1. DELEGATION OF CLIENT CARE

2. Objectives Define the term delegation Define the term delegation Define the term unlicensed assistive personnel Define the term unlicensed assistive personnel Understand the legal implications of making Understand the legal implications of making assignments to other healthcare personnel Recognize barriers to successful delegation Recognize barriers to successful delegation Make appropriate assignments to team members Make appropriate assignments to team members

3. DELEGATION

4. Definition of Delegation According to the American Nurses’ Association (ANA) The reassigning of responsibility for the performance of a job from one person to another. (ANA: Registered Professional Nurses and Unlicensed Assistive Personnel, ed 2. ANA, Washington, DC, 1996.) The reassigning of responsibility for the performance of a job from one person to another. (ANA: Registered Professional Nurses and Unlicensed Assistive Personnel, ed 2. ANA, Washington, DC, 1996.)

5. Concepts of Delegation Is not a new concept Is not a new concept – Moses was instructed to identify 70 elders so they would share the burden of the nation and the people would no longer have to carry the burden by themselves. – Florence Nightingale discussed delegation in her Notes on Nursing in 1859. Delegation is a process that transfers to a competent individual the authority to perform a selected nursing task in a specific situation Delegation is a process that transfers to a competent individual the authority to perform a selected nursing task in a specific situation

6. CONCEPTS OF DELEGATION The responsibility for the task is transferred. The responsibility for the task is transferred. Accountability remains with the person who is delegating tasks. Accountability remains with the person who is delegating tasks. Delegation may be either direct or indirect. Delegation may be either direct or indirect.

7. DIRECT DELEGATION Usually verbal direction Usually verbal direction The registered nurse (RN) decides which staff member is capable of performing a specific task The registered nurse (RN) decides which staff member is capable of performing a specific task

8. INDIRECT DELEGATION Contained in a listing of tasks that has been approved and established by an institution Contained in a listing of tasks that has been approved and established by an institution Tasks permitted may vary with different institutions Tasks permitted may vary with different institutions

9. ASSIGNING TASKS The RN may assign a more skilled individual to perform specific tasks. The RN may assign a more skilled individual to perform specific tasks. The RN may not assign an individual to perform a task that is outside that individual’s job description or scope of practice. The RN may not assign an individual to perform a task that is outside that individual’s job description or scope of practice.

10. DELEGATION VERSUS SUPERVISION

11. SUPERVISION Usually more direct than delegation Usually more direct than delegation Requires directly overseeing the work or performance of others Requires directly overseeing the work or performance of others Includes checking in with individuals throughout the day Includes checking in with individuals throughout the day May entail the delegation of tasks and activities (i.e., the nurse manager performs both delegation and supervision) May entail the delegation of tasks and activities (i.e., the nurse manager performs both delegation and supervision)

12. NURSING PROCESS AND DELEGATION

13. Compare Delegation Process to the Nursing Process Assessment Assessment Delegation Delegation – Planning – Planning – Implementation – Implementation Monitoring Monitoring Evaluation Evaluation

14. ASSESSMENT Is the foundation of the delegation process, just like the nursing process or any scientific process o Assess patient needs. Without accurate and thorough assessment, there can be no delegation Without accurate and thorough assessment, there can be no delegation o Set patient goals. o Match staff members who have appropriate skills to care for that patient.

15. PLANNING Planning prevents future problems. Planning prevents future problems. Mentally identify the person who is best suited for the task or activity. Mentally identify the person who is best suited for the task or activity.

16. IMPLEMENTATION Assign staff members who have the appropriate level of expertise that is necessary to deliver the patient care and perform the activities.

17. FIVE RIGHTS Right task Right task Right concern Right concern Right person Right person Right direction/communication Right direction/communication Right supervision Right supervision

18. AS AN RN YOU SHOULD ALWAYS ASK- “Can this task be delegated safely?” “Can this task be delegated safely?” “Is there anything about the client’s condition or the environment which would preclude this assistant from performing the task as delegated?” – Every client is different and the same activity may differ in each situation “Is there anything about the client’s condition or the environment which would preclude this assistant from performing the task as delegated?” – Every client is different and the same activity may differ in each situation “Is the task within the scope of practice of the individual I am asking to perform it?” “Is the task within the scope of practice of the individual I am asking to perform it?”

