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DELEGATION

The main focus of this presentation is to explain the reason behind increased delegation to UAP especially in long term care facilities, and outline the impact to nursing quality care. Then, the question about whether this practice is good for nursing profession or not, and does this practice pose any threat to professional nurses and standard of care.

DELEGATION

Delegation is literarily defined as “a person or group designated to act for or represent another or others” (reference.com). This is a common or simple task with other disciplines, but completely different in nursing due to the complexity of delegation in healthcare organizations. Also, due to the complexity of nursing care now when compared with the early 1970s (Yoder-Wise, 2003, Pg. 370).

DELEGATION

When a professional nurse delegate, the nurse still retains the outcome responsibility of the delegated task, hence it is important to delegate with care. Delegation in nursing is defined in different or multiple ways, but all have two main elements namely a delegator and one or more delegate (Yoder-Wise, 2003, Pg.371).

DELEGATION

Regardless of the duty or task to be delegated there must be a professional registered nurse present to assess the task and delegate to competent unlicensed assistant personnel (UAP).The word “competent” is very important because if the UAP is not competent for the task; it will be irresponsible to delegate no matter how simple the task is or how much support for delegation to UAP by the organization.

DELEGATION

Yoder-Wise therefore defined delegation as “achieving performance of care outcome for which you are accountable and responsible by sharing activities with other individuals who have the appropriate authority to accomplish the work” (Yoder-Wise, 2003, Pg.371). The nurse delegating the task retains the accountability, while the person delegated for the task retains the authority to act for the best outcome.

DELEGATION

Historically, delegation in acute care was less complex because most care was delivered in hospital settings (Yoder-Wise, 2003, Pg. 370), but with the increased demand for nurses and the need to control the exploding health care cost; nursing homes, independent living, and home care nursing services are utilizing the services of UAP for less complex care.

DELEGATION

History of delegation: could be traced back to Florence Nightingale, and is therefore not a new thing but it has evolved over the years, transitioning from primary to multi-level nursing care since 1990s (Hasson, Mckenna & Keeney, 2012, Pg.230)

DELEGATION

Why is delegation necessary?

As a student nurse, I believed that the process of delegation has allowed me to learn my roles better, and helped prepare me for the challenges of nursing care, there is a general saying that “practice makes perfect” and there are some skills in nursing care that cannot be impacted in new nurses without practice. A good example is patient assessment; this cannot be delegated to UAP for any reason, but can be delegated to a student nurse. Some tasks that can be delegated to UAP are patient vital signs, monitoring and measuring input and output.

DELEGATION

Unfortunately, some nurses are saddled with the responsibilities of delegation to UAP without the necessary skills required to delegate safely and appropriately (Hasson, McKenna & Keeney, 2012, Pg.229). They are unable to identify the components of delegation namely:

DELEGATION

•Right task.•Right circumstances.•Right person.•Right direction.•Right supervision.

(Anthony, Hertz, & Standing, 2001, Pg. 211)

DELEGATION

UAP are called HealthCare Assistants (HCA) in the United Kingdom, and referred to as Certified Nurse’s Aide (CNA) in the United States, they have little or no nursing educational baseline or training for standardized care (Hasson, Mckenna & Keeney, 2012, Pg.230).

ISSUES IN DELEGATION TO UAP

Some nursing care omitted, due to poor delegation includes:

Turning

Ambulating

Feeding

Toileting

Mouth care.

(Hasson, Mckenna & Keeney, 2012, Pg.230).

DELEGATION

Conflicting views of delegating authority

• Differing views on student nurse delegation capability- Academic leaders believed that 90% of student nurses can delegate while nurse executives believed that only 10% can provide safe care and delegate appropriately.

• Conflict of understanding of roles by nurses: Some nurses believe that they are not responsible for delegated tasks, and it is part of UAP assignment.

• Nurses with less authority tried to avoid conflict and tend to be overworked and delegate less than appropriate.

DELEGATION

Solution:

Ability to delegate is essential skill for all nurses. The delegating nurse needs to understand the UAP’s role before delegation, must be able to supervise the UAP after delegation, and provide feedback.

Authority to delegate must not be based on protocol, but should rest solely on the nurse delegating the task; this will eliminate the problems of delegating to less than competent assistants. This will also standardize what should be delegated across the board, for example some establishments allowed UAP’S to bladder scan, glucose check, and Foley catheter placement while some do not.

