Nurses have authority to assign selected activities of care to other qualified and competent helpers while protecting the health, safety, and welfare of every patient. Registered Nurses (RNs) determine the tasks that can be delegated; they rely on other assistive caregivers as a necessary component of safe staffing. Organizations rely on assistive workers to provide a cost-effective skill mix. Threats of nursing shortages, mandates for reportable quality outcomes, and data supporting greater RN presence as improving nurse-sensitive measures have increased the urgency to ensure appropriate RN staffing inclusive of effective delegation.
Delegation unburdens the RN from unnecessary work others can do, while the RN retains accountability for care and outcomes. With increased complexity of patients, nurses increasingly must use critical thinking skills to evaluate the type of care, circumstances, and competence of assistive caregivers prior to delegation. Delegation remains an underdeveloped skill among nurses, and one that is difficult to measure. It relies on personality, communication style, and cooperation. The success or failure of delegation depends on a positive two-way relationship of mutual respect and trust between the RN and the helper who assumes responsibility for specific tasks. This dynamic exchange between the RN and the helper requires constant evaluation, feedback, and modification to achieve the results needed to meet patient care goals.
The six initial articles in this topic address a variety of considerations that are important in successful delegation. These considerations include traditional and emerging thought about the common skills necessary for delegation and the unique challenges across practice settings. A number of common themes emerge in this topic. First is the importance of understanding the legal authority to delegate to other qualified individuals. In the United States (US) each state issues its own definitions and regulations regarding delegation, whereas there is no legal definition of nursing in the United Kingdom (UK), making delegation even more challenging. Additionally, in any practice setting, developing trust is a fundamental requirement for successful delegation. Nurses’ delegation skills develop over time, building on critical thinking, and growing from being uncomfortable delegating to others to being confident in this delegation process. Competence in delegation is as important for the nurse as are other cognitive or psychomotor skills. This competence requires ongoing education and development. The influence of delegation on quality and safety outcomes should not be underestimated. Growing sophistication in our ability to measure nurse-sensitive outcomes creates an imperative to assess the contributions of all who contribute to care under the direction of the RN. The initial articles in this topic offer a variety of resources to help nurses develop and maintain their delegation skills.
Building delegation skills starts with all nurses understanding the provisions of their nurse practice acts, and also understanding of the concepts of responsibility, accountability, and authority. In Developing Delegation Skills, Weydt walks the reader through the fundamental five rights of delegation as articulated by the National Council of State Boards of Nursing (NCSBN). These include the right task; circumstance; person; direction and communication; and supervision and evaluation. She points out two major ways delegation occurs, by simple task assignment based on job descriptions or matching a staff member’s expertise to a patient’s needs. Weydt stresses the need for: (a) clarity in delegation, (b) ongoing development of delegation skills, (c) assuring that the person to whom a task is delegated is qualified to perform the task, and (d) assuring the RN retains final accountability.
Anthony and Vidal describe how the right communication, one of the five rights of Delegation, influences effective delegation. In Mindful Communication: A Novel Approach to Improving Delegation and Increasing Patient Safety, they explore ‘mindful’ communication which requires individuals to recognize the significance of facts and how the facts relate to a current patient condition or situation. Scenarios amplify the relationship of delegation to safety and quality outcomes. Some of the tasks typically delegated, for example turning, ambulating, providing personal care, and/or glucose checking, are directly associated with nurse-sensitive outcomes, such as preventing complications and maintaining physiologic balance. The right communication transmitted via timely and clear messages makes communication meaningful. Reflecting on the communication concepts of ‘information decay’ and ‘information saliency,’ the authors underscore that RNs must emphasize to the assisting caregiver what information is important and clarify any information that can be interpreted in more than one way. Just as communication breakdown is responsible for sentinel events, it also has a significant effect on effective delegation in our daily practice.
The National Labor Relations Act (NLRA), adopted1935 and amended in 1947, was enacted to protect the rights of employees and employers to engage in collective bargaining and to protect the welfare of workers, business, and the U.S. economy. The protection was extended to education and healthcare in 1974. In When Does Delegating Make You a Supervisor?, Matthews explores the history and controversy around the question of who must be recognized by an employer for purposes of collective bargaining. She focuses attention particularly on nurses who function in the charge nurse role. For years, the National Labor Relations Board, charged with administering the NLRA, had interpreted the law such that nurses working within their scope of practice and directing other employees were not deemed to be supervisors. In 1999 the U.S. 6th Circuit Court of Appeals ruled that nurses directing assistive personnel were in fact supervisors because the nurses worked for the interest of the employer exercising independent judgments beyond typical RN duties. A National Labor Relations Board ruling set a precedent that any nursing role with least 10-15% of time in a charge nurse capacity equates to that of a supervisor, making the individual ineligible for collective bargaining. This precedent remains in effect today. Nurses should be aware of the status of their roles if they are concerned about the right to be included or excluded in collective bargaining.
