Delegation and supervision

Effective Delegation and Supervision

Delegation and Supervision in the Health Care System

Issues Affecting Staffing Patterns Reduced reimbursement from Medicare, Medicaid,

and private insurance companiesProspective payment system Growing uninsured populationRapid advances in medical technologyNursing shortage

Changes in Staffing Patterns Decline in the number and utilization of registered

nurses (RNs) and an increase in the employment of nursing assistive personnel (NAP)

Increased utilization of NAP forces the RN to delegate more nursing tasks.

Roles and responsibilities of care providers (RNs, licensed practical nurses/licensed vocational nurses [LPNs/LVNs], NAP) are significantly overlapping

Economic NecessityNeed competent, appropriately supervised NAP

and LPNs/LVNs in patient careRNs’ confidence with delegation and supervision

skills is essentialRNs must understand legal responsibility related to

delegation and supervision


What Is Delegation?

Definition Transfer of responsibility for the performance of an

activity from one individual to another while accountability for the outcome is retained

RN transfers responsibility and authority for the performance of an activity but remains accountable for overall nursing care

Management strategy used to ensure the accomplishment of cost-effective patient care

Two-Way Process RN delegator is responsible for the following:

The act of delegation Supervising the performance of the delegated

task Assessment and follow-up evaluation Any intervention or corrective action that may

be required to ensure safe and effective care

Two-Way Process The delegatee (LPN/LVN, NAP) is accountable

for the following: His or her own actions Accepting delegation within the parameters

of his or her training and education Communicating the appropriate information

to the delegator Completing the task


What Should and Should Not Be Delegated?

No Definitive List No definitive list of what can and cannot be delegated

Varies among states, organizations, and specific situations

Assessment, evaluation, and nursing judgment cannot be delegated.

No Definitive List RNs will have to seek guidance and integrate

information from State Nursing Practice Acts Patient needs Job descriptions Employee competency Policies and procedures Clinical situation Professional standards of nursing practice

State Nursing Practice Acts State Nursing Practice Acts

Will provide guidance for legal delegationDelegation criteria may not be clearly spelled out

or may be presented in various parts of the ActState board of nursing also may offer guidanceRN should understand the legal scope of practice

for an LPN/LVNPractice by NAP is generally governed by the

health care organization’s standards

Patient Needs RN is required to perform a patient assessment

and to know the level of care requiredGenerally, the more stable the patient, the more

likely delegation is to be safeMany tasks that can be delegated may be

intertwined with a nursing responsibility

Job Descriptions Delineates the tasks, duties, and responsibilities

required as a condition of employmentGenerally comply with state laws and the health

care organization’s standards of careRN should be aware of the job training required to

function as described in the job descriptionIn all cases, legal requirements related to

delegation supersede any organizational policy or job description

Competencies Staff member must have the skills and knowledge

necessary to perform a task before it is delegatedCompetencies confirm that the individual has

demonstrated specific knowledge and skillsRegulatory and accrediting agencies, such as The

Joint Commission, require written documentation of staff competencies

RNs should be knowledgeable about the documented competencies of staff members whom they supervise

Competencies Examples of competencies for an ambulatory care

clinic: Medication management Telephone triage Infection control Glucose testing Reporting abuse and neglect

Organizational Policies and Procedures The specific skill and supervision requirements

for various tasks are designated in written policies and procedures

Ensure that the delegatee is trained in and understands the organization’s general standards of care (e.g., infection control)

Clinical Situation Does the NAP/LPN/LVN realistically have time to

perform the task?Is the staff member familiar with characteristics of

the patient population?How complex is the task? Does the individual have the resources (supplies,

equipment) to perform the task? Is the RN able to provide an adequate level of

supervision?

