Delegation of Nursing Care

This presentation is intended to satisfy the exemplar Delegation under the concept of Managing Care in NUR 213 for the NC CIP Concept Based curriculum. Please see the corresponding case study that may be used with it. 1Delegation of Nursing CareDr. Sheryl Cornelius, EdD, MSN, RN

Hello, I am Dr. Sheryl Cornelius, nursing faculty of Mitchell Community College in Statesville, NC2Objectives: Upon completion of this module the student will be able to:Define delegation and concepts surrounding the management of patient careUtilize Five Rights of Delegation to determine appropriate delegation of patient careCorrelate barriers to delegation with methods for successOutline the delegation process and key behaviors when delegating tasks.

3What is Delegation? Definition: the act of empowering to act for another

So What is Delegation? Websters Dictionary defines it as the act of empowering to act for another. So when I delegate I am giving someone the power to do a portion of my duties for me. Its still my job, its still my responsibility but I cannot do it all so I am giving them a small part to ensure that it all gets done. Teamwork.4Position Statement NC Board of Nursing Position Statement for RN and LPN practice on Delegation and Assignment of Nursing Activities

http://www.ncbon.org

So when we want to know more about a particular topic we research it through the expert is in the area, correct? In this case, as registered nurses, we start with the Board of Nursing. The NC BON has a position statement on delegation. So lets take a look at that. Pull out your tablets, Go to the website here, www.ncbon.org, on the left side of the screen you will find practice, under practice you will find position statements, and under position statements you will find delegation and assignment of nursing activities. Ill give everyone a minute to pull up this document. 5Assign to other licensed or unlicensed assistive personnel (UAP)

Their own license

Assessment of the clients status

Clinical competence of the person the duty is being assigned

Any variables that may impact

(NCBON, 2010)

So does someone want to read that small paragraph at the top for us? The issue that is clarified in this position statement.

Based on this statement the person assigning or delegating as we call it needs to know their own license- what they themselves can and cannot do. -needs to know the assessment of the clients status are they stable or not? Clinical competence of the person the duty is being assigned because we would not assign something to someone that they do not know how to do or are not checked off on- anything else that may effect that decision maybe the person is not oriented to that floor or that person is just out of orientation this may effect how and what you delegate

6Before assigning/delegating nursing activities to staff, the licensed nurse needs access to information about the RN-validated competencies for each individual. (NCBON, 2010)

And finally that statement at the end: Before assigning/delegating nursing activities to staff, the licensed nurse needs access to information about the RN-validated competencies for each individual. So what does this mean to you?

You need to know your facilities policies and proceduresYou need to know your facilities orientation program and job responsibilities for each job title you will delegate to. You need to know or have worked with the employees you are going to delegate toThere needs to be a trust and understanding between the team, There needs to be a communication if something is unclear Each person on the team needs to be able to express needs for help 7Definitions From NCBONAuthority

Accountability

Assigning-

Delegating

Supervision -

So back to that position statement we were looking at: the board gives us some definitions-

Authority - The source of the power to act. The team leader in many cases is the authority and this is generally a registered nurse. You know I dont like always or never because we can always come up with exceptions to most any statement, but generally the team leader is an RN in an acute care setting.

Accountability - Being responsible and answerable for actions or inactions of self, and of others in the context of delegation or assignment. In this context, the licensed nurse retains the accountability for appropriate assignment and/or delegation. The person to whom an activity is assigned and/or delegated is accountable for carrying out the task correctly. As we have discussed, the RN team leader is responsible for the group. Not just the part that she/he did but the entire group.

Assigning- Designating responsibility for implementation of a specific activity or set of activities to a person licensed and competent to perform such activities. This is where we get into scope of practice and competency what a person can do or not do.

