Delegation and Supervision for Victorian
Nurses and Midwives
Element 3: An individual’s requirements
For nurses, midwives and the assistive workforce
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 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 and 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/unlicensed healthcare worker 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 evaluation 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 person performing the delegated activity has the necessary
support and guidance.
Decision making tree
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?
NO
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?
NO
YES
Right person
• Is the task within the scope of practice or role parameters of the person you are delegating to?
• Does the person you are delegating to have the appropriate knowledge, skills and competency to
perform the delegated tasks?
NO
YES
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?
Do not delegate
YES
NO
YES
Right supervision and evaluation
• Is there ongoing monitoring and evaluation of the outcomes of care by the supervising RN/RM?
NO
YES
Delegation is appropriate
Acknowledgements:
• National Council of State Boards of Nursing, 2005
• Nursing Council of New Zealand, 2011
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.
Case Scenarios
Introductory video
• There are 8 case scenarios included in the package. Each
case scenario highlights key elements of delegation.
• Whilst some of the scenarios take place in a particular
setting and involve a specific role, the learning is applicable
across settings and can be applied working with other types
of roles and workers.
• Working through case scenarios can help link theory to the
application to real-life workplace scenarios.
Introductory video
YouTube link:
http://www.youtube.com/watch?v=k0qH1GGq4LA
Case scenario 1:
Delegating to undergraduate students
You are an experienced nurse/midwife that has been
assigned a third-year undergraduate student to work with
you for the shift.
One of your patients is Ms Sullivan, is a 30 year old lady
who is normally ambulate and self caring however due to
pain and limited range of movement needs assistance in
the shower.
What are the key things to consider relating to the level of
delegation that could occur to the undergraduate student?
Case scenario 1:
Delegating to undergraduate students
YouTube link:
http://www.youtube.com/watch?v=pBBmdCAzqzo
Case scenario 2:
Scope of role and responsibilities
You are an enrolled nurse and you have been asked by a doctor to assist
with a procedure. You have not learnt about the procedure, or achieved
competency in this task.
How should you respond?
Things to consider:
• Who is able to delegate activities to an enrolled nurse?
• How can I respond without seeming unhelpful?
• What do I do if I have concerns about undertaking the task being asked
of me?
Case scenario 2:
Scope of role and responsibilities
YouTube link:
http://www.youtube.com/watch?v=O5DNBlKh5Ng
Case scenario 3:
Responsibilities of roles
You are the registered nurse in charge of your ward/unit/facility.
You have allocated an enrolled nurse to take care of Ms Smith.
During that morning the enrolled nurse is assisting Ms Smith
with her hygiene requirements in the bathroom. Whilst the
enrolled nurse is removing Ms Smith’s anti-embolitic stockings
she notices a pressure injury on her leg, which Ms Smith states
it is very painful.
• What are the enrolled nurse’s responsibilities?
• What are the registered nurse’s responsibilities?
Case scenario 3:
Responsibilities of roles
YouTube link: http://www.youtube.com/watch?v=oHxRS25j2o
Case scenario 4:
Right supervision and evaluation
You are a registered nurse working with a relatively new enrolled nurse, who
has been working on the ward for a few months following completion of their
Diploma.
When working with this enrolled nurse which tasks or activities will require
direct supervision and which will require indirect supervision?
Things to consider:
• Are the tasks or activities within the scope of practice for EN’s?
• If so, has the EN received education and training in a particular task or
activity, and have they been formally assessed as competent?
• Have you personally provided direct supervision for them undertaking the
task or activity before?
• How has their learning and competence progressed since commencing
employment?
• How will you know that the task or activity is been undertaken
satisfactorily?
Case scenario 4:
Right supervision and evaluation
YouTube link:
http://www.youtube.com/watch?v=dqh4Bt9AuSY
Case scenario 5:
ENs working with unlicensed healthcare workers
You are an experienced enrolled nurse working a busy morning shift. An
unlicensed healthcare worker is also working that morning as part of the
team.
What are your responsibilities as an enrolled nurse and how do you work
with an unlicensed healthcare worker?
Things to consider:
• How do I differentiate the responsibility and accountability of the
registered nurse and enrolled nurse in the delegation of nursing care?
• Have I already been delegated the task by a registered nurse?
• Has the unlicensed healthcare worker been allocated or assigned to
work with me by a registered nurse?
• Are there shared activities where both the unlicensed healthcare worker
and I are competent to undertake the task, and is this supported by my
employer?
