Nursing Management May 1999
BY MARIE FISHER, RN,C, MS
East Winthrop, Me.
Nurses and UAPs need education and a supportive environment to safely delegate and accept tasks.
ABSTRACT: Read how to build a work environment that combines your organization's policies and standards, legal regulations, and nurses' expertise into a safe delegation system with positive impact.
Nurse leaders are experts at delegation. After all, if you weren't, you wouldn't get anything done. Many of you manage multiple units where nurses must accomplish the most work for the least cost. But how do you confer those delegation skills to your staff nurses?
Staff nurses often need to delegate tasks to unlicensed assistive personnel (UAPs) and need your guidance to do so effectively. As a nurse leader, your role in supporting effective delegation begins with administrative planning.
The National Council of State Boards of Nursing (NCSBN) published five rights of delegation for those who work in executive and management positions at all levels.1
Right task. Nurse leaders determine those activities nurses may perform in the organization. They build the organizational policies and set the standards and limitations of nursing practice. Staff nurses then work with UAPs, delegating only those tasks deemed appropriate in the guidelines. For each situation, the nurse must consider the patient's condition, the complexity of the activity, the UAPs' capabilities, and the amount of supervision the nurse will be able to provide.
Right circumstances. Nurse leaders consider community needs, staffing needs, and staffing mixes and teach staff members to delegate according to these values and criteria. Again, the staff nurse evaluates the individual clients and the individual UAPs and matches the two together. The nurse assesses the client's needs, looks at the care plan, and considers the setting, ensuring that UAPs have the proper resources, equipment, and supervision to work safely.
Right person. Nurse leaders make sure that the organization establishes policies consistent with the law. They need to point out what's consistent with the law and what isn't. They must ensure that the organization establishes competency standards and that managers adhere to them as they hire nurses who will perform daily delegation procedures. Additionally, they have a responsibility to report inappropriate or illegal activities to the board of nursing as required by law.
Once you have ensured the competence of the nurses who delegate, you must teach them to assess the UAPs' competence. Does the organization have written proof of the UAPs' demonstrated skills? Do UAPs know how to collect and report data, working as the nurse's eyes and ears in the patient's room?
Right direction and communication. The nurse leader needs to communicate the acceptable activities, competencies, and qualifications for the organization, as well as the standards of care. The staff needs to clearly understand the organization's policies and procedures to carry out effective delegation.
In turn, staff nurses need to direct UAPs' actions and communicate clearly about each delegated task. Nurses must be specific about how and when UAPs should report back to them. For example, UAPs can tell the nurse that an I.V. bag is almost empty, but they can't adjust the flow or change the bottle. Nurses need to discuss the nature of each task with UAPs and the skills needed to perform it. Nurses should feel comfortable asking, "Do you know how to do this? Where did you learn? How many times have you done it in the past? Where is your experience documented?"
Right supervision and evaluation. Nurse leaders must ensure that each unit has adequate staffing and time, identify the tasks inherent to each staff role, and evaluate the impact of the organization's nursing service on the community. The information can fuel quality improvement processes and help the organization manage risk.
The delegating nurse then must supervise, guide, and evaluate UAPs' task implementation. The nurse ensures that UAPs meet expectations and intervenes if they aren't performing well. The nurse needs to give feedback and solicit the UAPs' feedback. Then the nurse can assess how the delegation worked and how she can improve the process. She evaluates the patient's outcome, the tasks' success, and results of the tasks.
To delegate, the nurse must make decisions about nursing care, but have UAPs carry out the tasks on her behalf. This can create concern. Can the nurse delegate effectively? Who's accountable for the effects of the delegated task? Who's accountable for the UAPs' actions?
In the context of delegation, accountability means bearing responsibility for both the action and inaction of yourself and those to whom you delegate tasks. This worries nurses most. Nurses frequently say, "It's my license on the line. I'd rather just do this myself." The nurse risks her license when she doesn't delegate appropriately. Appropriate delegation occurs when the nurse understands the principles of delegation and implements them correctly.