Delegating - Transferring to a competent individual the authority to perform a selected nursing activity in a selected situation. The nurse retains accountability for the delegation. So we had the definition: to empower to act for another. This one is more specific to nursing and is clarified by the board. Supervision The provision of guidance or direction, evaluation, and follow-up for accomplishment of an assigned or delegated nursing activity or set of activities. UAP (Unlicensed Assistive Personnel) - Any unlicensed personnel, regardless of title, who may participate in patient care activities through the delegation process. We tend to use UAP anymore because not everyone is a CNA. We have med techs, we have health techs, transporters, there are dozens of names facility specific for UAPs.

8The Five Rights of DelegationRight Task

Right Circumstances

Right Person

Right direction/communication

Right Supervision/Evaluation (National Council of State Boards of Nursing, Inc, 1997)

Let us talk about some specifics about how to delegate as the National Council of State Boards of Nursing have said it. Here we have the 5 rights of Delegation. In order for you to properly delegate all 5 of these things have to be in place. Not 3 of the 5, not all but one. ALL five MUST be there for a proper delegation to take place. So lets do it one by one -

Just because you delegated the dressing change to the LPN does not mean that you can assume it was done and never think about it again. You must follow up and ensure that it was 9Right TaskAppropriate delegation activities are identified for specific client(s).

Appropriate activities are identified for specific UAP.

(National Council of State Boards of Nursing, Inc, 1997)

Appropriate delegation activities are identified for specific client(s).So what does that mean? Would you assign the first feeding post bronchoscopy to a UAP? The RN would need to assess first that the swallowing and gag reflex are present before a task of that nature is delegated to a UAP. Would you assign initial diabetic teaching to an LPN? The initial teaching needs to go to the RN so assessments can be made.

Appropriate activities are identified for specific UAP.What does this mean? If you work on a renal floor with many peritoneal dialysis patients would you tell the UAP pulled from the OB floor to get a weight on a certain patient without further direction? No. The UAP should know how to weigh a patient but will they know that you want a wet and a dry weight on the CAPD pt if they have never been involved with this type of pt? What if you have a new lift system that not everyone has been educated on? Would you assign the task of getting a patient up with this lift to a UAP that has not been checked off on the equipment used for the procedure?

10Right CircumstancesAssess health status of individual client(s), analyze the data and identify client specific goals and nursing care needs.

Match the complexity of the activity with the UAP competency and with the level of supervision available.

Provide for appropriate monitoring and guiding for the combination of client, activity and personnel.(National Council of State Boards of Nursing, Inc, 1997)

Okay for these we have three rows in here. I want the first row to talk to your neighbor and come up with an example for this first one, second row the second one and third row speak to your neighbors in row three and come up with an example for this third one here.

I will give you 3 minutes and then we will continue discussing. GO!

So Row one anyone want to give us an example? Great, so when the RN knows the pt and has a good understanding of what the pt needs he/she can be more specific about what is delegated

Row two? Exactly, so you wouldnt give an inexperienced person a task that needed much supervision and a good understanding of the client. If you do not have the time to devote to assisting that person if they need help then it is not the right fit for that circumstance

Row three? And row threeVital signs for stable patients you might check at the end of the day if the UAP has not come to you with any abnormals. If you know the client has a very high BP then you should check quicker and maybe even do it yourself to ensure that the clients care is appropriate11Right PersonInstruct and/or assess, verify and identify the UAPs competency on an individual and client specific basis.

Implement own professional development activities based on assessed needs; assess UAP performance; perform evaluations of UAP based upon standards; and take steps to remedy failure to meet standards.

(National Council of State Boards of Nursing, Inc, 1997)

As we discussed in an earlier slide, it is the team leader or delegators duty to know what the person you are delegating to can and cannot do. You should be aware if the person is out of orientation, has been working regular enough to keep up with the competencies and is capable of completing the task set in front of them.

Maybe you can have the person verbalize the procedure for you before you send them off to complete so you can assess if there is anything that may be left out. Maybe you want to go with the UAP for the first blood sugar check of the day to watch her/him and then you know whether you feel comfortable letting that person complete the task on all other patients for the day.

