CHAPTER 9CHAPTER 9

DDELEGATIONELEGATIONOF CLIENT CAREOF CLIENT CARE

OBJECTIVESOBJECTIVES

Define delegation and unlicensed Define delegation and unlicensed assistive personnel.assistive personnel.

Identify the Identify the rightsrights of delegation of delegation and the implications of each.and the implications of each.

Understand the legal implications Understand the legal implications of making assignments to other of making assignments to other healthcare personnel.healthcare personnel.

Discuss the process of delegation Discuss the process of delegation and the coordination of and the coordination of assignments.assignments.

ObjectivesObjectives

Differentiate delegation from work Differentiate delegation from work allocation.allocation.

Outline how delegation benefits the Outline how delegation benefits the patient, staff and the organization. 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 Examine the criteria for safe delegation.delegation.

OBJECTIVESOBJECTIVESDiscuss 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.

OBJECTIVESOBJECTIVES

Compare delegation in professional Compare delegation in professional practice as it relates to responsibility, practice as it relates to responsibility, accountability and authority.accountability and authority.

Illustrate critical thinking when Illustrate critical thinking when making assignments and delegating making assignments and delegating tasks. tasks.

Illustrate how to communicate Illustrate how to communicate assignments and delegated tasks and assignments and delegated tasks and recognize barriers to successful recognize barriers to successful delegation.delegation.

Differentiate the models of care delivery - Functional, Team, Total Client Care

OBJECTIVESOBJECTIVESApply delegation concepts, and Apply delegation concepts, and

critical thinking to client scenarios critical thinking to client scenarios and NCLEX-style questions.and NCLEX-style questions.

Illustrate critical thinking when Illustrate critical thinking when making assignments and delegating making assignments and delegating tasks. tasks.

Illustrate how to communicate Illustrate how to communicate assignments and delegated tasks assignments and delegated tasks and recognize barriers to successful and recognize barriers to successful delegation.delegation.

Apply delegation concepts, and Apply delegation concepts, and critical thinking to client scenarios critical thinking to client scenarios and NCLEX-style questions.and NCLEX-style questions.

DEFINITIONDEFINITION

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

Concepts of DelegationConcepts of Delegation

The responsibility of the The responsibility of the task is transferred.task is transferred.

Accountability remains Accountability remains with the delegator.with the delegator.

Delegation may be direct Delegation may be direct or indirect.or indirect.

Direct DelegationDirect Delegation

Usually verbal directionUsually verbal direction

RN decides which staff RN decides which staff member is capable of member is capable of performing a specific taskperforming a specific task

Indirect DelegationIndirect Delegation

Contained in an approved listing of tasks established by an institution

Permitted tasks may vary from institution to institution

CONSIDERATIONSCONSIDERATIONSWhether 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.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 The Five Rights of DelegationDelegation

Right taskRight circumstancesRight personRight direction/communication

Right supervision/evaluation

Right TaskRight TaskWhat can the nurse not What can the nurse not delegate?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 CircumstanceRight Circumstance

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

Right PersonRight PersonRN accountable and responsible

for meeting patient needsDelegated care (to UAP) should

be for stable patientsCompetencies: 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 & Right Direction & CommunicationCommunication

Right Supervision and Right Supervision and EvaluationEvaluation

Monitoring◦Guidance◦Direction

Feedback

Red FlagsRed Flags

Complexity of nursing activity

Unidentified client needsMissing requisite knowledge and skills

Insufficient opportunity to train

Insufficient opportunity to monitor

Assigning TasksAssigning Tasks

The RN may assign a more skilled The RN may assign a more skilled individual to perform a taskindividual to perform a task

The RN may not assign an The RN may not assign an individual to perform an activity individual to perform an activity outside of a job description or the outside of a job description or the scope of practicescope of practice

Consider the following situation…Consider the following situation…

Mr. Ross was admitted to the neurological unit Mr. Ross was admitted to the neurological unit

from the Neuro ICU. She suffered a grade II from the Neuro ICU. She suffered a grade II

subarachnoid hemorrhage 2 weeks ago and has subarachnoid hemorrhage 2 weeks ago and has

a left hemiparesis. She has difficulty with a left hemiparesis. She has difficulty with

swallowing and receives tube feedings through swallowing and receives tube feedings through

a PEG tube; however, she has been advanced to a PEG tube; however, she has been advanced to

a pureed diet. She needs assistance with a pureed diet. She needs assistance with

personal care, toileting, and feeding. A PT personal care, toileting, and feeding. A PT

comes BID to get her up for gait training; comes BID to get her up for gait training;

otherwise, the physician wants her in a chair as otherwise, the physician wants her in a chair as

much as possible.much as possible.

