CHAPTER 9
DELEGATION
OF CLIENT CARE
OBJECTIVES
Define delegation and unlicensed assistive
personnel.
 Identify the rights of delegation and the
implications of each.
 Understand the legal implications of making
assignments to other healthcare personnel.
 Discuss the process of delegation and the
coordination of assignments.

Objectives
Differentiate delegation from work
allocation.
 Outline how delegation benefits the 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 delegation.
OBJECTIVES
Discuss the task related and relationshiporiented 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.

OBJECTIVES
Compare delegation in professional practice
as it relates to responsibility, accountability
and authority.
 Illustrate critical thinking when making
assignments and delegating tasks.
 Illustrate how to communicate assignments
and delegated tasks and recognize barriers to
successful delegation.
 Differentiate the models of care delivery Functional, Team, Total Client Care

OBJECTIVES
Apply delegation concepts, and critical
thinking to client scenarios and NCLEXstyle questions.
 Illustrate critical thinking when making
assignments and delegating tasks.
 Illustrate how to communicate assignments
and delegated tasks and recognize barriers to
successful delegation.
 Apply delegation concepts, and critical
thinking to client scenarios and NCLEXstyle questions.

DEFINITION
The reassigning of responsibility for
the performance of a job from one
person to another. (ANA, 1996)
Concepts of Delegation
 The
responsibility of the task is
transferred.
 Accountability remains with the
delegator.
 Delegation may be direct or
indirect.
Direct Delegation
 Usually
 RN
verbal direction
decides which staff member is
capable of performing a specific
task
Indirect Delegation
 Contained
in an approved listing of
tasks established by an institution
 Permitted
tasks may vary from
institution to institution
CONSIDERATIONS
Whether 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.
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 Delegation
Right task
 Right circumstances
 Right person
 Right direction/communication
 Right supervision/evaluation

Right Task
What can the nurse not 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 Circumstance
 Relate
to patient condition
 To delegate task, outcome must be
reasonable, predictable, and the task
must not require ongoing assessment
or critical decision making
Right Person





RN accountable and responsible for
meeting patient needs
Delegated care (to UAP) should be for
stable patients
Competencies: basic nursing skills that
include standard reoccurring procedures
Appropriate assignment: predictable
outcomes
Abilities: Performs care for routine
procedures---feeding, bathing, routine
VSs, transferring patient
Right Direction & Communication
 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 Supervision and Evaluation
 Monitoring
◦ Guidance
◦ Direction
 Feedback
Red Flags
 Complexity
of nursing activity
 Unidentified client needs
 Missing requisite knowledge and
skills
 Insufficient opportunity to train
 Insufficient opportunity to
monitor
Assigning Tasks

The RN may assign a more skilled
individual to perform a task

The RN may not assign an individual to
perform an activity outside of a job
description or the scope of practice

Consider the following situation…

Mr. Ross was admitted to the neurological unit from
the Neuro ICU. She suffered a grade II subarachnoid
hemorrhage 2 weeks ago and has a left hemiparesis.
She has difficulty with swallowing and receives tube
feedings through a PEG tube; however, she has been
advanced to a pureed diet. She needs assistance with
personal care, toileting, and feeding. A PT comes BID
to get her up for gait training; otherwise, the physician
wants her in a chair as much as possible.
Delegation vs Supervision

Supervision usually more direct than
delegation

Requires directly overseeing the work
or performance of others

Could include reevaluation
The Nursing Process and Delegation
Assessment
Assess client needs
 Set client-specific goals
 Match the personnel with the
appropriate skills to care for the client

Planning


Mentally identify who is best suited for
the task or activity
Planning prevents later problems
Implementation

Assign the appropriate personnel who
have the level of expertise necessary to
deliver the care or carry out the
activities

Evaluation
Oversee the care or activities
 Determine if client care needs have
been met
 Allow for feedback

Coordinating Assignments:
Methods to Help Organize Care

Care plans

Clinical (Critical) pathways

Computerized information sheets

Personalized worksheets
Tips for Organizing Care
Plan 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 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 Personnel
(UAPs)
Individuals trained to function in an
assistive role to the nurse
 Perform delegated tasks
 Under direct supervision of the RN
 May or may not be certified

Decision -Making Grid

Method 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 Tasks
Vital signs
 Skills learned through special training:

◦ Blood drawing
◦ ECGs
Measuring intake and output
 Non-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 Client Care
Activity Should be Delegated
Potential for harm to the patient
 Complexity of the nursing activity
 Problem-solving and innovation
necessary to complete the task or
activity
 Predictability of outcome
 Extent of interaction

When should the nurse 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 concern:
Ability
 Priorities
 Efficiency
 Appropriateness

Relationship-Oriented Concerns
Fairness
 Learning opportunities
 assignments
 Compatibility
 Preferences

Obstacles to Delegating
 Inadequate
experience and
education
 “I can do it better”
 Lack of skill
 Confidence in UAP
 Need to feel indispensable
 Fear of losing authority
 Lack of time
Obstacles to accepting delegation
 Fear
of criticism
 Lack of self-confidence
 Lack of time
LPN vs RN roles
NP Phase
LPN
RN
Assess
Gather data
ID 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 LPN
 Competencies:
Technical
skills
 Appropriate assignment:
Stable patient with
predictable outcomes
 Abilities: More complex
care than UAP; sterile
technique, medication
administration…
Models of Care Delivery
Major Concept
Functional
Team
Primary
Total Care
Advantages
Disadvantages
Division of tasks with
clearly defined roles
Efficient, economical,
productive
Fragmented care
RN team leader
supervises ancillary
staff
More holistic
RN must take time to delegate
RN maintains 24 hour Emphases on
responsibility for
accountability and
client
client satisfaction
Extremely costly; primary nurse
must be capable of meeting all
client needs
One RN with total
responsibility for care
Costly; no efficient use of staff
Continuity of care
The Five Rights of Delegation
Right task
 Right circumstances
 Right person
 Right direction/communication
 Right supervision/evaluation

In Conclusion,
Points to Consider:
Delegation is not new
 Delegation is essential today
 Organizational skills are a prerequisite
for delegation
 Understanding client needs is essential
for appropriate delegation

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.