Element 1: Regulatory requirementsFor nursing and midwifery leaders

Delegation and Supervision for VictorianNurses and Midwives

Regulatory requirements

• The Nursing and Midwifery Board of Australia (NMBA) undertakes functions as set by the Health Practitioner Regulation National Law.

• NMBA sets the registration standards as well as professional codes, standards and guidelines that underpin safe and competent practice.

• The NMBA’s requirements of nurses and midwives relating to delegation and supervision are outlined in its publication ‘A national framework for the development of decision-making tools for nursing and midwifery practice’.

Delegation and supervision guidelines for Victorian nurses and midwives

• In order to become registered, nurses and/or midwives must meet the National Board’s mandatory registration standards.

• To be effective, nurses and midwives need to have a clear understanding of the requirements.

• Released in 2014, the guide seeks to reinforce the NMBA publications around decision making, by making practical recommendations and outlining a framework

Delegation and supervision guidelines for Victorian nurses and midwives

• The guide was developed following consultancy with key stakeholders, discussions with Victorian nurses/midwives and an international literature review.

• Makes a number of recommendations, assuming a shared responsibility between:

o individuals, o employers, o education providers, o professional bodies, and the o Department of Health & Human Services.

Accountability when delegating

• Delegation and supervision is, and always has been, a core responsibility of Registered Nurses and Midwives

• The Registered Nurse or Midwife remains accountable for monitoring and evaluating the effect of any care that has been delegated

Accountability when accepting a delegation

Can include EN’s, unlicensed healthcare workers, junior RN/RM’s, other workers:

• A staff member who accepts a delegation is accountable for their actions or decisions

• A staff member should not accept a delegation if it is beyond their training and competency, and/or if they are not confident undertaking the delegation

Principles of Delegation

Delegation is an exercise in professional judgement by the RN/RM. It involves the transfer of authority to a competent person to perform a specific activity in a specific context.

Considerations when delegating include:

• Patient health status (stability and complexity)• Complexity of the delegated activity• Context of care• Level of knowledge, confidence, skill and experience of the person to

whom the task has been delegated• The expected outcomes of the delegated task • How outcomes will be monitored and communicated• Legislative requirements

The Five Rights of Delegation

1. Right Activity

2. Right Circumstances

3. Right Person

4. Right Communication

5. Right Supervision and Evaluation

Acknowledgement: National Council of State Boards of Nursing, 2005

Right Activity

The right activity that, in the professional judgement of the RN/RM:

• can be safely delegated to another staff member who has the level of knowledge and competency to perform the task, and

• is appropriate for the needs of the specific health consumer

• The activity being delegated needs to be within the scope of practice of the enrolled nurse or role boundaries unlicensed healthcare worker accepting the delegation

Right Circumstances

Consideration of appropriate and right circumstances include:

• The appropriate patient or patient group (based on the severity and complexity of their condition)

• The resources available including skill mix, staff availability and capacity for supervision, and

• other relevant factors including monitoring and communication of progress

Right Person

The right person is delegating the right activity to the right person with the right skills and knowledge to assist the right patient:

• The delegating RN/RM can only delegate care that they themselves are competent to perform

• The nurse/HA accepting the delegation needs to have the appropriate training and knowledge and competence to provide the required care

• The Patient whose care is delegated must not require complex observations, decision making, critical thinking or nursing judgement

Right Communication

The right communication is clear, concise description of the activity to be undertaken, including the objective and expected outcomes.

The delegating RN/RM should ensure that the enrolled nurse or unlicensed healthcare worker clearly understands:

• What activities are being delegated

• Who and when to ask for assistance or report concerns

• How concerns should be reported

• The enrolled nurse or unlicensed healthcare worker must inform the delegating RN/RM if they have not been trained to perform an activity or if they are uncertain of any aspect of the delegation

Right Supervision and Evaluation

The right supervision and direction refers to appropriate monitoring, evaluation, intervention as needed, and feedback.

The delegating RN/RM retains accountability for ensuring that:

• the delegated activities are performed to the required standard,

• monitoring and evaluating the impact and outcome of delegated care is undertaken,

• direct or indirect supervision is available as required,

• the enrolled nurse or unlicensed healthcare worker performing the delegated activity has the necessary support and guidance.

Supervision

The NMBA identifies 3 types of supervision within nursing/midwifery practice; specifically managerial supervision, professional supervision and clinically focused supervision.

Clinically focused supervision

Clinically focused supervision specifically relates to supervision of delegated nursing and/or midwifery tasks and activities, including:

• providing education, guidance and support for individuals who are performing the delegated activity

• directing the individual’s performance

• monitoring and evaluating outcomes, especially the consumer’s response to the activity

Supervision

The level of supervision should be appropriate to the degree of risk of the activity

Direct Supervision

• Is when the supervisor is present and personally observes, works with, guides and directs the person being supervised

Indirect Supervision

• Is when the supervising RN/RM is on site and easily contactable and available for reasonable access but does not directly observe the activity

Responsibilities when delegating

The professional’s responsibilities include:

• teaching (although this may be undertaken by another competent person, and teaching alone is not delegation)

• competence assessment

• providing guidance, assistance, support and clinically focussed supervision

• ensuring that the person to whom the delegation is being made understands their accountability and is willing to accept the delegation

• evaluation of outcomes

• reflection on practice.

