\H1\Lines of Authority
Nursing assistants receive their assignments from the team leader or charge nurse, and report
completion of the assignment to the same person. This is the assistant’s immediate line of
authority and communication.
The assistant works with a team whose leader is a licensed nurse. In this case, the immediate
superior is the team leader. The team leaders receive their instructions from the charge nurse.
The charge nurse is responsible for the total care of a certain number of patients. Sometimes this
includes all the patients on a wing, a unit, or a floor of the facility. Supervisors are responsible
for several charge nurse units. They receive direction from the director of nursing. Health care
facilities vary in the complexity of their staffing. You must learn the lines of authority in your
facility, as shown in Figure 2-4. As a student, your immediate authority is your instructor.
The physician directs the patient’s medical care. The registered nurse carries out the physician’s
orders and plans and evaluates the nursing care. When you accept the responsibility for an
assignment, you must understand what is expected and be able to handle it. If you have any
doubts, discuss them with the supervising nurse (Figure 2-5).
[Insert Figures 2-4, 2-5]
\H2\Delegation
Delegation is the transfer of responsibility for the performance of a nursing activity from a nurse
to someone who does not already have the authority. Once the task has been delegated, only the person
given the authority may perform the procedure. In other words, this person cannot delegate the
assignment to someone else. The licensed nurse is accountable for the task and its outcome. He or she
must be confident that the unlicensed person can complete the assignment correctly.
In some states, the nurse practice act describes how nurses assign or delegate duties. Some states
have passed laws that specifically prohibit nursing assistants from performing certain activities. Some
states further define the terms assign and delegate. In these states, an RN assigns tasks to unlicensed
workers. In this context, assigning means advising, instructing, or informing another person to complete a
task. Tasks are delegated only to licensed nurses. Your instructor will clarify the definitions used by your
state.
\H2\Five Rights of Delegation
Before delegating a task, the nurse must decide if delegation is appropriate. Appropriate
delegation assures that:

The nursing assistant is permitted to perform the procedure in the facility.
— He or she has been taught to perform the procedure correctly.
— If asked, the assistant can demonstrate the procedure safely and efficiently.

The patient does not need frequent nursing assessments during the procedure.

The nurse believes patient’s response to the procedure is reasonably predictable.

In the nurse’s opinion, the nursing assistant will obtain the same or similar results as an
RN in performing the procedure.

The nurse is certain that delegating the activity to a nursing assistant is not against the
law.
The National Council of State Boards of Nursing has developed a guide called the Five Rights of
Delegation. Nurses use this list to help them delegate correctly. Reading this list will help you learn if a
delegation is appropriate. The rights are:

Right Task -- one that can legally be done by a nursing assistant who has been taught the
proper way to do the procedure. Further, your instructor or other licensed nurse must
have checked your competency in the procedure and approved you to perform it on
patients. You must be permitted to perform the procedure according to your state law and
facility policy.

Right Circumstances -- the nursing assistant understands the purpose of the procedure,
can perform it safely, and has the right supplies or equipment to perform the procedure
safely.

Right Person -- the right person delegates the right task to the right nursing assistant, to
be performed on the right patient.

Right Direction/Communication -- the nurse delegating the activity has given complete
instructions, described the procedure clearly, and has identified the limits (if any), and
expected outcome(s) of the procedure. Always ask for directions if you do not understand
your assignment.