Professional Standards of Nursing Practice

Professional standards of nursing practiceAgreed-upon levels of nursing practice as determined

by the American Nurses Association (ANA) and specialty nursing organizations

ANA’s standard states that in delegation, the RN will consider the following: Assessment of the patient condition Capabilities of the nursing and assistive staff Complexity of the task to be delegated Amount of clinical oversight (supervision) the RN

will be able to provide Staff workload


ANA has delineated activities that can be delegated by the nurse Functions that are technical and assistive

in nature and can be taught (e.g., feeding, ambulating a stable patient)

Activities that provide amenities to the patient (e.g., making beds, cleaning the environment)


ANA has delineated activities that the RN cannot delegate: Initial nursing assessment and any subsequent

assessment that requires nursing knowledge, judgment, and skill

Determination of nursing diagnoses Establishment of nursing care goals Development of nursing plan of care Evaluation of patient’s progress Health counseling or teaching Activities that require specialized nursing

knowledge, skill, or judgment


Developing Safe Delegation Practices

Establish a Foundation of Knowledge

Establish a foundation of knowledge Know delegation criteria delineated in the state’s

Nursing Practice Acthttp://www.state.tn.us/sos/rules/1000/1000-01.pd

fKnow specific skill requirements designated in

written policies, procedures, and standards of care

Know delegatee’s scope of practice, competencies, and job description

Know professional standards for nursing practice and specific recommendations on delegation

Know the Patient Assess the patient before delegationWhat is the potential for change in the patient’s

condition as a result of the delegated task?Can the patient’s safety be maintained with

delegated care?

Know the Staff Member Does the staff member have the skills and

knowledge necessary to perform the task?Does the staff member perform the task on a

routine basis?Be involved in training programs and the

development of job descriptions for NAP and LPNs/LVNs

Know the Task to Be Delegated RN delegator must be competent and skilled in

performing the taskTask must be in the RN’s scope of practiceRoutine, standardized tasks are the safest to

delegateComplex tasks or activities that convey high risk

for patient complications or unpredictable outcomes must be carefully considered

Explain Task and Outcomes Failure to effectively communicate may result in

unsatisfactory performance, errors, or patient harm

Clearly explain the task, what must be done, and the expected outcomes

Demonstration and return demonstration may be required

Expect Responsible Action Delegatee becomes responsible for his or her

own actionsRN should supervise appropriatelyRN should not intervene unless assistance is

requested, or an unsafe situation is recognized

Assess and Supervise Job Performance

Assess and supervise job performance:Make frequent rounds, observe, and communicateProvide the appropriate level of supervisionBe available for questions or unexpected problemsSupervise in a positive and supportive mannerIntervene immediately if the task is not being

performed safely and appropriatelyNever ignore poor performance—Document and reportUse mistakes as learning opportunities

Provide for Positive Outcomes

Ongoing communication and support are vital Necessary resources to perform the tasks should be

available

Evaluate and Follow Up Evaluate and follow up:

Always evaluate the delegated action by reassessing the patient

Evaluate the staff member’s performanceFollow up with any interventions that may be

requiredReview and document the skills that were learned

Characteristics of High-Risk Delegation

Delegated task can be performed only by the RN according to law, organizational policies, or professional standards of nursing practice

Delegated task could involve substantial risk or harm to a patient

RN knowingly delegates a task to an individual who does not have appropriate training

RN fails to provide adequate supervisionRN does not evaluate the delegated action by

reassessing the patient

Delegation and the Nursing Process Components of the delegation process become

familiar when compared with the nursing processAssess the patient and plan the care, then identify

tasks that someone else can performImplement the plan of care, and assign and

supervise task performanceEvaluate the delegatee’s performance, planned

outcomes, and client response

“Five Rights of Delegation” Right task: Delegated tasks must conform to

established guidelinesRight circumstances: Delegated tasks do not require

independent nursing judgmentRight person: One who is qualified and competentRight direction and communication: Clear explanation

about the task and outcomes and when the delegatee should report back to the RN

Right supervision and evaluation: Feedback to assess and improve the process; evaluate patient outcomes


Supervision

Definition The active process of directing, guiding, and

influencing the outcome of a worker’s performance

On-site supervision—The nurse is physically present or is immediately available while the activity is being performed

Off-site supervision—The nurse has the ability to provide direction through various means of written and verbal communication

Definition Distinction between on-site and off-site

supervision has become unclear with the use of telecommunications technologies

ANA has established operational guidelines for supervision related to telecommunication technologies Who is in control of the activity? How should controls be instituted?