If you find that the UAP is not doing something the way it needs to be done then take the time to remediate right then if possible and then send them for education at a later time also if needed. Sometimes it is just that you were not clear enough in your communication in the first place. 12Right Direction/CommunicationCommunicate delegation decision on a client specific and UAP-specific basis. The detail and method (oral and/or written) vary with the specific circumstances.

Situation specific communication includes: specific data to be collected and method and timelines for reporting, specific activities to be performed and any client specific instruction and limitation, and the expected results or potential complications and time lines for communicating such information.(National Council of State Boards of Nursing, Inc, 1997)

Communication is probably the most important part in ensuring what you delegate is completed properly. As we delegate we should use open body language, eye contact, face-to-face positioning, and I statements. For example, I would likeWe get comfortable when we work with people day in and day out. We know what they will do and what we will need to do in response. We know what the routine is for our unit. We know what the people we work with have been checked off on and what they may need help with. This heightened comfort level is what often leads to poor communication. We assume the other person knows what to do. We assume they know what we expect. This is where mistakes can be made. In addition to the communication that comes from the delegator, the delegatee is responsible for accepting the delegation, seeking clarification of and affirming expectations, performing the task correctly and timely communicating results to the nurse. 13Right Supervision/EvaluationSupervise or assign supervision to other licensed nurses

Provide directions and clear expectations

Evaluate the entire delegation process

Supervise performance of specific nursing activities or assign supervision to other licensed nurses.

Provide directions and clear expectations of how the activity is to be performed: monitor performance, obtain and provide feedback, intervene if necessary, and ensure proper documentation.

Evaluate the entire delegation process: evaluate the client, and evaluate the performance of the activity.

14Barriers to DelegationLack of trust/confidence in delegatee Preference for working aloneLack of experience in the job or delegatingFear of loss of controlFear of being dislikedLack of organizationPerfectionism

So how do we ensure that this process is successful?These are some words to consider: Trust the trust you have in another staff member dictates whether that task is delegated or not. If you dont trust that they can do it then perhaps it is not appropriate to be delegated. Preference for working alone we all have a bit of the super nurse in us. We all have thought at one time or another that it is easier to do it ourselves then to take the time to ask someone else for help. This is not fair to you, to the fellow employees, to the patientLack of experience in the job or delegating- we are all new at one time or another. The only way to gain experience though is to do it. Fear of being disliked- Lack of organization- I am so far behind I dont even know what to ask you to do!Perfectionism- No one is going to do it the same way as you but it doesnt mean that it is not done or even done right. 15How todelegate to a UapNC Board of Nursing Decision Tree for Delegation to UAP

www.ncbon.org

Lets look at this document, shall we? It is on the same page that you pulled up the position statement earlier.

Pick a task that you might delegate to a UAP. Turn to your neighbor and discuss if it is appropriate to delegate this or not. Then your partner can come up with one for you to put through the tree. Now remember you cannot just say vital signs be specific to who you are delegating to and which client we are talking about. For instance, you might say delegate blood pressure checks on a stable cardiac cath patient to a UAP that is oriented and competent on your unit. When you put that through the decision tree then it fits and it is appropriate. Now what if we used the task of vital signs on a patient with a new complaint of chest pain and shortness of breath? Would that be appropriate? No because the nurse needs to assess a new complaint such as that to ascertain whether the client is stable and it appropriate for the UAP to be checking the vital signs. So chat with your neighbor work through a few. 16Tasks that may not be delegated to a uapAssessment

Interpretation of data

Making a nursing diagnosis

Creation of a care plan

Evaluation of care effectivenessCare of invasive lines

Administering medications

Client education

Performing triage

Giving telephone advice

These are some things that we would never delegate to a UAP can anyone tell me why? Mainly out of the scope of practice, right? These are things that an RN should do and in some circumstances an LPN, but never a UAP. 17How to delegate to an LPNFollow up assessments

Reinforcement of teaching

Procedures

Medication administrationContinued implementation of the established care plan

The most important thing to remember when delegating to an LPN is that the RN does anything initial. The initial assessment, the initial teaching, the initial dressing change, the first time a procedure has been implemented for a client, and the initiating of the care plan.

