delegating to undergraduate students
You are an experienced nurse/midwife that has been assigned a third-year undergraduate student to work with you for the shift. One of your patients is Ms Sullivan, is a 30 year old lady who is normally ambulate and self caring however due to pain and limited range of movement needs assistance in the shower. What are the key things to consider relating to the level of delegation that could occur to the undergraduate student?
Things to consider:
What is causing the patient’s pain and limited range of movement? Is it appropriate for you to delegate this task to an undergraduate student taking into consideration the patient’s current condition and past-history?
If so, how well do you know the undergraduate student’s skills and competency level?
Is this task or activity within the scope of practice for a student at this stage in their education?
If so, has the undergraduate student received education and training in a particular task or activity, and have they been formally assessed as competent?
Have you personally provided direct supervision for them undertaking the task or activity before?
How will you know that the task or activity is been undertaken satisfactorily?
Key considerations:
If the patient is stable and the pain and limited range of movement is from an known cause, and you have confidence in the student's ability and and they have been formally deemed competent in that task or activity, then in most circumstances indirect supervision is appropriate.
However, as the registered nurse/midwife who is accountable for the delegated task or activity, you must be confident and satisfied that the task you are delegating is being undertaken safely and appropriately. If you have not personally provided direct supervision of the student before, it is appropriate to discuss the task with them to establish their level of confidence and competence. If during this discussion it is evident that the student has established competence in this activity then indirect supervision would be appropriate. If not provide direct supervision to establish their level of competence.
When you delegate a task, it is important that you follow up on the outcome of that delegated task. This can be undertaken in a number of different ways, including direct observation and supervision, discussion with other members of the healthcare team, regularly checking-in on the student and their progress and asking the student to report back to you when they have finished.
As the registered nurse/midwife accountable for the delegated task, you must be confident that the task has been appropriately completed, and that you have assessed and documented the outcome, including any variance in the patient’s condition

23. Case scenario 1: Delegating to undergraduate students
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24. Case scenario 2: Scope of role and responsibilities
You are an enrolled nurse and you have been asked by a doctor to assist with a procedure. You have not learnt about the procedure, or achieved competency in this task.
How should you respond?
Things to consider:
Who is able to delegate activities to an enrolled nurse?
How can I respond without seeming unhelpful?
What do I do if I have concerns about undertaking the task being asked of me?
It is possible that other roles within the ward or patients and visitors may mistakenly presume that an enrolled nurse or au unlicensed healthcare worker is a registered nurse. Even if they are aware of the staff member’s role, they may not understand the duties and responsibilities.
Enrolled nurses and unlicensed healthcare workers are part of the healthcare team, and therefore work with all members of that team. In many settings it is very appropriate for other disciplines or professions to delegate to enrolled nurses/unlicensed healthcare workers if it is within their scope of practice/duty list.
Enrolled nurses/unlicensed healthcare workers should always have a registered nurse accessible to provide supervision (either direct or indirect) as required.
If another discipline or a patient asks an enrolled nurse to assist them or undertake a task that is outside of their position description and scope of practice then the enrolled nurse should politely refuse the delegation, and refer them to their supervising registered nurse, or refer back to the registered nurse themselves.
This can sometimes be challenging, as people do not want to be perceived as though they are being difficult or unwilling to help. In these circumstances the best outcome will usually be achieved if the staff member responds in a friendly manner, giving the other person insight into why they cannot help them and then ensuring that they actively communicate the need to the appropriately qualified person.
Developing a script and possible responses can help the staff member to effectively deal with these scenarios. For example, the enrolled nurses in this scenario could respond to the situation above with something like, ‘I’m an enrolled nurse, you will need a registered nurse to assist you with that procedure. I will go and let <the registered nurse’s name> know that you need assistance.’
Remember it is the responsibility of an enrolled nurse to ensure they are always working within the parameters of the position description authorised by their employer and scope of practice.
All staff should feel confident that they have been appropriately trained and capable of safely performing the task or activity being delegated before accepting the delegation. If concerned about their capacity to undertake a task, or about whether the task or activity lies within their scope of practice and position description, they should immediately raise their concerns with the person seeking to delegate the task.
Through open discussions about their concerns, it should be possible to identify whether the delegation is appropriate or if any additional training, assistance or support is needed to enable the staff member to undertake the task. If concerns remain, the staff member should seek advice from their line manager.

