Actual delegation can be complicated but may provide the nurse with a welcome relief when patient care responsibilities are mounting. This article will attempt to provide guidance with regard to how delegation can be accomplished safely. We will begin with definitions.
Definitions
The definition of Delegation from the Nebraska Nurse Practice Act is (§38-2201 to 38-2238) “a means of transferring to another individual the authority, responsibility and accountability to perform nursing interventions.” Supervision The active process of directing, guiding, and influencing the outcome of an individual’s performance of an activity. Assignment Transfer of accountability and responsibility to another.
What are the responsibilities by licensure or certification?
RN Responsibility
The Nurse Practice Act clearly delineates that the RN has the responsibility for patient outcomes Nurse Practice Act 30-2212. The RN may assign other licensed team members to provide care as part of that team. Through the process of supervision, the RN directs, guides and evaluates care provided by the care team. The RN is legally accountable for the outcomes of patient care. The RN is responsible for analyzing data gathered by all team members. The RN is accountable for initial patient assessment as well as for intermittent patient evaluations. Nursing delegation may decrease direct, hands-on care for the RN. However, the supervisory work increases, depending on the composition of the care team. The RN does not delegate to the LPN because the LPN has a license.
DELEGATION PROCESS
NAC 172 Chapter 99 outlines the delegation process as consisting of four broad steps:
- Assessing client/patient(s) and resources.
- Developing a delegation plan.
- Implementing the delegation plan by providing direction and supervision; and
- Evaluating the delegation plan
There are four things an RN can NOT delegate: assessment, planning, evaluation and nursing judgment. These four things are the basis of the independent role of the RN in nursing care. A key component of nursing delegation to an unlicensed individual involves assessing the competency of that individual to perform the delegated task. If the individual is competent and safe to perform the task, the RN delegates the task, following up on evaluating outcomes of all elements of care (delegated tasks included).
One Diagram of Delegation
LPN Responsibility
The role of the LPN is clearly defined in the Nurse Practice Act as well in the Nurse Practice Act 38-2211. The LPN contributes to the plan of care and functions at the direction of a licensed practitioner or registered nurse. The LPN in Nebraska does not legally delegate care to unlicensed individuals but does assign and direct nursing interventions that are performed by others. The LPN contributes to the assessment of patients, implements interventions, and participates in evaluation of patient care. This includes provision of IV therapy within facility policies. Facility policy may narrow the scope of practice of any licensed individual, but never expand it. LPN education generally prepares the nurse to care for a chronic, stable patient population.
Unlicensed Person Responsibility
The unlicensed individual is essentially ‘given’ a role or set of tasks through nursing delegation. The RN must know or establish the competency of the individual providing the tasks in support of nursing and IS responsible for patient outcomes secondary to care provision Nurse Practice Act 38-2210.
Another group of unlicensed individuals that frequent acute and long-term care settings are nursing students. Nursing students and faculty are present under a clinical contract between the school and the facility. Nursing students can be held accountable to the level of their education and preparation for a clinical assignment. The RN assigned to the patient IS accountable for the patients assigned to him/her for the shift and works in collaboration with the student and instructor for the time the student is on the unit. Students do NOT work under the license of the staff RN or the nursing instructor.
If the unlicensed assistant does not know how to perform a task or is not comfortable doing the task, they need to speak up. Inform the nurse of the situation before tasks are assigned.
DEVELOPING A PLAN
A delegation plan allows a Registered Nurse to provide care to a large group of patients, while retaining accountability for outcomes of the nursing plan of care. This can be done at the facility level, through a plan developed by nursing service administration or at the unit level by RNs delegating direct patient care.
Selecting the Right Task and Circumstance
Step one involves selecting and identifying noncomplex nursing interventions which may be delegated. Examples are those tasks that frequently reoccur in the daily care of a client/patient or group of patients; those which do not require nursing judgment to complete; those which do not require complex application of the nursing process; those that use a standard and unchanging process, and the results are predictable, and the risk is minimal. Noncomplex interventions can be safely performed according to exact directions and do not require alteration of the procedure, or for which the results and patient response is predictable.
