Delegation 2013 Fall

Delegation & Prioritization

Work Reality

With the increasing shortage of nurses, complex advance technology and increasing acuity of patient’s condition, nursing assistive personnel (administrators, RNs, LVNs, CNAs, UAPs) should work effectively to pave way for safe delivery of health care.

Delegation

the transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome.

American Nurses Association, 1997

“transferring to a competent individual the authority to perform a selected nursing task in a selected situation.”

National Council of State Boards of Nursing, 1995, p.2

Delegation“is a complex skill requiring sophisticated clinical judgment and final accountability for patient care.”

Grumet (2005)

Assignment“describes the distribution of work that each staff member is to accomplish on a given shift or work period.”

NCSBN, 2005 p. 193

“typically developed by nurse manager or charge nurse from the previous shift.”

NCSBN, 2005 p. 193

Principles of Delegation by NCSBN and ANA……………......09-12-2006

The RN takes responsibility and accountability for the provision of nursing practice.

The RN directs care and determines the

appropriate utilization of any assistant involved in the direct patient care.

Principles of Delegation by NCSBN and ANA……………......09-12-2006

The RN may delegate components of care but does NOT delegate the nursing process itself. The practice pervasive functions of assessment, planning, evaluation, and nursing judgment CANNOT be delegated.

Principles of Delegation by NCSBN and ANA……………......09-12-2006

The decision whether or not to delegate or assign is based upon the RN’s judgment concerning the:

- condition of the patient- the competence of all members of the nursing team and- the degree of supervision that will be required of the RN if a task is delegated.

Principles of Delegation by NCSBN and ANA……………......09-12-2006

the provision of guidance and oversight of a delegated nursing task.

ANA – refers to onsite supervisionNCSBN – refers to direct supervision

Both have to do with physical presence and immediate

availability of the supervising nurse.

upervision

Principles of Delegation by NCSBN and ANA……………......09-12-2006

The RN delegates only those tasks for which she or he believes the other health care worker has the knowledge and skill to perform, taking into consideration training, cultural competence, experience and facility/agency policies and procedures.

Principles of Delegation by NCSBN and ANA……………......09-12-2006

The RN individualizes communication regarding the delegation to the nursing assistive personnel and client situation and the communication should be clear, concise, correct and complete. The RN verifies the comprehension with the nursing assistive personnel and that the assistant accepts the delegation and the responsibility that accompanies it.

Principles of Delegation by NCSBN and ANA……………......09-12-2006

Communication must be two-way process. Nursing assistive personnel should have the opportunity to ask questions and/or for clarification of expectations.

Principles of Delegation by NCSBN and ANA……………......09-12-2006

The RN uses critical thinking and professional judgment when following the Five Rights of Delegation, to be sure that the delegation or assignment is:

Principles of Delegation by NCSBN and ANA……………......09-12-2006RIGHT

S

Principles of Delegation by NCSBN and ANA……………......09-12-2006

RIGHTS

Taskone that is delegable for a specific patient

Principles of Delegation by NCSBN and ANA……………......09-12-2006

RIGHTS

Circumstance

appropriate patient setting, available resources, and other relevant factors considered

Principles of Delegation by NCSBN and ANA……………......09-12-2006

RIGHTS

Personright person is delegating the

right task to the right person to be performed on

the right person

Principles of Delegation by NCSBN and ANA……………......09-12-2006

RIGHTS

Directionclear, concise description of the task, including its objective, limits and expectations

Communication&

Principles of Delegation by NCSBN and ANA……………......09-12-2006

RIGHTS

Supervisionappropriate monitoring, evaluation, intervention as needed and feedback

Principles of Delegation by NCSBN and ANA……………......09-12-2006

Chief Nursing Officers are accountable for establishing systems to assess, monitor, verify and communicate ongoing competence requirements in areas related to delegation.

Principles of Delegation by NCSBN and ANA……………......09-12-2006

There is both individual accountability and organization accountability for delegation.

Principles of Delegation by NCSBN and ANA……………......09-12-2006

Organizational accountability for delegation relates to providing sufficient resources, including:

• Sufficient staffing with appropriate mix;

Principles of Delegation by NCSBN and ANA……………......09-12-2006

Organizational accountability for delegation relates to providing sufficient resources, including:

• Documenting competencies for all staff providing direct patient care and for ensuring that the RN has access to competence information for the staff to whom the RN is delegating care;

Principles of Delegation by NCSBN and ANA……………......09-12-2006

Organizational accountability for delegation relates to providing sufficient resources, including:

• Organizational policies on delegation are developed with the active participation of all nurses and acknowledge that delegation is a professional right and responsibility.