• Am I able to supervise the unlicensed healthcare worker in any aspects
of their work?
Case scenario 5:
ENs working with unlicensed healthcare workers
YouTube link:
http://www.youtube.com/watch?v=T0tJJsFm5sQ
Case scenario 6:
Right activity, circumstance and communication
You are a registered nurse working along side an unlicensed healthcare
worker, and together you have been allocated 4 patients.
It is 8am, and you have completed your initial assessments. You want to
ensure you are effectively delegating to the unlicensed healthcare
worker.
Select how you would delegate, and explain your rationale.
Case scenario 6:
Right activity, circumstance and communication
Your patients:
Mr Lee (70-year-old male, diagnosis: urinary
tract infection). Mr Lee is alert but is
experiencing some confusion. Vital signs are
ordered every four hours. He is experiencing
urinary frequency. He is a falls risk, and needs
to be reminded to use the urinal rather than
getting out of bed on his own to use the
bathroom.
Ms White (43-year-old female, diagnosis:
admitted for a hysterectomy). Ms White had a
hysterectomy two days ago. Her postoperative
course has been uncomplicated. The surgeon
wants Ms White to ambulate three times per
day. Her vital signs are stable. She is alert,
oriented, and cooperative.
Mr Williams (46-year-old male, new admit,
diagnosis: suspected Crohn’s disease). Mr
Williams has been having abdominal pain and
severe bouts of diarrhoea for the past several
months. He was admitted this morning. He is
NBM to rest his bowels and to prepare for an
upper gastrointestinal diagostic series. He has
been hypotensive and has IV fluids running
and prn pain medications.
Mrs Taylor (66-year-old female, diagnosis:
congestive heart failure). Mrs Taylor was
transferred onto the ward early this morning.
She was admitted four days ago with acute
pulmonary oedema. She has history of CHF
and takes diuretics, digoxin, and an ACE
inhibitor at home. She is alert and oriented.
She is short of breath, on 2L of O2 with oxygen
saturation at 93%. She has an IDC in situ and
is on strict fluid balance.
Case scenario 6:
Right activity, circumstance and communication
YouTube link:
http://www.youtube.com/watch?v=Va6oZ8eaeJI
Case scenario 7:
Effective and safe allocation and assignment
You are an associate nurse unit manager working on a busy acute ward.
You are in charge of a morning shift and have an unlicensed healthcare
worker as part of your ward team. The team has just received handover
and after reviewing the patient profile and the staff skill mix you are about
to allocate your staffing resources for the shift.
• Which patients will you allocate the unlicensed healthcare worker to and
why?
• How will you undertake the allocation and assign the unlicensed
healthcare worker and will the unlicensed healthcare worker be
allocated to work with one nurse or, more than one nurse?
• How will the unlicensed healthcare worker be assigned once they have
completed a set of activities?
Case scenario 7:
Effective and safe allocation and assignment
Things to consider:
• How do I allocate the unlicensed healthcare worker to enhance the safe,
efficient and effective provision of care for that shift?
• How do I ensure that the unlicensed healthcare worker is being utilised
where they are needed most, making the best use of their competencies
within the parameters of their role?
• How do I manage the demand from the nursing team for assistance
from the unlicensed healthcare worker? How do I prevent the
unlicensed healthcare worker being subjected to competing demands
from different members of the ward team?
Case scenario 7:
Effective and safe allocation and assignment
YouTube link:
http://www.youtube.com/watch?v=ZckZZiwYwSs
Case scenario 8:
Right communication, supervision and evaluation
Develop a sequence of sentences to effectively delegate a task
to an enrolled nurse or unlicensed assistive worker.
• Ms Jackson is a 45-year-old female admitted two days ago
for a hysterectomy.
• Her postoperative recovery has been uncomplicated.
• The surgeon wants Ms Jackson to ambulate three times per
day.
• You have assessed Ms Jackson and have determined that
an unlicensed healthcare worker could help with the
ambulation.
• You approach the unlicensed healthcare worker on your
team.
Case scenario 8:
Right communication, supervision and evaluation
YouTube link:
http://www.youtube.com/watch?v=4oQ2l5_h0Ss
Questions and discussion
More information available:
• Nursing in Victoria
http://www.nursing.vic.gov.au/
• Nursing & Midwifery Board of Australia
http://www.nursingmidwiferyboard.gov.au/Codes-GuidelinesStatements/Codes-Guidelines.aspx#dmf
Full reference list included in the guideline.