Selecting the Right Person and Communication
The RN must evaluate the competency of the unlicensed individual to perform the task selected for delegation. Questions might include: have you ever done this task before, are you comfortable doing this task with this patient? If the answer is ‘no’ to either of these questions, the RN must either teach, re-teach or accompany the person to perform the task.
Selecting the Right Supervision and Evaluation
The RN must determine the method and frequency of supervision. RNs may utilize both direct and indirect methods of supervision. Direct supervision means that the RN is physically present in the clinical area and available to assess, evaluate or respond immediately, if necessary. It does not mean looking over the shoulder of the delegate. Indirect supervision means that the RN is available for periodic inspection and evaluation, which may include tele-communication.
Implementing the Delegation Plan
Mrs. Jones is a 77-year-old female, 5 days post AP resection for colon cancer with a permanent colostomy. She was moved to the sub-acute unit for pain control. She needs help with self-care of her ostomy as well.
Right person: Nurse Aide Peters is a 20-year-old, just off her six-week orientation.
Plan: develop patient’s self-care of colostomy
Instruction: Mrs. Jones has a permanent colostomy from her surgery 5 days ago. Have you ever cared for a colostomy? (no) My goal is for her to become independent in her colostomy care, but she is still having some pain. Let’s plan to work with her together, so I can show you how to empty the pouch, while evaluating how much Mrs. Jones knows and will do for herself.
Supervision: (direct) RN engages aide and patient in emptying pouch which as determined to be a noncomplex nursing intervention; teaching about when and how to empty. Patient is refusing to do self-care; so, aide return demonstrates and encourages patient on next pouch emptying opportunity with patient. Evaluation: teaching both patient and nurse aide together allows for each to encourage the other in a new skill, with the RN taking accountability for the learning/performance of both.
Evaluating the Delegation Plan
In the preceding example… Mrs. Jones reliance on the RN for assessment and management of postoperative pain was a complex nursing intervention. Nurse Aide Peters provided the patient with bath assistance, postoperative ambulation and was effectively directed to assist the patient with emptying the colostomy pouch— all noncomplex interventions. Noncomplex interventions can become complex. Mrs. Jones refusal to participate in the emptying of the colostomy pouch required further evaluation and modification of the plan of care by the nurse.
The Practice of Delegation: Asking the Important Questions
- Is it appropriate to delegate (based on legal and institutional factors)?
- Is the person able and willing to do this specific task?
- The right circumstances Would the delegation process suggest that the circumstances are right?
- Is staffing such that the circumstances demand delegation strategies?
- TIs the prospective delegatee a willing and able employee?
- Are the patient needs a “fit” with the delegvatee?
- Do you and the delegatee have “common communication language”? (Do words, such as time frames, needs, and critical, mean the same to both of you?)
- Does the delegatee know what and when to report? Is your communication based on a “fit” with the situation and culture?
- Do you know how and when you will interact about patient care with the delegatee?
- How often will you need to provide direct observation?
Based on work by the National Council of State Boards of Nursing. (2005).
SUMMARY
Patient safety is always the first priority.
Only RNs can delegate nursing interventions to unlicensed persons. Nursing delegation relies on appropriate direction, assignment and supervision of others by nurses. Optimal patient outcomes rely on the delivery of high-quality services provided by qualified individuals. Nurses and employers share responsibility for understanding and complying with all statutory and regulatory provisions. No health care professional functions in isolation of the other, but rather to support each other in the care of the patients that are entrusted to them.
References
172 NAC 99. (2004). Regulations Governing the Provision of Nursing Care. (2004). Retrieved from http://www.sos.ne.gov/rules-and-regs/regsearch/Rules/Health_and_Human_Services_System/Title-172/Chapter-099.pdf.
American Nurses Association [ANA]. (2015). Nursing: Scope & standards of practice (3rd ed.). Washington, DC: American Nurses Association.
Medication Aide Act. (2013). Retrieved from https://dhhs.ne.gov/licensure/Documents/MedicationAideAct.pdf.
Nebraska Department of Health and Human Services (2018). Nursing Examination and Retesting.
Uniform Credentialing Act [UCA]. (2017). Retrieved from https://dhhs.ne.gov/licensure/Documents/UniformCredentialingAct.pdf -search=uniform credentialing act
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