Again, you would know what your LPN is capable of, some are IV certified and some are not. You would also want to know how your facility interprets what an initial assessment is. Admission, every 24 hours? Your policy defines what initial means the board of nursing just says initial. 18In conclusionDelegator ultimately responsible

Communication is key

Follow up is essential

Even though you are giving someone the power to complete a portion of the duties they are still your duties to ensure are complete and completed properly 19The nurse has assigned the vital signs and daily weights of her patients to the unlicensed assistive personnel (UAP) on duty for that shift. It is still important for the nurse assigned to the patient to reassess each patient throughout the shift because:A) The nurse remains accountable for the patients' care.B) The UAP is not trustworthy.C) The UAP cannot report to the next shift.D) The nurse maintains the authority to care for the patients.

(NC Concept-Based Learning Editorial Board, 2011)

Question 1

Now that we have had some basics lets see what you learned. 20The nurse has assigned the vital signs and daily weights of her patients to the unlicensed assistive personnel (UAP) on duty for that shift. It is still important for the nurse assigned to the patient to reassess each patient throughout the shift because:A) The nurse remains accountable for the patients' care.B) The UAP is not trustworthy.C) The UAP cannot report to the next shift.D) The nurse maintains the authority to care for the patients.

Answer 1

The nurse remains accountable for the care of patients during delegation to the UAP. The UAP may be untrustworthy, but the reason the nurse checks on the patients is because the accountability belongs to the nurse. The nurse could take a report from the UAP and report that to the next shift. The nurse transfers the authority for the delegated care to the UAP.

21Toward the end of the shift, an LPN reports to the RN that the recently hired UAP has not totaled client's I&O for the past 12 hours. Which action should the nurse take?A) Confront the UAP about not completing the intake and output measurements.B) Delegate this task to the LPN since the UAP may not have been educated on the task. C) Ask the UAP if assistance is needed to complete the I&Os.D) Notify the nurse manager to include this on the UAP's evaluation.

Question 2(NC Concept-Based Learning Editorial Board, 2011)

22Toward the end of the shift, an LPN reports to the RN that the recently hired UAP has not totaled client's I&O for the past 12 hours. Which action should the nurse take?A) Confront the UAP about not completing the intake and output measurements.B) Delegate this task to the LPN since the UAP may not have been educated on the task. C) Ask the UAP if assistance is needed to complete the I&Os.D) Notify the nurse manager to include this on the UAP's evaluation.

Answer 2

First assess the situation. Did the UAP get behind and need help? Did the UAP not understand what was expected of her? Did she do it but not chart it? Did she do it but not chart it in the correct place?

Once you have asked the UAP if they have needed assistance then you proceed from their answer. 23For client education about non pharmacological alternatives, which topic could you delegate to an experienced LPN, who will function with your continued support and supervision? A) Therapeutic touchB) Application of heat and coldC) MeditationD) Transcutaneous electrical nerve stimulation (TENS)

Question 3(LaCharity, Kumagai, & Bartz, 2011)

For client education about non pharmacological alternatives, which topic could you delegate to an experienced LPN, who will function with your continued support and supervision? A) Therapeutic touchB) Application of heat and coldC) MeditationD) Transcutaneous electrical nerve stimulation (TENS)

Answer 3

Application of heat and cold is a standard therapy with guidelines for safe use and predictable outcomes, and an LPN will be implementing this therapy in the hospital under the supervision of an RN.Therapeutic touch requires further training, meditation requires an assessment of spiritual and cultural beliefs and TENS unit is usually applied by a physical therapist. 25Which pediatric pain client should be assigned to a newly graduated RN?A) An adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient-controlled analgesia (PCA) device to a long acting oral analgesic; he has been continually asking for an increased dose. B) A child who is receiving palliative end of life care; the child is receiving analgesics around the clock to relieve suffering , but there is a progressive decrease in alertness and responsiveness. C) A child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures.D) A child who has chronic pain and whose medication and nonpharmacological regimen has recently been changed; the mother is anxious to see if the new regimen is successful.