DELEGATION

According to Yoder-Wise “delegation is a complex, loophole-ridden, work enhancing strategy”, this complex situation can be simplified by preparing new nurses with the necessary skills for appropriate delegation.

While we are debating whether delegation is a good or bad thing in nursing, let us look at some issues with delegation and assignments.

A nurse assignment delegated to UAP is not good for appropriate care.

Delegated tasks turned to nurse assignment will lead to burnout, uneven distribution of responsibilities, and decreased morale.

Assignment delegated to fellow nurse is appropriate.

PROS

Advantages of delegating to UAPs

It is cost effective

It is an alternative solution to nurse shortage.

It promotes good care when done the right way.

It saves time by delegating too many at a time.

Patients get more attention from increased number of employees with basic care skills.

PROS Allow the RN to spend more time on

critically sick patients while UAPs can help with less complex patients.

New nurses will be able to learn new skills before licensure.

UAPs are trained and ready to go in weeks, thus allowing for steady supply for increasing demand.

UAP provide qualitative care when appropriately delegated to.

Less frustration for RNs, because they spend more time on core nursing care.

(Zimmerman, 1995, Pg. 541-6)

CONS

Disadvantages of delegating to UAPs:

Too much focus on cost saving may have negative impact on quality of care.

Use of UAPs and sizable saving may lead organizations to ignore other cost saving measures like re-imbursements, physician residency program, malpractices cost, and technology advancement.

Cost saving may take some time to materialize.

RN tends to be less loyal to employer that excessively delegate nursing care to UAPs.

Inappropriate delegation will lead to time wasting, and not time saving.

CONS No universal standard for UAPs, leaving trails of

confusion on what and when to delegate.

Decreased quality of care when delegation inappropriate.

Legal dilemma about responsibility of care outcome.

Increased medication error, and decreased patient satisfaction.

Fragmented care with RN inability to complete assignment.

Source: Pros and cons of delegation.

CONSIDERATIONS BEFORE DELEGATIONFactor to be considered before delegating (Yoder-

Wise, 2003, Pg. 377)

Potential for harm. If delegated task will affect safe patient care, then do not delegate.

Complexity of task-if too complex for UAPs, do not delegate

Need for problem solving and innovation-experienced UAPs will require less supervision with better outcome.

Unpredictability of outcome- If outcome is unpredictable, do not delegate.

Level of interaction with patient –delegate according to your patients preference of caregiver. (Male caregiver to a young female will not be appropriate.

DELEGATION RATINGS

Rating delegation outcome by scoring the above mentioned factors-Developed by America Association of Critical Care Nurses (AACN)

0-3=appropriate

15-not appropriate

The higher the score, the lower the appropriateness of delegation.

Source: Texas State Board of Nursing Delegating Decision-Making Tree.

Discussion answer:

Step in and offer to help, if you have the authority to effect a change, re-delegate with education, but if not share your concerns with delegating nurse in a professional manner.

ABILITY TO DELEGATE

Nurses’ Beliefs About Their Abilities to Delegate Within Changing Models of Care (Anthony, Hertz, & Standing, 2001)

This study showed that long term care nurses believed they are more experienced at delegation- why? Because they do delegate more often than acute care settings nurses. Long term care setting allow for more delegation with authority for cost saving purpose.

RESIDENTIAL CARE DELEGATION

Residential care setting and delegation to Nursing Assistants (NAs)

Delegated tasks according to Sikma, & Young, 2001:

Medication administration, Nose/Eye drops, and suppositories.

Clean dressing change

Feeding through PEG (not PEJ) when healed and established.

Ostomy care when healed and established

Enemas administration

Clean urinary catherization.

Glucose monitoring.

CONDITIONS OF DELEGATION

All the above mentioned may be delegated post

1. RN determination of delegation

2. UAP training (Minimum of 8 hours)

3. RN education and delegated task as needed.

4. Competency check every 60 days.

5. Patient allows delegation by consent.

6. UAP ability to document care and also understand plan of care

7. No RN will be forced to delegate (do we have a choice?)

ISSUES WITH ASSISTED LIVING DELEGATION

Issues with Assisted Living Center (AL)

• AL residents take about the same number of medications as nursing home or hospital patients with little or no supervision

• Fragility (Physical and Mental) pose a risk to their medication management and administration

• California/Connecticut/Delaware do not allow medication administration by UAPs, but states that allows it does not have a standardized list of task for UAPs.

• 22 states allow nurse to delegate medication administration, 24 states did not, and the other 4 states position is not clear on the issue.