Right Supervision -- the nurse delegating the activity has answered the nursing assistant’s
questions, and is available to manage changes in the patient’s condition. The nursing
assistant reports completion of the task and the patient’s response to the nurse who
delegated the activity.
In some situations, delegating even simple activities is inappropriate. For example, the nursing
assistant routinely takes the vital signs of stable patients. However, assigning a nursing assistant to take
the vital signs of an unstable patient may be an inappropriate delegation. In this situation, the patient
needs the assessment skills of a licensed nurse. Do not feel offended if the nurse takes the vital signs or
performs other patient care duties in a situation like this.
\H2\Delegated Activities
As you can see, delegating activities is a serious matter for nurses. When you accept the
responsibility for a delegated task, you are responsible for your own actions. If you think that performing
a procedure is unsafe for the patient, discuss your feelings with the RN. Report your observations about
the patient’s condition, and be prepared to explain why you are uncomfortable with the procedure. Ask
for help, if necessary.
If you believe that a procedure is not within your legal scope of practice, you have not been
taught and approved to perform it, or believe that the activity will harm the patient, you may refuse the
delegation. If you are unsure how to carry out a procedure, inform the nurse. Do not feel embarrassed. It
is better to ask for help than to make an error and injure a patient. Likewise, if you do not understand the
instructions, or do not have the proper supplies, you may also refuse until the problem has been
addressed. However, you must explain the reason for your refusal to the RN. He or she can probably
resolve your concerns, enabling you to safely complete the activity. Do not refuse because you do not
have time, or because the procedure is unpleasant. Good communication is the key to successful
delegation and patient safety. Be honest, tactful, and sensitive. If honest communications are ineffective,
you can use the chain of command to address the problem with the next person in line. If you are assigned
to a task, your supervisor assumes that you will do it. Never ignore an assignment. If you cannot complete
the activity, discuss the situation with your supervisor.
\H1\Your Workday: Managing an Assignment
Your work day will begin with communication, in the form of a shift report. This is described in greater
detail in Unit 8. Oral reports are used frequently to communicate information about patients. The nurse
who worked the previous shift will report to oncoming staff. In some facilities, the shift report is
tape-recorded. Listen carefully to the report because it will help you plan your assignment
(Figure 2-6). Your assignment tells you:
• Which patients you will care for during your shift
• The procedures you will need to do for these patients
Your supervising nurse will give you additional information about your assignment based on the
shift report. This information will include orders, procedures, care, and observations to make for
specific patients. Unit 8 gives additional information about oral reports.
\H3\Completing an Assignment.\xc\ Report the completion of your assignment and the patient’s
response to the nurse. You may be tempted to skip reporting if you will be documenting the
activity. Reporting even simple tasks may be important.
[Insert Figure 2-6 ]
\H1\Organizing Your Time
Successful time management is a key to nursing assistant success. Time management skills
cannot be mastered in the classroom. Practice and use good organizational skills in the skills lab and
clinical portions of your class until they become automatic. This will translate to good organization on the
nursing unit. Mastering good organization and time management skills helps you work more efficiently,
and reduces stress. Once mastered, organizational skills become a part of you, and you will not have to
think about them. A bonus is that these skills are also very useful at home and in your personal life.
Time is a borrowed commodity. Once used, it is gone and cannot be replaced or reclaimed. You
can only manage yourself in relation to time. Each day begins with 86,400 seconds, 1,440 minutes, or 24
hours. This equals 168 hours each week. If you work an 8 hour shift, you have:
●
28,800 seconds or 480 minutes in which to get your work done each day.
If you work a 12 hour shift, you have:
●
43,200 seconds or 600 minutes in which to get your work done each day.
The total time available for getting your work done is set by your employer. You can only control how
you use the time. Cutting corners, skipping breaks, and working longer hours are not good techniques for
managing time, and may cause ethical and legal problems for you. At best, managing time in this manner
is stressful. At worst, it is dangerous. You manage the time available. It does not manage you. Do this by
working smarter, not harder.
\H2\Developing and Perfecting Time Management Skills
Lack of good organizational skills plague health care workers at all levels. Avoid becoming so
focused on “tasks” that you fail to see the larger picture of things for which you are responsible, such as:
<begin bulleted list>
●
Making important or significant observations as you circulate around the unit.
●
Overseeing your patients, noticing if certain patients are becoming sick, having behavior problems, or
other abnormalities.
●
Informing the nurse of patients’ problems, complaints, and changes in condition.
<end bulleted list>
\H2\Making Rounds
If you do not manage your time, others will do it for you. This can be both difficult and stressful.
Making rounds is an important part of your time management strategy. Making regular rounds will save
you many trips up and down the hallway, and gives you a more complete picture of patient needs. Patients
and their families will feel confident and secure in your ability. Setting priorities, and focusing on
efficiency are key assets in developing good time management skills. Avoid losing your focus. Ensuring
quality care and patient safety are your greatest priorities. Perfecting good organization and time
management skills will make a difference in your personal life and the care you give.
●
Establish and develop a systematic daily routine for things.
— Make rounds as soon as possible after report to identify patient needs and problems. Meet
immediate needs during this round, such as assisting with toileting.
— Develop your plan for each patient while making rounds.
●
Practice good communication skills with patients and families while making rounds; this will save
you time and prevent them calling you to the room later. Let them know you are on top of things. Ask
questions and obtain patient input on the plan you are mentally formulating.
— Stop to visit with concerned family members briefly. Do not wait for them to seek you out. This
may seem like a time waster, but it promotes satisfaction, garners support, and may end up saving you
time. Offer simple information to families. For example, “Your mother ate a good breakfast today”,
“The night nurse said your father had a restful night,” and ”Your auntie really enjoyed her visit from
the church members yesterday.”
— Families usually know the patient well. They may offer important information about the patient.
Do not be timid about asking for their opinion. For example, “Does he seem stronger to you?”
— Avoid becoming defensive if family members express concerns about patient conditions. Report
concerns, observations, and needs to the nurse after you have made rounds on all your patients. Listen
to what patients have to say. Tell them what you will do about their concern, and give them a follow
up time if needed, such as, “I will let you know tomorrow.” Thank them for sharing their concerns.
Keep the nurse informed.
●
Determine which patients need frequent monitoring
— Monitoring is simple oversight, such as looking in on or speaking with a patient, taking or
reviewing vital signs, watching for new problems and changes in condition, and addressing known
problems.
Develop a personal plan for organizing your time by following these suggestions:
<begin bulleted list>
●
Plan and organize your work. Be sure the plan is realistic.
— Write down your plan; make a new "to do" list every day. Writing the plan is important.