Question 4(LaCharity, Kumagai, & Bartz, 2011)

26Which pediatric pain client should be assigned to a newly graduated RN?A) An adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient-controlled analgesia (PCA) device to a long acting oral analgesic; he has been continually asking for an increased dose. B) A child who is receiving palliative end of life care; the child is receiving analgesics around the clock to relieve suffering , but there is a progressive decrease in alertness and responsiveness. C) A child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures.D) A child who has chronic pain and whose medication and nonpharmacological regimen has recently been changed; the mother is anxious to see if the new regimen is successful

Answer 4

The set of circumstances is least complicated for the child with the fracture and this would be the best client for the new and relatively inexperienced RN. The child will likely have a good response to pain medication and this will relieve some of the anxiety. The other three children have complex social and psychological issues related to pain management.27In care of the client with pain and discomfort, which task is most appropriate to delegate to the UAP?

A) Assisting the client with preparation for a sitz bathB) Monitoring the client for signs of discomfort while ambulating.C) Coaching the client to deep breathe during painful proceduresD) Evaluating relief after applying a cold compress

Question 5(LaCharity, Kumagai, & Bartz, 2011)

28In care of the client with pain and discomfort, which task is most appropriate to delegate to the UAP?

A) Assisting the client with preparation for a sitz bathB) Monitoring the client for signs of discomfort while ambulating.C) Coaching the client to deep breathe during painful proceduresD) Evaluating relief after applying a cold compress

Answer 5

The UAP is able to assist the client with hygiene issues and knows and knows the principles of safety and comfort for this procedure. Monitoring the client, teaching techniques, and evaluating outcomes are nursing responsibilities. 29The nurse is caring for a client with esophageal cancer. Which task could be delegated to a UAP? A) Assist the client with oral hygiene. B) Observe the patients response to feedings.C) Facilitate expression of grief or anxiety.D) Initiate daily weights.

Question 6(LaCharity, Kumagai, & Bartz, 2011)

The nurse is caring for a client with esophageal cancer. Which task could be delegated to a UAP? A) Assist the client with oral hygiene. B) Observe the patients response to feedings.C) Facilitate expression of grief or anxiety.D) Initiate daily weights.

Answer 6

Oral hygiene is within the scope of duties of a UAP. It is the nurses responsibility to observe response to treatments and to help the patient deal with loss or anxiety. The UAP can be directed to weigh the patient but not know when to initiate a new order. 31When care assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be most appropriate to assign to an LPN under the supervision of a team leader RN? A) A patient with severe anemia secondary to GI bleedingB) A patient who needs enemas and antibiotics to control GI bacteriaC) A patient who needs pre op teaching for bowel resection surgery D) A patient who needs central line insertion for chemotherapy

Question 7(LaCharity, Kumagai, & Bartz, 2011)

32When care assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be most appropriate to assign to an LPN under the supervision of a team leader RN? A) A patient with severe anemia secondary to GI bleedingB) A patient who needs enemas and antibiotics to control GI bacteriaC) A patient who needs pre op teaching for bowel resection surgery D) A patient who needs central line insertion for chemotherapy

Answer 7

Administering antibiotics and enemas is within the scope of practice of the LPN. Although some states may allow blood to be given by an LPN, in general, administering blood, providing preop teaching, and assisting with central line insertion are the responsibilities of the RN. 33An 8 year old child has stomatitis secondary to chemotherapy. Which task would be best to delegate to a nursing assistant? A) Report evidence of severe mucosal ulcerationB) Assist the child in swishing and spitting an anesthetic mouthwashC) Assess the child's ability and willingness to drink through a strawD) Help the client to eat a bland, moist, soft diet

