Hello, this is Professor Forsythe. Today we're going to talk about delegation in the clinical setting. This is for also topic four. This is chapter 14. That's in page 325 of your nursing today.
Let's begin in defining what does delegation mean. The State Board of Nursing and professional associations such as the American Nursing Association and the National National Council State Board of Nursing have certified or clarified definitions of the terms related to clinical leadership. Clinical delegation has been with us from the beginning of nursing, but teamwork has taken on new meaning as many types of assisted personnel have been added to our care delivery models. Current evidence points to the conclusion that inappropriate care assignment delegation and supervision may be leading to miscare and untoward clinical outcomes. The RN's choice of nursing assistant, the care of which they are supervised, and how well the RN interprets patient data provided by the assisted personnel may be either life-threatening or life-saving to patients.
The practice gaps and key causes that bring harm to patients constitute clear evidence of a lack of nursing knowledge, competence, including lack of professional responsibility in 73% and lack of intervention in 47% of a 2016 National Council State Board of Nursing analysis of nursing errors reported by boards of nursing. The crucial clinical supervisory role of the nurse impels us to perfect our skills to delegation, supervision, and accountability. So let's define delegation. This is the process for nurses to direct another person to perform nursing tasks and activities.
The National Council State Board of Nursing describes this as the nursing's transferring authority whereas the ANA calls this a transfer responsibility. Both mean that an RN can direct another individual to do something that the person would not normally be allowed to do. Both articles stress that the nurse retains accountability for the delegation.
The National Council State Board of Nursing Model Nursing Practice Act simplified the definition of delegation to transferring to a competent individual the authority to perform a selected nursing skills in a selected situation. Supervision meme. Supervision is the process of guidance or oversight by a qualified nurse for the accomplishment of nursing tasks or activity with an initial direction of task or activity and periodic inspection of the actual act of accomplishing this task activity. Nurses are often confused regarding supervision.
This responsibility does not belong to only the one with the title of manager or house supervisor. Rather, the expectation by law is that any time you delegate or assign a clinical task to someone else, you will be held accountable for the initial direction you give and the timely follow-up or periodic inspection. to evaluate the performance of that task. This clinical care supervision should not be confused as the hiring or progressive discipline of employees that your manager or department director would perform.
And once you delegate that responsibility, it is your job to supervise. Let's talk about the delegation process. To determine when and how an RN should delegate, the ANA and the NCSBN and your own state's nursing practice acts offer decision-making support.
So if you look at figure 14.1, this is a, in your book, this is a decision tree for delegation by registered nurses. It's a guideline to help when we're delegating. So the step one is assessment and planning. What are the rules or are there rules, laws? place to support delegation is that is the task within the scope of the delegating nurse has there been an assignment or an assessment of the patient needs is the delegation nurse delegating nurse competent enough to make a delegating decision?
Does the nursing assistant have the appropriate knowledge, skills, and abilities to accept the delegated task? And is it appropriate? Is appropriate supervision available?
After determining that the RN is available to delegate through assessment and planning, the RN must communicate. Initial direction Initial direction and ongoing discussion must be a two-way process involving the nurse who is assessing the nursing-assisted personnel, understanding of the delegated task, and the nursing-assisted personnel who asks questions regarding the delegation and seeks clarification of the expectations. The next step is the surveillance and supervisions. It's ongoing throughout the episode of care or throughout that care.
The purpose of surveillance and monitoring is related to the nurse's responsibility for patient care within the context of the patient population. The nurse supervises the delegation by monitoring the performance of the task or function and ensuring compliance within standards of practice, policies, procedures, frequency, and procedures. Frequency, level, and nature of monitoring vary with the needs of the patient and the competence of the team member.
And the last step is evaluation and feedback. Can be forgotten step, okay, in delegation and should include a determination of whether the delegation was successful. So evaluating that, and we do this part of our nursing process.
So this is even, this is important when we delegate a task. to evaluate that outcome of that delegated task and that that the patient results determine the effectiveness of that delegation we always have to evaluate the effectiveness of that task okay or what we've done for that patient and ensuring that it was a positive outcome let's move on to talking about accountability it's one of the biggest questions concerning teamwork and delegation is the issue of personal accountability. Definition of delegation already notes that the nurse is accountable for the total nursing care of the individuals. So what does that really mean?
Accountability is being answerable for what one has done in standing behind that decision or action. Accountability to be answerable to oneself and others. for one's own choices, decisions, and actions measured against a standard. Some nurses equate accountability with I am the one to blame. And this is a no wonder why many nurses are afraid to delegate if someone else might make the mistake, might make a mistake, and then they're going on to take the blame.
So we have to understand accountability and what it's meaning and what that is. So Our individual choices to take action, personal accountability, is based on our professional knowledge and judgment, unleashing the art and science of nursing as applied to real-time individual patient and family situation using the gifts of skill of the team members each day. An important reminder about accountability before you take the weight of the world on your shoulders, the following statement.
So understanding the following statement, delegation is accountable to accept activities based on their own competency level, maintain competency for the delegated responsibility, and maintain accountability for delegated activity. It's important to focus on what you are accountable for in the process and let the delegate also assume his or her own level of accountability. Okay, it's also true that it's also true that delegates level of education experience may mean they don't know what they don't know. So you must use your, your comprehensive understanding of the patient, their condition to guide you and to ask the right questions to instruct the delegate who you're delegating that task to and keep patients safe, accountable for the following. assessing the patient's needs, assessing when to delegate or assign activities, planning the desired outcome, assessing the competency of the delegate, giving clear direction and obtaining acceptance from the delegate, following up on the completion of that task, and providing feedback to the delegate.