So the big question is

WHO CAN DO WHAT?????

Registered NurseAdmission assessment

IV meds

Blood products

Initiation of Care Plan

Client Teaching

Unstable Clients

Acute Diseases

Licensed Vocational NurseVital signs

Uncomplicated skills

Stable clients

Chronic diseases

Oral/SQ/IM medications

Teaching: Initiated by the RN

Dressing changes

Unlicensed Assistive PersonnelVital Signs

Feeding

Bathing

Ambulation

Client transport

Grooming

Hygiene measures

Positioning

ROM exercises

I & O

Strategies for SuccessFor the NCLEX-RNExamination 2010by SilvestreChapter 10 p. 115

Nursing Now! 2009 4th ed by Joseph Catalano Chapter 15 p. 299

Keep this in mind…

Avoid using agency policies and procedures and agency position descriptions to answer the question, UNLESS the question provides information to do so, because they are specific to do so.

Considerations in Delegation

The RN assigns or delegates tasks based on the:- needs and condition of patient- potential for harm- stability of patient’s condition- complexity of task- predictability of the outcomes- abilities of the staff to whom the task is delegated- and the context of other patient needs

Barriers to Effective Delegation

Internal barriers

External barriers

Internal Barriers• Lack of experience in delegating• Lack of confidence in others• Demanding perfectionism• Poor organizational skills• Fear of not being liked by

everyone• Micromanaging management

style

External Barriers• Unclear policies about delegation• Policies that do not tolerate

mistakes• Management-by-crisis model

facility• Lack of competence• Unclear delineation of authority and

responsibility

Prioritization“deciding which needs or problems require immediate action and which ones could be delayed until a later time because they are not urgent.” (Silvestri 2004, p. 65)

More on PrioritizationIt also includes evaluating and weighing each competing task or process with the following criteria: Is it life threatening

or potentially life threatening if the task is not done?

Would another client be endangered if I do this now or leave this task for later?

More on Prioritization

Is this task or process essential to client or staff safety?

Is this task or process essential to the medical or nursing plan of care?

(Hansten and Jackson, 2004, pp. 163-164)

More on PrioritizationA nurse is caring for a patient with the diagnosis of pneumonia. Health care provider prescribed Levaquin 1 gm IV every day and D5W one liter to run at 125 ml/hr upon admission. The nurse reviews the patient’s clinical lab results for the day and performs a physical assessment. What should the nurse do first? 1. Notify the health care

provider.2. Continue formulated care

plan.3. Monitor patient’s status every

shift.4. Encourage the patient to turn

every two hours.

Vital Signs:0700:T=98.6 F P=78 R=17 BP= 119/70

1100: T=97.9 FP=84 R=19 BP= 125/80

CHART

Lab Results:Day 1Na = 147BUN = 22WBC = 12K/mm3

NE%= 72% (H)

Day 3Na = 140BUN = 20WBC = 11K/mm3

NE%= 12% (H)

First Level: ABC plus vital signs

Second Level: Includes issues such as mental changes, untreated medical issues, acute pain, acute elimination problems, abnormal laboratory results and risks

Third Level: Long term issues in health education, rest, coping

Three Levels of Priority Setting(Critical Thinking and Clinical Judgment , by Rosalinda Alfaro-Lefevre (2004)

1 23

What about NCLEX-RN’s stance on delegation?

Delegating to the right person requires that the nurse be aware of the qualifications of the delegatee: appropriate education, training, skills, experience and demonstrated and documented competence.

Remember the nursing process: assessment, diagnosis, planning and evaluation (any activity requiring your nursing judgment) MAY NOT be delegated to UAP. Delegated activities fall within the implementation phase.

What about NCLEX-RN’s stance on delegation?

UAPs generally DO NOT perform invasive or sterile procedures.

The RN is accountable for adhering to the three basic aspects of supervision when delegating to the other health care personnel such as LVNs, graduate nurses, inexperienced nurses, student nurses and UAPs.

What about NCLEX-RN’s stance on delegation?

Priorities often center on which client should be assessed FIRST by the nurse.Ask yourself: Which client is most critically ill? Which client is most likely to experience a significant change in condition? Which client requires assessment by an RN?

What about NCLEX-RN’s stance on delegation?

The nurse manager needs to analyze all the desired outcomes involved when assigning rooms for clients or assigning client care responsibilities.

A client with an infection should not be assigned to share a room with a surgical or immunocompromised client.

A nurse’s client care management should be based on the nurse’s abilities, the individual client’s needs and the needs of the entire group of assigned clients. SAFETY AND INFECTION CONTROL are high priorities.