25. Case scenario 2: Scope of role and responsibilities
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26. Case scenario 3: Responsibilities of roles
You are the registered nurse in charge of your ward/unit/facility. You have allocated an enrolled nurse to take care of Ms Smith.
During that morning the enrolled nurse is assisting Ms Smith with her hygiene requirements in the bathroom. Whilst the enrolled nurse is removing Ms Smith’s anti-embolitic stockings she notices a pressure injury on her leg, which Ms Smith states it is very painful.
What are the enrolled nurse’s responsibilities?
What are the registered nurse’s responsibilities?
Enrolled nurse responsibilities:
Report presence of pressure injury to the registered nurse
Clean and dress the pressure injury (if within scope of practice, and delegated by RN)
Investigate contributing factors to pressure injury development
Complete appropriate documentation, including documenting presence of pressure injury in medical record
Undertake risk assessment of pressure injury risk, and put in place preventative measure
Complete adverse event reporting relating to the pressure injury
Registered nurses responsibilities:
Communicate pressure injury to the treating team
Discuss care requirements, contributing factors and expectations with the enrolled nurse relating to management of existing pressure injury, risk assessment and future preventative measures
Assess the enrolled nurse’s knowledge, skill and competence to undertake tasks being delegated.
Assess the wound, ensure appropriate documentation and updated care plan has been completed
Provide the appropriate level of supervision (direct or indirect)
Monitor and evaluate the outcome of the interventions.

27. Case scenario 3: Responsibilities of roles
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28. Case scenario 4: Right supervision and evaluation
You are a registered nurse working with a relatively new enrolled nurse, who has been working on the ward for a few months following completion of their Diploma.
When working with this enrolled nurse which tasks or activities will require direct supervision and which will require indirect supervision?
Things to consider:
Are the tasks or activities within the scope of practice for EN’s?
If so, has the EN received education and training in a particular task or activity, and have they been formally assessed as competent?
Have you personally provided direct supervision for them undertaking the task or activity before?
How has their learning and competence progressed since commencing employment?
How will you know that the task or activity is been undertaken satisfactorily?
If a task or activity is within the position description and scope of practice of the enrolled nurse, and they have been formally deemed competent in that task or activity, then in most circumstances indirect supervision is appropriate.
However, as the registered nurse who is accountable for the delegated task or activity, you must be confident and satisfied that the task you are delegating is being undertaken safely and appropriately. If you have not personally provided direct supervision of the enrolled nurse before, it is appropriate to discuss the task with them to establish their level of confidence and competence. If during this discussion it is evident that the enrolled nurse has established competence in this activity then indirect supervision would be appropriate. If not provide direct supervision to establish their level of competence.
When you delegate a task, it is important that you follow up on the outcome of that delegated task. This can be undertaken in a number of different ways, including direct observation and supervision, discussion with other members of the healthcare team, or asking the enrolled nurse to report back to you when they have finished. As the registered nurse accountable for the delegated task, you must be confident that the task has been appropriately completed, and that you have assessed and documented the outcome, including any variance in the patient’s condition

29. Case scenario 4: Right supervision and evaluation
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30. Case scenario 5: ENs working with unlicensed healthcare workers
You are an experienced enrolled nurse working a busy morning shift. An unlicensed healthcare worker is also working that morning as part of the team.
What are your responsibilities as an enrolled nurse and how do you work with an unlicensed healthcare worker?
Things to consider:
How do I differentiate the responsibility and accountability of the registered nurse and enrolled nurse in the delegation of nursing care?
Have I already been delegated the task by a registered nurse?
Has the unlicensed healthcare worker been allocated or assigned to work with me by a registered nurse?
Are there shared activities where both the unlicensed healthcare worker and I are competent to undertake the task, and is this supported by my employer?
Am I able to supervise the unlicensed healthcare worker in any aspects of their work?
Unlicensed healthcare workers include roles such as health assistants (nursing), assistants in nursing, health care assistants, personal care attendants, constant patient observers, orderlies, ward attendants.
On accepting a delegation from a registered nurse or registered midwife, the enrolled nurse is accountable and responsible for the care and activities they perform under that delegation within their own level of competence and scope of practice.
The registered nurse or midwife always retains the responsibility and accountability for the nursing or midwifery care activities and tasks that they delegate to either enrolled nurses or non-nurses, including unlicensed healthcare workers.
If activities of nursing care have already been delegated to the enrolled nurse by a registered nurse or midwife, then the task cannot be re-delegated by the enrolled nurse to any other individual including an unlicensed healthcare worker. If changes in the context occur that necessitate re-delegation, the enrolled nurse must consult with a registered nurse or midwife.
If the registered nurse or midwife has allocated or assigned the unlicensed healthcare worker to work with an enrolled nurse, the enrolled nurse is able to assist in supervising unlicensed healthcare workers provided that they are suitably qualified and experienced.
The enrolled nurse is able to work alongside the unlicensed healthcare worker where delegated by a registered nurse or midwife, to collaboratively work together within the confines of their respective position descriptions to ensure that the care of the patient is appropriately and safely delivered. For example if a registered nurse has delegated an unlicensed healthcare worker to work with an enrolled nurse to deliver care to their assigned patients, the enrolled nurse is able to request the unlicensed healthcare worker to undertaken tasks that are within their position description and duty list. So if a patient needs to have their weight measured and recorded, the unlicensed healthcare worker is able to undertake this so long as it is in the unlicensed healthcare worker’s position description, and that they have been deemed as being competent in undertaking that task.