Question 8(LaCharity, Kumagai, & Bartz, 2011)

An 8 year old child has stomatitis secondary to chemotherapy. Which task would be best to delegate to a nursing assistant? A) Report evidence of severe mucosal ulcerationB) Assist the child in swishing and spitting an anesthetic mouthwashC) Assess the child's ability and willingness to drink through a strawD) Help the client to eat a bland, moist, soft diet

Answer 8

Helping the child to eat is within the scope of practice of the UAP. Determining extent of ulcerations, assisting with medications, assessing willingness are all the duties of the RN. 35Case StudyConcept: Managing CareExemplar: DelegationCourse: NUR 213Delegation: A registered nurse (RN) has a group of ten clients on a medical surgical unit in an acute care setting. There is also assigned a licensed practical nurse (LPN) and unlicensed assistive personnel (UAP) to the same group.

The clients are as follows:

Room 101: A 48 year old female with breast cancer one day post bilateral mastectomy that has been crying all night and is asking that no visitors be allowed. She refuses to get out of bed and refuses to look at her bandages. Room 102: A 92 year old male with dementia and pneumonia. He has a bed alarm and has a history of falls. He has a large list of medications to be administered daily crushed and in applesauce. Room 103: An obese 72 year old female with a diabetic foot ulcer. Blood sugars have been 250-400 mg/dL since admission and her family continues to bring her food from fast food restaurants. She is on a calorie and carbohydrate restricted diet which she eats in addition to the food her family brings. Room 104: A 36 year old male three days status post open spleenectomy following a motor vehicle accident. He is anxious to get home and back to work for fear he will lose his job. He is being discharged today. He is employed as a stone worker where he lifts heavy stones every day.Room 105: A 54 year old female three days status post abdominal hysterectomy with subsequent dehiscence of wound 12 hours post op. The wound is being packed with normal saline soaked Nugauze three times a day. Room 106: A 67 year old male with Clostridium Difficile and Vancomycin Resistant Enterococcus (VRE). He has been complaining of abdominal cramps and diarrhea all night. The stools have subsided and he has just gone to sleep. Room 107: A newly admitted 55 year old female with anemia and possible gastrointestinal (GI) bleed that has not been assessed. She does not have an IV access. She will be receiving 2 units packed red blood cells (PRBC) ASAP. Room 108: An 89 year old male with resolving pneumonia that is being discharged back to the nursing home later this afternoon. He requires turning, feeding, and bathing. Room 109: A 49 year old male with hypertension and resolved stroke for possible discharge today. Room 110: A 43 year old female with new onset Type II diabetes mellitus. She has met with the diabetic educator and has been checking her own blood sugars and ordering her own meals.

Questions to answerWhich duties cannot be delegated therefore the RN must complete? Provide rationale. What clients or tasks should be delegated to the LPN? Provide rationale. What tasks should be delegated to the UAP? Provide rationale. What is the RNs responsibility before the end of the shift in reference to the delegated activities? Provide rationale.Should the charge RN need to help with any of the days tasks? Why or why not?

38References and further readingsAACN Delegation Handbook 2nd editionAmerican Association of Critical Care Nurseswww.aacn.org

Guidelines to Effective Nursing Delegationwww.nursetogether.com

Position Statement on Delegation and Assignment of Nursing ActivitiesNorth Carolina Board of Nursingwww.ncbon.org

LaCharity, L., Kumagai, C. & Bartz, B., (2011) . Prioritization, Delegation, and Assignment. Port Ludlow, Washington: Mosby, Elsevier.

National Council of State Boards of Nursingwww.ncsbn.org

North Carolina Concept-Based Editorial Board, (2011). Nursing: A Concept Based Approach. Upper Saddle River, New Jersey: Pearson Education, Inc.

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