Nursing assistants and licensed practical nurses provide, under the direction of a registered nurse, the major portion of care to long term care (LTC) residents. Research team members, Corazzini, Anderson, Rapp, Mueller, McConnell, and Lekan present the results of a qualitative study in Delegation in Long-Term Care: Scope of Practice or Job Description?, Interviews with 33 LTC nursing leaders who described the process of delegation, the effect of delegation on quality, and the relationship of delegation to RN control of practice in nursing homes, identified two approaches used in assigning care tasks. The first was to follow the job description assigning care to nursing assistants (NA) based on prescribed duties. The second method was to consider a set of tasks (scope of practice) that fit with the nursing assistant’s skill set and were in accord with state definitions and regulations. The authors acknowledge frequent policy and procedure conflicts within nurse practice acts related to delegation. For example only half of the state nursing boards allow LPNs to delegate care, yet there is often a routine cascade of responsibilities in LTC from the RN to LPN to NA. These perceived incomplete or contradictory delegation guidelines affect key activities, such as medication administration. As in other settings, a successful partnership in delegation results in assistants feeling empowered and having a sense of trust. Barriers to successful delegation included poor partnerships, unhealthy attitudes, and lack of a sense of team.
In Delegation in the School Setting: Is it a Safe Practice?, Resha points out that school nurses are providing more care than ever before, with limited numbers of providers. In many locations the ratio of RN to students is five times the recommended 1 to 750 well students. Nurses are called upon to perform health screenings, immunizations and reporting, health teaching, case management, and management of medically fragile children with complex needs, including ventilators, pacemakers, and insulin pumps. Safe delegation can occur for some of these activities if there is adequate training of assistive personnel and close supervision. However, for school nurses assigned to multiple buildings and locations, close supervision is a myth. In some schools there is no support for a nurse helper. When the RN is not present, other substitutes, for example administrators, teachers, and/or parents, may step in to provide care; this presents a risk to safe patient care as well as to the school nurse. School nursing practice includes playing a role in development of school policies, being competent in the five rights of delegation, educating assistive personnel, and building relationships to ensure proper delegation.
Delegation is a universal nursing skill. With the looming world-wide nursing shortage, any change in skill mix will undoubtedly lead to an increase in the amount of delegation of certain aspects of care. In the UK delegation is recognized as an important skill at all levels of practice. Gillen and Graffin describe the authority, accountability, and responsibility for delegation in the UK, along with facilitators and barriers in their article, Delegation in Nursing in the United Kingdom. With no legal definition of a nurse in the UK it is imperative that there be clarity in procedures for delegation as well as clarity between the RN and Health Care Assistant. Many delegation similarities exist between the UK and the US. In both countries the RN retains accountability and responsibility for care, but the person who accepts the assigned work also accepts responsibility for performing the work. Appropriate delegation assumes that prior to assignment of tasks, the RN uses judgment and demonstrates critical thinking to assess the skill, competence, attitude, and experience of the helper, as well as the patient requirements and nature of the circumstances. Building of trust, effective communication, and mutual support contribute to success in the US and the UK, and around the world.
The journal editors invite you to share your response to this OJIN topic addressing Delegation Dilemmas either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.
Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN
Dr. Pamela Cipriano has been a chief nursing officer and hospital administrator in academic medical centers for over twenty years, during which time Magnet Recognition was achieved (2006) at the University of Virginia Health System (UVa) in Charlottesville, VA. Currently she serves as a special advisor to the Chief Nursing Officer at UVa and as Clinical Associate Professor in the School of Nursing. Dr. Cipriano chairs the American Academy of Nursing’s Workforce Commission, which is studying technology solutions to improve the work environment so as to make patient care safer and more efficient. She is Editor-in-Chief of American Nurse Today, the official journal of the American Nurses Association (ANA). She has been a leader in national nursing organizations addressing issues of clinical practice, policy, administration, quality, and technology. As a former chair of ANA’s Congress on Nursing Economics (1994), Dr, Cipriano facilitated early discussions leading to publication of official statements about RNs and delegation to unlicensed assistive personnel.