DELEGATION OF
CLIENT CARE
Objectives
Define the term delegation
 Define the term unlicensed assistive personnel
 Understand the legal implications of making
assignments to other healthcare personnel
 Recognize barriers to successful delegation
 Make appropriate assignments to team
members

DELEGATION
Definition of Delegation
According to the American
Nurses’ Association (ANA)
 The
reassigning of responsibility for
the performance of a job from one
person to another. (ANA: Registered
Professional Nurses and Unlicensed
Assistive Personnel, ed 2. ANA,
Washington, DC, 1996.)
Concepts of Delegation

Is not a new concept
– Moses was instructed to identify 70 elders so they would
share the burden of the nation and the people would
no longer have to carry the burden by themselves.
– Florence Nightingale discussed delegation in her Notes
on Nursing in 1859.

Delegation is a process that transfers to a competent
individual the authority to perform a selected nursing
task in a specific situation
CONCEPTS OF DELEGATION
 The
responsibility for the task is
transferred.
 Accountability
remains with the person
who is delegating tasks.
 Delegation
indirect.
may be either direct or
DIRECT DELEGATION
 Usually
 The
verbal direction
registered nurse (RN) decides
which staff member is capable of
performing a specific task
INDIRECT DELEGATION

Contained in a listing of tasks that has
been approved and established by an
institution

Tasks permitted may vary with different
institutions
ASSIGNING TASKS
 The
RN may assign a more skilled
individual to perform specific tasks.
 The
RN may not assign an individual
to perform a task that is outside that
individual’s job description or scope of
practice.
DELEGATION
VERSUS
SUPERVISION
SUPERVISION

Usually more direct than delegation

Requires directly overseeing the work or
performance of others

Includes checking in with individuals throughout
the day

May entail the delegation of tasks and activities
(i.e., the nurse manager performs both delegation
and supervision)
NURSING PROCESS
AND
DELEGATION
Compare Delegation Process to
the Nursing Process
 Assessment
 Delegation


– Planning
– Implementation
Monitoring
Evaluation
ASSESSMENT
Is the foundation of the delegation process, just
like the nursing process or any scientific process
Assess patient needs.
Without accurate and thorough
assessment, there can be no delegation
o Set patient goals.
o Match staff members who have appropriate
skills to care for that patient.
o
PLANNING

Planning prevents future problems.
Mentally identify the person who is
best suited for the task or activity.

IMPLEMENTATION
Assign staff
members who have the
appropriate level of expertise that is
necessary to deliver the patient care and
perform the activities.
FIVE RIGHTS
 Right
task
 Right concern
 Right person
 Right direction/communication
 Right supervision
AS AN RN YOU
SHOULD ALWAYS ASK
“Can this task be delegated safely?”
“Is there anything about the client’s condition or
the environment which would preclude this assistant
from performing the task as delegated?”
– Every client is different and the same activity
may differ in each situation

“Is the task within the scope of practice of the
individual I am asking to perform it?”

“Have I communicated clearly and directly what
is expected in the performance, reporting and
documentation of this task?”
“Will I be available and accessible to this
individual while he/she completes the delegated
task?”
“Do I have the requisite skills to assist the
individual in completing the task as delegated?”
ASSESSMENT RED FLAGS
Complex nursing activity
 Unidentified client needs
 Requisite knowledge and skills missing
 Insufficient opportunity to train
 Insufficient opportunity to
monitor/supervise

DELEGATION
PROCESS
 Communication
of task to be
elegated
 Mutual agreement
 Transfer of Authority

• Communication of the specific task
– Generally do not use the term assignment when
dealing with unlicensed assistants.
– Assignment is defined as designating nursing
activities to be performed by an individual
consistent with his/her licensed scope of
practice. Since assistants do not have a legal
scope of practice, they cannot accept
assignments but they can accept delegated tasks.
The outcome of assignment and
delegation is the same (the nursing
activity is completed), the decision
making process is similar, but the
authority to perform the activity must
be transferred to the assistant, while
the licensed nurse already has legal
authority.