ISSUES WITH ASSISTED LIVING DELEGATION

• Other licensing agency other than Board of Nursing (BON) regulate UAPs license, and this make it difficult for BON to effectively regulate UAPs practice.

• BON lack of knowledge about AL model of operation and medication management makes regulation more difficult.

• Medication not properly secure –issue with dementia or cognitively impaired patients

• Less than adequate assessment by UAPs –prior to medication administration

• RN skill needed for assessing the AL resident’s ability to self-medication.

ISSUES

• Medication errors including wrong patient, dose, route, site, day, and time.

• Medication given despite vital sign holds order (e.g. hold medication for systolic blood pressure below 100) bp of 90/60 and still gives medication.

• Failure to document refusal, omission

• Medication given with allergy documented present.

• Expired order still being carried out.

DELEGATION AND NURSING CARE

Conclusion:

Is increased delegation to UAPs good for nurses and quality of care?

After reading, reviewing, and analyzing more than twelve reliable nursing journals/articles, it was unanimously agreed upon that the use of UAPs will be beneficial to healthcare and nursing care in particular if it is done appropriately. It was also agreed upon that improving RN delegation skill will enhance appropriate delegation. In assisted living/skilled nursing facilities, the fear of RNs losing ground to UAPs is unfounded because it will require a registered nurse to initiate care after obtaining order from the physician, and then UAPs can carry out part of the plan of care that may be delegated

NURSES ROLE IN DELEGATION

Even though UAPs perform some complex tasks as delegated by the RN, it is nurses who must initiate the care before delegation.

Due to the cost cutting benefit of using UAPs, and the increasing demand for nurses, it is safe to say that UAP use will increase as well, and delegated task will continue to increase as well. It is important to delegate safely when needed. RN will then need to be educated on what they need to know before delegating.

TIPS Below are ten tips for successful delegation by Carol J Huston:

1. Delegate for the right reason.

2. Delegate to the right person.

3. Delegate at the right time

4. Give others the right to refuse a delegated task and do the same yourself

5. Choose your words carefully (be polite and cordial)

6. Don’t create situation that require you to redo delegated tasks.

7. Define the desired outcome of the delegation, but allow latitude in how the task is completed (be flexible)

8. Provide authority and resources for delegated task

9. Oversee completion of delegated task and provide feedback

10.Celebrate successful completion of the delegated task.

(Huston, www.nursing2009.com)

REFERENCESAnthony, M. K., Standing, T. S., Delegation: What it means to acute care

nurses

Applied Nursing Research, Volume 21, Issue 1, February 2008, Pages 8–14

Anthony, M. K., Standing, T. S., & Hertz, J. E. (2001). Nurses' beliefs about their abilities to delegate within changing models of care. Journal Of Continuing Education In Nursing, 32(5), 210-215.

Flores, S., Mitty, E. Assisted Living Nursing Practice: Medication Management: Part 1 Assessing the Resident for Self-Medication Ability. Geriatric Nursing, Volume 28, Issue 2, March–April 2007, Pages 83–89

Hasson, F., McKenna, H. P., & Keeney, S. (2013). Delegating and supervising unregistered professionals: The student nurse experience. Nurse Education Today, 33(3), 229-235.

Huston, C.J. 10 tips for successful delegation. Retrieved from: www.nursing2009.com

Kane, R.S., Quinn, W.V., Reinhard, S.C., Young, H.M. Nurse delegation of medication administration for older adults in assisted living. Nursing Outlook, Volume 54, Issue 2, March–April 2006, Pages 74–80

REFERENCESMitty, E. (2007). Assisted Living Nursing Practice: Medication

Management: Part 2 Supervision and Monitoring of Medication Administration by Unlicensed Assistive Personnel. Geriatric Nursing, Volume 28, Issue 3, May–June 2007, Pages 153–160.

Sikma, S.K, Young, H.M., (2001). Balancing freedom with risks: The experience of nursing task delegation in community-based residential care settings. Nursing Outlook, Volume 49, Issue 4, July–August 2001, Pages 193–201

Simon, E. (1998). Delegation competencies. Nurse Educator, 23(6), 47.

Zimmerman, P.G. (1995). Increased use of unlicensed assistive personnel: Pros and Cons. Emergency Nurses Association, 1995;21:541-9.

Yoder-Wise, P. S. (2014). Leading and managing in nursing: Revised reprint (3rd ed.). St. Louis, MO: Elsevier Inc.