Components of Supervision Initial direction: instructions provided when the

task is first delegatedPeriodic inspection: the decision the RN makes

regarding frequency of monitoring the delegatee’s performance

Levels of Supervision Unsupervised

One RN works with another RN in a collegial relationship

Neither RN is in the position of supervising the other

Levels of Supervision Initial direction/periodic inspection

RN is supervising a licensed or unlicensed caregiver

Knows the individual’s training and competencies

Has developed a working relationship with the individual

Levels of Supervision Continuous supervision

RN has determined that the delegatee will need very frequent to continual support and assistance

Continuous supervision is required when The working relationship is new The task is very complex The delegatee is inexperienced or has not

demonstrated an acceptable level of competence


Assigning versus Delegating

Definition of Assignment Distribution of work that each staff member is

responsible for during a given work periodDesignates activities consistent with job position

and description, legal scope of practice, and educational background

The staff member assumes responsibility and is accountable for completing the assignment.

Assignment Considerations Assigning groups of clients to various care

providers, including NAP and LPNs/LVNs is not appropriate

NAP assignments would include functions and tasks

LPNs/LVNs may be assigned specific clients for which to perform care, but RNs remain responsible for all nursing practice activities

Assignment Considerations The RN is responsible for assignments made to

nursing personnel and should consider the following: Patient’s physiologic status and complexity

of care Infection control or cross-contamination

issues Level of supervision required Staff development opportunities such as

assigning a less experienced nurse to a more complex patient with an increased level of supervision

Utilizing the Interdisciplinary Health Care Team

Interdisciplinary team members will be valuable in meeting patient care needs

RNs should know scope of practice and training background of team members

Utilizing the Interdisciplinary Health Care Team

RN should know how the work is delegated or assigned to interdisciplinary team members Interdisciplinary team members may report to

the RN, who is responsible for assigning and delegating patient care tasks

Interdisciplinary team members may report to supervisors in their individual disciplines and may work in a collaborative manner with the RN to provide patient care


Building Delegation and Supervision Skills

Novice Nurses’ Barriers to Effective Delegation

Fear of being disliked, losing control, taking risks, making mistakes

Lack of confidenceLack of knowledge

Communicate Effectively Know exactly what needs to be done and what

outcomes are expectedMaintain self-control and confidenceListen carefully to the delegatee’s responseAsk for feedback by using open-ended,

nonthreatening statements if the delegation action elicits a negative response

Create an Environment of Trust and Cooperation

Maintain a nonthreatening and nonjudgmental attitude—Problems will be reported more quickly

Avoid blaming and criticizing when mistakes occur—Look for root causes such as inadequate training or too heavy workload

Encourage staff members to report and discuss problems

Create an Environment of Teaching and Learning

Remember that inadequate training is a common cause for poor performance in the work setting

Identify staff learning needs and provide educational programs aimed at building skills and competencies

Be willing to teach and demonstrate how to perform a task rather than merely telling how it should be done

Promote Patient Satisfaction Clients need and want to know their caregivers’

qualificationsThe RN is responsible for describing the health

care team to the client

Provide Feedback and Follow Up Delegation process is not complete until the RN

reassesses the patient and adjusts the plan of care as indicated

Provide honest feedback to the delegatee about his or her performance

Praise good performanceAddress poor job performanceStop inappropriate, unsafe, or incompetent

performance immediately; document and report to the nurse manager or supervisor

Request additional training or other appropriate action to ensure that patient safety is protected

Documents

Delegation and supervision