Delegation vs Delegation vs SupervisionSupervision

Supervision usually more direct than delegation

Requires directly overseeing the work or performance of others

Could include reevaluation

Assessment

Assess client needsSet client-specific goalsMatch the personnel with the appropriate skills to care for the client

The Nursing Process and The Nursing Process and DelegationDelegation

PlanningPlanning

Mentally identify who is best Mentally identify who is best suited for the task or activitysuited for the task or activity

Planning prevents later Planning prevents later problemsproblems

ImplementationImplementation

Assign the appropriate personnel who have the level of expertise necessary to deliver the care or carry out the activities

EvaluationEvaluation

Oversee the care or Oversee the care or activitiesactivities

Determine if client care Determine if client care needs have been metneeds have been met

Allow for feedbackAllow for feedback

Coordinating Coordinating Assignments:Assignments:Methods to Help Methods to Help Organize Care Organize Care Care plans

Clinical (Critical) pathways

Computerized information sheets

Personalized worksheets

Tips for Organizing Tips for Organizing CareCarePlan 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 DelegationThe 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 Unlicensed Assistive Personnel (UAPs)Personnel (UAPs)

Individuals trained to function in an assistive role to the nurse

Perform delegated tasksUnder direct supervision of the RN

May or may not be certified

Decision -Making GridDecision -Making GridMethod 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 TasksExamples of Tasks

Vital signsSkills learned through special training:◦Blood drawing◦ECGs

Measuring intake and outputNon-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 Five Factors for Determining if Client Care Activity Should be Client Care Activity Should be

DelegatedDelegated

Potential for harm to the patient

Complexity of the nursing activity

Problem-solving and innovation necessary to complete the task or activity

Predictability of outcomeExtent of interaction

When should the nurse When should the nurse intervene?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 Primary task-related concern:concern:

AbilityPrioritiesEfficiencyAppropriateness

Relationship-Oriented Relationship-Oriented ConcernsConcerns

FairnessLearning opportunitiesassignmentsCompatibilityPreferences

Obstacles to Obstacles to DelegatingDelegating

Inadequate experience and education

“I can do it better”Lack of skillConfidence in UAPNeed to feel indispensable

Fear of losing authority

Lack of time

Obstacles to accepting Obstacles to accepting delegationdelegationFear of criticismLack of self-confidenceLack of time

LPN vs RN rolesLPN vs RN rolesNP Phase

LPN RN

Assess Gather dataID strengths

Gather extensive data; Group & analyze data; ID resources

Nsg Dx n/a Draw conclusions;Use judgment;Assign Nsg Dx

Planning Contributes Short/long-term goals; Establish Priorities; Collaborate/refer

Implement

Provide basic care measures, teaching, documents

Manage patient care – perform/delegate, teaching, referrals, collaborate team members, Document

Evaluate Eval effects of care

Evaluate plans overall effectiveness, analyze new data, modify plan

Delegating to LPNDelegating to LPNCompetencies: Technical skills

Appropriate assignment: Stable patient with predictable outcomes

Abilities: More complex care than UAP; sterile technique, medication administration…

Models of Care Models of Care DeliveryDelivery

Major Concept Advantages Disadvantages

Functional Division of tasks with clearly defined roles

Efficient, economical, productive

Fragmented care

Team RN team leader supervises ancillary staff

More holistic RN must take time to delegate

Primary RN 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 Care One RN with total responsibility for care

Continuity of care Costly; no efficient use of staff

The Five Rights of The Five Rights of DelegationDelegation

Right taskRight circumstancesRight personRight direction/communication

Right supervision/evaluation

In Conclusion, In Conclusion, Points to Consider:Points to Consider:Delegation is not newDelegation is essential todayOrganizational skills are a prerequisite for delegation

Understanding client needs is essential for appropriate delegation

The RN Needs to: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.