19. “Have I communicated clearly and directly what is expected in the performance, reporting and documentation of this task?” “Will I be available and accessible to this individual while he/she completes the delegated task?” “Do I have the requisite skills to assist the individual in completing the task as delegated?”

20. ASSESSMENT RED FLAGS Complex nursing activity Complex nursing activity Unidentified client needs Unidentified client needs Requisite knowledge and skills missing Requisite knowledge and skills missing Insufficient opportunity to train Insufficient opportunity to train Insufficient opportunity to monitor/supervise Insufficient opportunity to monitor/supervise

21. DELEGATION PROCESS Communication of task to be elegated Communication of task to be elegated Mutual agreement Mutual agreement Transfer of Authority Transfer of Authority

22. Communication of the specific task Communication of the specific task – Generally do not use the term assignment when dealing with unlicensed assistants. – Assignment is defined as designating nursing activities to be performed by an individual consistent with his/her licensed scope of practice. Since assistants do not have a legal scope of practice, they cannot accept assignments but they can accept delegated tasks.

23. The outcome of assignment and delegation is the same (the nursing activity is completed), the decision making process is similar, but the authority to perform the activity must be transferred to the assistant, while the licensed nurse already has legal authority. The outcome of assignment and delegation is the same (the nursing activity is completed), the decision making process is similar, but the authority to perform the activity must be transferred to the assistant, while the licensed nurse already has legal authority.

24. Mutual agreement Mutual agreement – by both the person delegating and the assistant that the task is to be delegated and that there is acceptance of the task to be performed by the assistant. – by both the person delegating and the assistant that the task is to be delegated and that there is acceptance of the task to be performed by the assistant.

25. Transfer of the authority to perform the task from the delegator to the assistant Transfer of the authority to perform the task from the delegator to the assistant – The nurse must still retain the accountability for its completion and for the outcomes of the task. – The nurse must still retain the accountability for its completion and for the outcomes of the task. – The source of authority is always legal (nursing license) and may be managerial (position description), – The source of authority is always legal (nursing license) and may be managerial (position description), Managerial authority cannot supersede legal authority. Managerial authority cannot supersede legal authority.

26. – A common use of the term assignment is to designate the overall workload, including delegation and assignment. – A common use of the term assignment is to designate the overall workload, including delegation and assignment. – Do not confuse the general use of the term to list the workload for which all staff members are responsible with the legal use of the term that designates nursing activities. – Do not confuse the general use of the term to list the workload for which all staff members are responsible with the legal use of the term that designates nursing activities.

27. DELEGATION WHO will do WHO will do WHAT by WHAT by WHEN and WHEN and HOW, WHERE, and HOW, WHERE, and WHY it will be done WHY it will be done No delegation can be complete without the above

28. DIRECTIONS Priority of activity Priority of activity Expected timeliness Expected timeliness Guidelines for consulting mid activity Guidelines for consulting mid activity Reportable conditions Reportable conditions Guidelines for reporting task completion Guidelines for reporting task completion Role as delegator and supervisor Role as delegator and supervisor

29. Use of written and visual resources may be used to reinforce direction Use of written and visual resources may be used to reinforce direction The communication style of the nurse and that of the assistant directly affects the working relationship. The communication style of the nurse and that of the assistant directly affects the working relationship. Repeat the directions Repeat the directions Look at the priority of activities Look at the priority of activities Provide a checkpoint throughout the process Provide a checkpoint throughout the process

30. IN COORDINATING ASSIGNMENTS, REMEMBER Plan your time around these activities Plan your time around these activities Do high-priority activities first Do high-priority activities first Determine which activities are best done in a cluster Determine which activities are best done in a cluster Remember that you are still responsible for activities delegated to others Remember that you are still responsible for activities delegated to others Consider your peak energy time when scheduling optional activities Consider your peak energy time when scheduling optional activities

31. DELEGATION RED FLAGS Refusal to accept delegation Refusal to accept delegation Incomplete directions Incomplete directions Failure to confirm expectations Failure to confirm expectations Failure to communicate Failure to communicate Your delegation may be inappropriate

32. CHANGE IN HEALTH CARE ENVIRONMENT In the 1990s the nursing shortage, health care reform, an increased need for nursing services, and demographic trends brought about changes In the 1990s the nursing shortage, health care reform, an increased need for nursing services, and demographic trends brought about changes The ANA defines an unlicensed assistive personnel. The ANA defines an unlicensed assistive personnel. Remember, certification differs from licensure Remember, certification differs from licensure