Mutual agreement
– by both the person delegating and
the assistant that the task is to be
delegated and that there is acceptance
of the task to be performed by the
assistant.

Transfer of the authority to perform the task
from the delegator to the assistant
– The nurse must still retain the
accountability for its completion and for the
outcomes of the task.
– The source of authority is always legal
(nursing license) and may be managerial
(position description),
• Managerial authority cannot
supersede legal authority.
–
A common use of the term assignment
is to designate the overall workload,
including delegation and assignment.
–
Do not confuse the general use of the
term to list the workload for which all
staff members are responsible with the
legal use of the term that designates
nursing activities.
DELEGATION

WHO will do

WHAT by

WHEN and

HOW, WHERE, and

WHY it will be done
No delegation can be complete without the above
DIRECTIONS
Priority of activity
 Expected timeliness
 Guidelines for consulting mid activity
 Reportable conditions
 Guidelines for reporting task completion
 Role as delegator and supervisor


• Use of written and visual resources may be used
to reinforce direction

• The communication style of the nurse and that
of the assistant directly affects the working
relationship.

• Repeat the directions

• Look at the priority of activities

• Provide a checkpoint throughout the process
IN COORDINATING
ASSIGNMENTS, REMEMBER
• Plan your time around these activities
 • Do high-priority activities first
 • Determine which activities are best done
in a cluster
 • Remember that you are still responsible
for activities delegated to others
 • Consider your peak energy time when
scheduling optional activities

DELEGATION RED
FLAGS
• Refusal to accept delegation
 • Incomplete directions
 • Failure to confirm expectations
 • Failure to communicate

Your delegation may be inappropriate
CHANGE IN HEALTH
CARE ENVIRONMENT

In the 1990s the nursing shortage, health care
reform, an increased need for nursing services, and
demographic trends brought about changes

The ANA defines an unlicensed assistive
personnel.

Remember, certification differs from licensure
DELEGATION
PROCESSMONITORING

This one frequently causes the most
problems

It is easy for someone to forget to check in
SUPERVISION

Provision of guidance or direction, evaluation
and follow up by the licensed nurse for a process
and the outcomes of a delegated task.
– Supervision includes monitoring the
performance, intervening if necessary, and
ensuring that proper documentation of the task
is completed.
DEGREE OF SUPERVISION
REQUIRED DEPENDS ON
– Client needs
– Stability of the client
– Competency of the assistant
– Nature of the task
– Available supervision
MONITORING RED FLAGS






Change in other client’s condition with impact
on workload
Failure of assistant to report unexpected events
or client outcomes
Work completed incorrectly
Work not completed
Inadequate direction from delegator
Inadequate or lack of monitoring from
delegator
The occurrences indicate that the
delegation may be inappropriate
and that the delegation decision
should be revisited to insure that
the 5 Rights still apply
EVALUATION




THIS IS YOUR FOLLOW-UP
Oversee the care and activities provided by the
employees.
Determine if patient care needs have been met.
Allow for feedback. Evaluation of the delegator /
assistant should be done
Evaluation is often the missing link in the
delegation process
DESIRED
OUTCOMES
Protection of client safety
 Achievement of desired client outcomes
 Reduction of health care costs
 Access to appropriate levels of health care
 Decreased nursing liability

INAPPROPRIATE
DELEGATION
MAY RESULT FROM:
 – Inadequate resources
 – Conflict of employee policies and law
 – Inappropriate employer direction
 – Lack of knowledge about delegation
 – Failure to accept accountability for nursing
care provided
CORRECTIVE
ACTION
• Educate and train
 • Restate expectations
 • Return skill demonstration
 • Identify specific checkpoints
 • Increase frequency of check ins
 • Evaluate directions