31. Case scenario 5: ENs working with unlicensed healthcare workers
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32. Case scenario 6: Right activity, circumstance and communication
You are a registered nurse working along side an unlicensed healthcare worker, and together you have been allocated 4 patients.
It is 8am, and you have completed your initial assessments. You want to ensure you are effectively delegating to the unlicensed healthcare worker.
Select how you would delegate, and explain your rationale.
Unlicensed healthcare workers include roles such as health assistants (nursing), assistants in nursing, health care assistants, personal care attendants, constant patient observers, orderlies, ward attendants.

33. Case scenario 6: Right activity, circumstance and communication
Your patients:
Mr Lee (70-year-old male, diagnosis: urinary tract infection). Mr Lee is alert but is experiencing some confusion. Vital signs are ordered every four hours. He is experiencing urinary frequency. He is a falls risk, and needs to be reminded to use the urinal rather than getting out of bed on his own to use the bathroom.
Ms White (43-year-old female, diagnosis: admitted for a hysterectomy). Ms White had a hysterectomy two days ago. Her postoperative course has been uncomplicated. The surgeon wants Ms White to ambulate three times per day. Her vital signs are stable. She is alert, oriented, and cooperative.
Mr Williams (46-year-old male, new admit, diagnosis: suspected Crohn’s disease). Mr Williams has been having abdominal pain and severe bouts of diarrhoea for the past several months. He was admitted this morning. He is NBM to rest his bowels and to prepare for an upper gastrointestinal diagostic series. He has been hypotensive and has IV fluids running and prn pain medications.
Mrs Taylor (66-year-old female, diagnosis: congestive heart failure). Mrs Taylor was transferred onto the ward early this morning. She was admitted four days ago with acute pulmonary oedema. She has history of CHF and takes diuretics, digoxin, and an ACE inhibitor at home. She is alert and oriented. She is short of breath, on 2L of O2 with oxygen saturation at 93%. She has an IDC in situ and is on strict fluid balance.
Examples of delegated tasks with rationales: The two patients that the unregistered healthcare worker would work the closest with are Ms White and Mr Lee. They are the two most stable patients.
Possible tasks for delegation: Assist Mr Lee with elimination (offer urinal), ambulate Ms White, assist and supervise Mr Lee and Ms White with their hygiene requirements are required.

34. Case scenario 6: Right activity, circumstance and communication
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35. Case scenario 7: Effective and safe allocation and assignment
You are an associate nurse unit manager working on a busy acute ward. You are in charge of a morning shift and have an unlicensed healthcare worker as part of your ward team. The team has just received handover and after reviewing the patient profile and the staff skill mix you are about to allocate your staffing resources for the shift.
Which patients will you allocate the unlicensed healthcare worker to and why?
How will you undertake the allocation and assign the unlicensed healthcare worker and will the unlicensed healthcare worker be allocated to work with one nurse or, more than one nurse?
How will the unlicensed healthcare worker be assigned once they have completed a set of activities?
Unlicensed healthcare workers include roles such as health assistants (nursing), assistants in nursing, health care assistants, personal care attendants, constant patient observers, orderlies, ward attendants.