List your main goals for the day. Your goals will help ensure the most important priorities
are done. Review each item on your list and ask yourself it makes the best use of your time.
— Goals without deadlines are dreams; set realistic and achievable deadlines
— Everything designated as a top priority must be completed immediately
— Next level priorities must be done a few minutes after top priorities
— Schedule your breaks into the plan. Take breaks at the assigned times. These are important to
reduce stress and prevent injury. Avoid overloading yourself. Avoid bringing work on your breaks.
●
Be flexible. Expect the unexpected. Accept that you may need to change your plan if conditions and
patient needs change.
●
Accept that your priorities may change
— Identify “no options” activities. These are things that must be done during your shift, without
exception.
— Identify events that must be done by specific times, versus things you can take care of later.
— Ask yourself what, where, when, why, who, and how of your priorities; this will help you devise a
strategy and plan for completing them.
— You control the timing of events for which you are responsible.
— Emergencies, new admissions, and patient or family demands are imposed on you by others, and
you cannot control them. Accept this as a fact, and learn to remain calm when things change
suddenly. On most days, these things will not be a burden if you do a good job organizing and
managing your time for events you can control.
— Focus on the patients’ needs instead of tasks needing to be done; by focusing on needs, you will
attend to the tasks with far less stress
●
Avoid repetition. Plan to do like jobs at the same time. Do them right the first time to prevent the
need to redo them.

Plan to do things simultaneously. For example, you must remain in the patient’s room while
she washes at the sink. Use the time productively! Make the bed or do another task instead of
standing impatiently.
●
When you have a task to complete, set a time limit for yourself. Be reasonable.
— Avoid becoming distracted. Focus on the task at hand
— Break tasks and responsibilities down into smaller, more manageable pieces, if possible

Constantly evaluate your efficiency and time management skills and work to improve on
them

Try to break your own record on time consuming tasks. If a job takes 30 minutes today, try to
get it done in 29 minutes tomorrow. Save a few seconds to a minute a day until you have
streamlined the task as much as possible. One caveat, however. Avoid cutting corners for the
sake of saving time. The time you save is not worth the price you will pay for harming a
patient or making a major error. If cutting corners is the only way you feel you can save time,
try a different routine.

Before beginning a task, organize what you will need
— When beginning a project, gather and organize your supplies in advance.
—Bring everything you will need into the patient’s room at once so you don’t waste time and energy
making trips up and down the hall to retrieve forgotten items.
●
Communicate with peers, colleagues, and others throughout your shift. Good communication helps
ensure success.
— Be tactful and polite in all communications.
— Treat others with dignity, respect, and integrity
●
Be assertive
— Help others when you can. Do not be afraid to ask for help when you need it.
●
Avoid wasting time; remain organized so you make good use of your time.
●
Note whether patients are sick, unstable, or displaying behavior problems; develop a plan for nursing
assistant action. Keep the nurse informed.
— Take the blinders off! Continue to make important observations as you circulate around the unit.
<end bulleted list>