33. DELEGATION PROCESS- MONITORING This one frequently causes the most problems This one frequently causes the most problems It is easy for someone to forget to check in It is easy for someone to forget to check in

34. SUPERVISION Provision of guidance or direction, evaluation and follow up by the licensed nurse for a process and the outcomes of a delegated task. Provision of guidance or direction, evaluation and follow up by the licensed nurse for a process and the outcomes of a delegated task. – Supervision includes monitoring the performance, intervening if necessary, and ensuring that proper documentation of the task is completed. – Supervision includes monitoring the performance, intervening if necessary, and ensuring that proper documentation of the task is completed.

35. DEGREE OF SUPERVISION REQUIRED DEPENDS ON – Client needs – Stability of the client – Competency of the assistant – Nature of the task – Available supervision

36. MONITORING RED FLAGS Change in other client’s condition with impact on workload Change in other client’s condition with impact on workload Failure of assistant to report unexpected events or client outcomes Failure of assistant to report unexpected events or client outcomes Work completed incorrectly Work completed incorrectly Work not completed Work not completed Inadequate direction from delegator Inadequate direction from delegator Inadequate or lack of monitoring from delegator Inadequate or lack of monitoring from delegator

37. The occurrences indicate that the delegation may be inappropriate and that the delegation decision should be revisited to insure that the 5 Rights still apply

38. EVALUATION THIS IS YOUR FOLLOW-UP Oversee the care and activities provided by the employees. Oversee the care and activities provided by the employees. Determine if patient care needs have been met. Determine if patient care needs have been met. Allow for feedback. Evaluation of the delegator / assistant should be done Allow for feedback. Evaluation of the delegator / assistant should be done Evaluation is often the missing link in the delegation process Evaluation is often the missing link in the delegation process

39. DESIRED OUTCOMES Protection of client safety Protection of client safety Achievement of desired client outcomes Achievement of desired client outcomes Reduction of health care costs Reduction of health care costs Access to appropriate levels of health care Access to appropriate levels of health care Decreased nursing liability Decreased nursing liability

40. INAPPROPRIATE DELEGATION MAY RESULT FROM: MAY RESULT FROM: – Inadequate resources – Inadequate resources – Conflict of employee policies and law – Conflict of employee policies and law – Inappropriate employer direction – Inappropriate employer direction – Lack of knowledge about delegation – Lack of knowledge about delegation – Failure to accept accountability for nursing care provided – Failure to accept accountability for nursing care provided

41. CORRECTIVE ACTION Educate and train Educate and train Restate expectations Restate expectations Return skill demonstration Return skill demonstration Identify specific checkpoints Identify specific checkpoints Increase frequency of check ins Increase frequency of check ins Evaluate directions Evaluate directions

42. EVALUATION RED FLAGS Failure to evaluate delegation effectiveness Failure to evaluate delegation effectiveness Failure to evaluate the delegator/assistant relationship Failure to evaluate the delegator/assistant relationship Failure to learn from work experience Failure to learn from work experience

43. COORDINATING ASSIGNMENTS

44. METHODS TO HELP ORGANIZE CARE Critical pathways Critical pathways Computerized information sheets Computerized information sheets Personalized worksheets Personalized worksheets Delegation tree Delegation tree

45. TIPS FOR ORGANIZING CARE Plan time around activities that must be done at a certain time. Plan time around activities that must be done at a certain time. Perform high-priority activities first. Perform high-priority activities first. Cluster activities that may be performed together. Cluster activities that may be performed together. Consider your peak time when performing optional activities. Consider your peak time when performing optional activities.

46. THE NEED FOR DELEGATION

47. CHANGES IN THE HEALTH- CARE ENVIRONMENT A nursing shortage A nursing shortage Health-care reform Health-care reform An increased need for nursing services An increased need for nursing services Demographic trends Demographic trends Use of unlicensed assistive personnel Use of unlicensed assistive personnel

48. UNLICENSED ASSISTIVE PERSONNEL (NA) Trained to assist the nurse Trained to assist the nurse Perform tasks delegated by the nurse Perform tasks delegated by the nurse Under the RN’s direct supervision Under the RN’s direct supervision May or may not be certified May or may not be certified