Nurses have the responsibility to ensure that appropriate assessment, planning, implementation, supervision, and evaluation go into their delegation. We can delegate only the tasks or implementation—the rest requires professional expertise. The nurse makes all care-related nursing decisions and is accountable for them.
For this reason, UAPs need to understand that they can only accept assignments within the parameters of their training and experience. They need to be able to say, "I don't know how, and I really can't do this," without feeling that their jobs are in jeopardy. Also, when a nurse delegates a task to UAPs, they can't tell someone else to do it. This destroys supervision, evaluation, and vital accountability.
If a nurse doesn't delegate appropriately or the UAPs do things the nurse hasn't authorized them to do, both the nurse and the UAPs are subject to legal action. Although UAPs can incur criminal charges when things go wrong, they don't get sued very often.
Additionally, remember that health care institutions can't legally mandate the practice of nursing by nonnurses. No matter how much an organization wants to assign nursing duties to UAPs, it doesn't have the legal authority to do so. It also can't mandate that nurses delegate when they know that doing so would be inappropriate or unsafe. Lots of nurses experience job pressure to overstep legal boundaries. You have to be strong from the start and say to an employer, "I'm not going to risk this. I will delegate only within the confines of the nurse practice act."
Nurse practice act
To understand our limitations, we must examine the sources of our delegation authority—law and regulation. Review your state's nurse practice act (NPA) and ask the following questions:
Aside from the NPA, employees must understand the policies and standards that specify what they can do in the institution. Professional nursing standards such as those from the American Nurses Association need to be addressed. Other standards may impact delegation, such as those of the Joint Commission on the Accreditation of Healthcare Organizations or other professional organizations to which you belong.
We need to educate nurses about delegation from the day they come through the door—how to accept or reject delegation and how to delegate to UAPs. Such education should begin in nursing schools. In addition, UAP education must incorporate delegation. UAPs must understand their role, including what they can and can't do.
To reduce risk and ensure effective delegation, the NCSBN developed a document called "Role Development: Clinical Components of Delegation Curriculum Outline"2 to teach nurses how to delegate and UAPs how to accept delegation. The NCSBN can also answer specific UAP questions.
In addition, the NCSBN has developed a delegation decision-making tree and grid. You can teach staff to use the tree in the context of everyday tasks.
The NCSBN's delegation decision-making grid asks a series of questions to help nurses decide what to delegate to whom. It addresses:
Many states also have put other kinds of delegation decision-making trees together for nurses to use.
Effective delegation produces desirable client outcomes and patient protection. It can reduce health care costs through employing cost-effective UAPs and using time and resources more effectively. Effective delegation can also facilitate access to care.
For nurse leaders, the delegation process clarifies accountability. It also decreases nurses' liability and enables them to demonstrate leadership skills for positive career movement. Both nurses and UAPs benefit from the fairly distributed workload, efficient use of time, and increased job satisfaction.
1. Delegation: Concepts and Decision-making Process. National Council of State Boards of Nursing, Inc., Chicago, Ill. 1995.
2. Role Development: Clinical Components of Delegation Curriculum Outline. National Council of State Boards of Nursing, Inc., Chicago, Ill. 1995.
The Nursing Institute is an affiliate of Springhouse Corporation, publisher of Nursing Management. The Institute is accredited as a provider of continuing education (CE) in nursing by the American Nurses Credentialing Center's Commission on Accreditation and by AACN. This test qualifies for AACN CERP category O. The Nursing Institute is also an approved provider of CE in states where it is mandatory for license renewal.* Your Nursing Instituteissued CE contact hours are valid wherever you reside.
*Provider numbers: Alabama, ABNP0210; California, 5264; Florida, 27I0600; and Iowa, 136 (Category 5), Texas (Type 1), AACN 8227.