EVALUATION RED
FLAGS
 Failure
to evaluate delegation
effectiveness
 Failure to evaluate the
delegator/assistant relationship
 Failure to learn from work experience
COORDINATING
ASSIGNMENTS
METHODS TO HELP ORGANIZE
CARE

• Critical pathways
• Computerized information sheets
 • Personalized worksheets
 • Delegation tree

TIPS FOR
ORGANIZING CARE




• Plan time around activities that must be done 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 HEALTHCARE ENVIRONMENT

• A nursing shortage
• Health-care reform
 • An increased need for nursing services
 • Demographic trends
 • Use of unlicensed assistive personnel

UNLICENSED ASSISTIVE
PERSONNEL (NA)

• Trained to assist the nurse

• Perform tasks delegated by the nurse

• Under the RN’s direct supervision

• May or may not be certified
Delegation of Unlicensed
Assistive Personnel
TASKS
Unlicensed assistive personnel perform numerous
tasks such as:
 • Taking vital signs
 • Demonstrating skills learned through special
training (e.g., drawing blood or administering an
electrocardiogram [ECG])
 • Measuring intake and output
 • Performing nonnursing duties
SAFE
DELEGATION
CRITERIA FOR SAFE
DELEGATION

• Potential for harm
• Complexity of the task
 • Problem solving and innovation are
necessary to complete the task or activity
 • Ability of the individual
 • Fairness of the task

TASK-RELATED
CONCERNS
ACCOUNTABILITY







• Being answerable for the actions or omissions
of self or others in the context of delegation.
• Accountable to
– Self
– Clients
– Employer
– Licensing Board
– Profession
NURSE’S ACCOUNTABILITY
• For Decision to delegate
– Ultimate accountability for the management and
provision of nursing care


• Delegated task

• Client outcomes
ASSISTIVE PERSONNEL
ACCOUNTABILITY
FOR
–
Decision to accept delegation
–
Performance
ASSISTIVE PERSONNEL
ACCOUNTABILITY
TO

• Self

• Delegating Nurse

• Employer
PRIMARY CONCERN
Does the individual assigned to the task
have the ability to perform it?
OTHER TASK-RELATED
CONCERNS
abilities
 • Priority of various tasks
 • Employee’s level of efficiency
 • Appropriateness of the assigned task

• Employee’s
RELATIONSHIP-ORIENTED
CONCERNS
The RN should consider the following when
assigning tasks to employees:





• Fairness
• Learning opportunities
• Health
• Compatibility
• Preferences
• Is the workload evenly distributed
– One might have less physical work to do, yet have
the work may require more emotional care

– Discuss with your team decisions you have made
that may be considered unfair

– If possible, allow the team to participate in
making decisions regarding assignments.

Assign so your staff will be stimulated and
motivated to learn

• Rotate your members through more difficult
jobs

• Work at helping your team to develop better
working relationships

• Explain your rationales and decisions
SUMMARY OF PROFESSIONAL
EXPECTATIONS







• Respect from others
• A reasonable workload
• Appropriate wages
• Determining his or her own priorities
• Ask for what he or she wants
• Be accountable
• Give and receive information in a professional
manner
DELEGATION
BARRIERS
BARRIERS
•
Level of experience
 • Licensure
 • Quality of care
 • Having to assign work to others
REMEMBER-THE FIVE RIGHTS
OF
DELEGATION
•
Right task
 • Right circumstances
 • Right person
 • Right direction and communication
 • Right supervision and evaluation
CONCLUSION
POINTS TO CONSIDER
• Delegation is not new.
 • Delegation is essential for good working
relationships.
 • Organizational skills are a prerequisite for
delegation.
 • An understanding of patient needs is
essential for appropriate delegation.

THE RN MUST UNDERSTAND:

• The state’s Nurse Practice Act

• The capabilities of each staff member

• The tasks that may be delegated

• His or her accountability when delegating
tasks
REMEMBER TO:

• Communicate continuously

• Value all team member contributions

• Develop trust between co-workers

• Learn from experience