36. Case scenario 7: Effective and safe allocation and assignment
Things to consider:
How do I allocate the unlicensed healthcare worker to enhance the safe, efficient and effective provision of care for that shift?
How do I ensure that the unlicensed healthcare worker is being utilised where they are needed most, making the best use of their competencies within the parameters of their role?
How do I manage the demand from the nursing team for assistance from the unlicensed healthcare worker? How do I prevent the unlicensed healthcare worker being subjected to competing demands from different members of the ward team?
As the unlicensed healthcare worker role joins a team, the allocation model and manner in which you assign their work will affect the way they work, either positively or negatively. There are many allocation models and no one correct way of doing things, however there are specific issues and guiding principles to consider when introducing a new role into the team.
Inclusion of the unlicensed healthcare worker in the nursing handover has been shown to be beneficial in optimising intra-ward communication, allocation and utilisation of the role. Effective hand-over contributes to improved patient outcomes, increasing safety, reducing repetition, avoiding errors and improvements in patient satisfaction (Talty 2013–14).
Allocation and assignment of the unlicensed healthcare worker should always be undertaken with consideration of their level of individual education, experience and competence, ensuring they are delegated activities within the parameters of their position description and duty list.
Any model that involves an unlicensed healthcare worker ‘floating’ between supervisors is not recommended, as their education, training and preparation does not adequately equip them with the skills and knowledge to be able to effectively work in this manner. Consideration should be given to ensuring that the overarching delegation of the unlicensed healthcare worker is undertaken by one staff member for a particular shift. Usually this is the nurse-in-charge of the shift or a team leader, given that these roles have the broadest oversight of the ward’s resourcing requirements for the shift. The initial unlicensed healthcare worker implementation pilots demonstrated that centralised delegation for unlicensed healthcare worker worked well by ensuring that the unlicensed healthcare worker is delegated activities where they are most needed. This worked irrespective of their nursing allocation model.
An example of how this may work is that the nurse-in-charge/team leader may assign the unlicensed healthcare worker to initially work with a nurse or nurses based on the ward’s needs and the patient care requirements. The unlicensed healthcare worker would work with the assigned nurse to undertake activities to assist them, and then reports back to the nurse-in-charge/team leader when they have finished those activities to be given their next delegation. This ensures that the unlicensed healthcare worker is being assigned to work where they are most needed and that as the shift progresses that re-delegation can meet the changing needs of the ward, without the unlicensed healthcare worker being subjected to competing demands from different members of the team.
When introducing the unlicensed healthcare worker role into a team, some trialling may be required to find the best model of allocation and assignment of these staff to meet the requirements of the ward, team and patient cohort. Undertaking this with consideration of the above principles, and continuing consultation with all members of the ward team will ensure the best results.

37. Case scenario 7: Effective and safe allocation and assignment
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38. Case scenario 8: Right communication, supervision and evaluation
Develop a sequence of sentences to effectively delegate a task to an enrolled nurse or unlicensed assistive worker.
Ms Jackson is a 45-year-old female admitted two days ago for a hysterectomy.
Her postoperative recovery has been uncomplicated.
The surgeon wants Ms Jackson to ambulate three times per day.
You have assessed Ms Jackson and have determined that an unlicensed healthcare worker could help with the ambulation.
You approach the unlicensed healthcare worker on your team.
Sample response
“I need your assistance to ambulate Ms Jackson. She needs to ambulate once per shift. It would be ideal if she could do it before lunch. She is steady on her feet, uses a wheelie-frame, and needs stand-by assistance. She should walk from her room to the staff station and back to her room. She is ready to walk when you have time. If you do walk with her, please stay with her the entire time. If you notice she is having trouble walking (not steady, becomes dizzy, etc.), assist her back to bed or into a chair. Do you have any questions or concerns? Do you think you’ll have time in your schedule to do this before lunch?”
Remember that delegation is not complete until the delegatee accepts responsibility.
After the interaction, ensure this has happened. You can say something such as, “I am just making sure that you plan to ambulate Ms Jackson before lunch. Is that right?”

39. Case scenario 8: Right communication, supervision and evaluation
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40. Questions and discussion
More information available:
Nursing in Victoria
Nursing & Midwifery Board of Australia Statements/Codes-Guidelines.aspx#dmf
Full reference list included in the guideline.