Responsibilities when accepting a delegation

The recipient’s responsibilities include:

• negotiate, in good faith, the teaching, competence assessment and level of clinically focussed supervision needed

• notify in a timely manner if unable to perform the activity for an ethical or other reason

• be aware of the extent of the delegation and the associated monitoring and reporting requirements

• seek support and direct clinically focussed supervision until confident of own ability to perform the activity

• perform the activity safely

• participate in evaluation of the delegation.

Decision making tree

Is it the right activity? • Has there been a RN/RM assessment of patient care need?• Are there organisational guidelines that support the delegation?• Can the task be routinely performed without complex observations, decision making or clinical

judgement?

Is it the right circumstance?• Does the RN/RM have the skills and knowledge to safely delegate?• Does the skill-mix in your ward/unit/environment enable you to undertake appropriate supervision?

Is it the right person?• Is the task within the scope of practice or role parameters of the person you are delegated to?• Does the person you are delegated to have the appropriate knowledge, skills and competency to

perform the delegated tasks?

Is it the right communication?• Does the person being delegated to understand and accept the delegated task; know when and

who to ask for assistance, and who to report to?

Is it the right supervision and evaluation?• Is there ongoing monitoring and evaluation of the outcomes of care by the supervising RN/RM?

YES

YES

YES

YES

YES

Do

no

t d

ele

ga

te

Delegation is appropriate

NO

NO

NO

NO

NO

Acknowledgements: • National Council of State Boards of Nursing, 2005• Nursing Council of New Zealand, 2011

Strengthening nursing and midwifery delegation within your organisation

• The guideline outlines a framework to support to enhance nursing/midwifery delegation and supervision.

• Framework based on recommendations on skill and knowledge development, alongside the development of tools and activities to support safe and effective practices.

• All parties play a role. As a nursing/midwifery leader, you play a vital role in the area of regulation within your organisation, by setting direction and enabling best practice to occur.

Framework

Element 1:Regulatory

Elem

en

t 2:

Org

anisa

tion

al

Element 3:Individual

• Decision making consistent with stated delegator/delegatee requirements

• Policy and procedure• Capability framework• Roles and responsibilities

• Leadership and management• Communication and team

interaction

• Checklist tool• Flow chart/summary card

• Position descriptions• Role clarity statements and

activities• Competency and credentialling

processes• Organisational and unit-level

direction and leadership

• Interpersonal skill development training package and activities

Supporting activities• Frequently asked questions resource• Comprehensive learning packages (covering all three key elements)• Partnering with education providers – pre-registration preparation• Partnering with nursing and midwifery leaders

Required skills and knowledge Recommended tools and activities

Check-list of possible actions

Leadership:

Consider obtaining a baseline, by asking staff about their current delegation and supervision skills

Ensure your nursing leaders are aware of and understand the key regulatory, organisational and individual factors that influence safe and effective delegation and supervision.

Consider including a specific focus on critical thinking, effective communication and team engagement into ongoing leadership developmental and educational programs.

Ensure that your managers are aware of rostering requirements relating to maintaining an appropriate skill-mix, to enable safe and effective delegation and supervision to occur.

Check-list of possible actions

Governance:

Ensure you have a clear and consistent organisational policy relating to safe and effective delegation and supervision of nursing/midwifery tasks and activities, that aligns with NMBA requirements and Victorian legislation.

Ensure all other policies align and are consistent with the overarching nursing/midwifery delegation and supervision policy.

Ensure policies are inclusive of roles and responsibilities for delegators/supervisors and delegatees/supervisees.

Check-list of possible actions

Role Clarity:

Ensure that the position descriptions for nurses, midwives and assistive staff are clear and informative.

Consider the development and implementation of a capability framework to assist registered nurses/midwives to identify skills and competency.

Ensure that the role differentiation between registered nurses/midwives, enrolled nurses and assistive staff is clearly documented.

Ensure that registered nurses/midwives have access to and knowledge of the approved duty list and competency levels achieved by any unlicensed assistive worker.

Check-list of possible actions

Education:

Ensure delegation and supervision is a core component of the ongoing education program for your nurses and midwives

Ensure that your nurses, midwives and assistant staff have access to a range of educational learning tools addressing effective and safe delegation and supervision.

Consider working closely with your education providers and university partners to enhance the opportunities to prepare pre-registration students for the role as delegators and supervisors.

Check-list of possible actions

Awareness:

Consider utilising tools and promotional material to raise awareness of delegation and supervision requirements within your nursing, midwifery and assistant workforce.

Consider the utilisation of a point-of-care tool to support effective delegation and supervision.

More information available:

• Nursing in Victoria http://www.nursing.vic.gov.au/

• Nursing & Midwifery Board of Australia http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx#dmf

Full reference list included in the guideline.

Questions and discussion