49. Delegation of Unlicensed Assistive Personnel

50. TASKS Unlicensed assistive personnel perform numerous tasks such as: Taking vital signs Taking vital signs Demonstrating skills learned through special training (e.g., drawing blood or administering an electrocardiogram [ECG]) Demonstrating skills learned through special training (e.g., drawing blood or administering an electrocardiogram [ECG]) Measuring intake and output Measuring intake and output Performing nonnursing duties Performing nonnursing duties

51. SAFE DELEGATION

52. CRITERIA FOR SAFE DELEGATION Potential for harm Potential for harm Complexity of the task Complexity of the task Problem solving and innovation are necessary to complete the task or activity Problem solving and innovation are necessary to complete the task or activity Ability of the individual Ability of the individual Fairness of the task Fairness of the task

53. TASK-RELATED CONCERNS

54. ACCOUNTABILITY Being answerable for the actions or omissions of self or others in the context of delegation. Being answerable for the actions or omissions of self or others in the context of delegation. Accountable to Accountable to – Self – Self – Clients – Clients – Employer – Employer – Licensing Board – Licensing Board – Profession – Profession

55. NURSE’S ACCOUNTABILITY For Decision to delegate For Decision to delegate – Ultimate accountability for the management and provision of nursing care Delegated task Delegated task Client outcomes Client outcomes

56. ASSISTIVE PERSONNEL ACCOUNTABILITY – Decision to accept delegation – Decision to accept delegation – Performance – Performance FOR

57. ASSISTIVE PERSONNEL ACCOUNTABILITY Self Self Delegating Nurse Delegating Nurse Employer Employer TOTOTOTO

58. PRIMARY CONCERN Does the individual assigned to the task have the ability to perform it?

59. OTHER TASK-RELATED CONCERNS Employee’s abilities Employee’s abilities Priority of various tasks Priority of various tasks Employee’s level of efficiency Employee’s level of efficiency Appropriateness of the assigned task Appropriateness of the assigned task

60. RELATIONSHIP-ORIENTED CONCERNS The RN should consider the following when assigning tasks to employees: Fairness Fairness Learning opportunities Learning opportunities Health Health Compatibility Compatibility Preferences Preferences

61. Is the workload evenly distributed Is the workload evenly distributed – One might have less physical work to do, yet have the work may require more emotional care – Discuss with your team decisions you have made that may be considered unfair – Discuss with your team decisions you have made that may be considered unfair – If possible, allow the team to participate in making decisions regarding assignments. – If possible, allow the team to participate in making decisions regarding assignments.

62. Assign so your staff will be stimulated and motivated to learn Assign so your staff will be stimulated and motivated to learn Rotate your members through more difficult jobs Rotate your members through more difficult jobs Work at helping your team to develop better working relationships Work at helping your team to develop better working relationships Explain your rationales and decisions Explain your rationales and decisions

63. SUMMARY OF PROFESSIONAL EXPECTATIONS Respect from others Respect from others A reasonable workload A reasonable workload Appropriate wages Appropriate wages Determining his or her own priorities Determining his or her own priorities Ask for what he or she wants Ask for what he or she wants Be accountable Be accountable Give and receive information in a professional manner Give and receive information in a professional manner

64. DELEGATION BARRIERS BARRIERS

65. BARRIERS Level of experience Level of experience Licensure Licensure Quality of care Quality of care Having to assign work to others Having to assign work to others

66. REMEMBER-THE FIVE RIGHTS OF DELEGATION Right task Right task Right circumstances Right circumstances Right person Right person Right direction and communication Right direction and communication Right supervision and evaluation Right supervision and evaluation

67. CONCLUSION

68. POINTS TO CONSIDER Delegation is not new. Delegation is not new. Delegation is essential for good working relationships. Delegation is essential for good working relationships. Organizational skills are a prerequisite for delegation. Organizational skills are a prerequisite for delegation. An understanding of patient needs is essential for appropriate delegation. An understanding of patient needs is essential for appropriate delegation.

69. THE RN MUST UNDERSTAND: The state’s Nurse Practice Act The state’s Nurse Practice Act The capabilities of each staff member The capabilities of each staff member The tasks that may be delegated The tasks that may be delegated His or her accountability when delegating tasks His or her accountability when delegating tasks

70. REMEMBER TO: Communicate continuously Communicate continuously Value all team member contributions Value all team member contributions Develop trust between co-workers Develop trust between co-workers Learn from experience Learn from experience