Okay, let's move into the five rights of clinical delegation. So those five rights of clinical delegation is the right task, under the right circumstances, to the right person, with the right direction and directions and communication, and under the right supervision and evaluation. So let's start with the right task.
So what can an RN delegate or assign? Fortunately, we have several references to help in making this determination. The first is the Nurse Practice Act of the state in which you work.
Each state board of nursing has a Nurse Practice Act that guides nursing decisions about what to delegate to nursing assistive personnel. Be sure you become familiar with the state's nursing practice statute, regulations, rules, policies, care standards, and advisory opinions. Considering this, a professional RN can delegate or assign discrete tasks or data retrieval based on patient-conditioned and planned outcomes. Tasks that the delegate is competent to do and is allowed to do according to your state regulations and organizational job description and skills checklist.
Tasks that the competent delegate has also agreed to do understands preferred outcome parameters and how and when to report to the delegating RN. If you work with LPNs or LVNs, consult your specific state rules and regulations along with your organizational job descriptions. LPN practice varies from state to state.
The National Council of State Board of Nursing model rules state that LPNs, licensed practical nurses, licensed vocational nurses, practices under the supervision of an RN. Advanced practice nurses. licensed physicians or other authorized health care providers. He or she participates and collaborates in nursing care.
This role is not one that allows independent practice and is designed from amplifying nursing care for stable, predictable conditions of both the site and with the patient. A key distinction between an RN and an LPN is related to the first step of the nursing process, assessment. The LPN collects data during the health history and physical examination, whereas the RN conducts a conducts a comprehensive physical assessment and develops a plan of care for the patient based on assessment findings.
Moreover, the RN initiates and provides patient teaching. discharge planning and evaluates the patient's response to the plan of care and his or her understanding of that information provided. The LPN contributes to the development and updates to the plan of care and reinforces patient teaching in discharge instruction. The RNs should remain in tune to the state's health divisions regulatory changes of new roles and responsibilities as they emerge. Is there anything an RN cannot delegate?
The first resource is always the law, so checking the law. Nursing is a knowledge-based process, discipline, and cannot be reduced solely to lists of tasks. The licensed nurse specialized education, professional judgment, and discretion are essential for quality nursing care.
While nursing tasks may be delegated, the licensed nurse generalist knowledge of client care indicates that the practice provisions of functions of assessment, evaluation, and nursing judgment must not be delegated. So these are the things that cannot be delegated. In-depth assessment that identify needs and problems and diagnose human response.
any aspect of planning including the development of comprehensive approaches to the total care plan this does not preclude other team members from collaborating and offering information any provisions of health counseling teaching referrals to other health care providers and the therapeutic nursing technique in comprehensive care. So do not delegate professional nursing judgment, clinical reasoning, critical decision-making, the RN nursing process, data gathering, and some tasks or interventions can be delegated, but the comprehensive assessment, nursing diagnosing, caring plan evaluation, and care coordination must not be delegated. The patient education. Although this is some variance by state to state of regulatory education, by the state regulation, education planning and comprehensive patient education are generally reserved for the RN. Let's discuss the right circumstances.
Through the right circumstances is the appropriate patient setting, available resources, and consideration. of other relevant factors. Other relevant factors looking at staffing mix, community needs, teaching obligations, and the type of patient receiving care should also be considered. Often motivated by fear that a delegate may make a mistake in an assigned task, nurses focus on the potential weakness of their team members. As nurses, we are educated to anticipate the worst so that we can prevent accidents, adverse drug reactions, negative impacts from disease process and treatments alike.
So assigning task bases on the strengths of a person will allow the person, will allow the patient or client to experience the very best care and allow the delegate to provide the very best care that they can. If assisted personnel are assigned only those tasks in which they perform well, then they may not. grow in their abilities of skills.
So we must, as nurses, recognize the strengths and encourage the best patient care possible by using the assistive personnel or the things that we delegate to them. But we also need to challenge what we delegate to grow. So it's important to understand our own strengths and weaknesses, but it's also important to understand both the strengths and weaknesses of our team members. and then delegating appropriately. But don't be hesitant to delegate things that maybe aren't the strongest for that assisted personnel, but what you must do in that situation then is be more directional, teaching them what they need to do, follow up and be more involved in that care or that delegated task.
and then building up that confidence of that team member, that is what's very important. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nursing obligation to provide optimum patient care. Be assured that although it is the responsibility of the RN to assess the competency of those they supervise, the... the delegate must be accountable for accepting the delegation and for his or her own actions in carrying out that task.
Causes performance weakness. Often we believe or we begin being clear about expectations is not enough. All of us have some blind spots in our performance.
Perhaps we think we're doing just fine meeting performance competencies and beyond. but colleagues have noted that we are not performing procedures according to policies. But those observations are not being shared, so we believe we're doing just fine. So it's important that clear expectations, but that feedback, constructive positive feedback, is important.
Another common origin of performance weakness is educational need. We make assumptions that well We don't need to provide more educational information because we're like, oh, well, they've done their annual bloodborne pathogen training, so they know everything about it. That's not necessarily true. So asking questions, ensuring that the individual understands the procedure or those kinds of things is very important.
The amount of supervision that's needed can be another source of performance problems. Again, we know that a person can independently do things, but it's important for the RN to periodically go and evaluate, okay, that they are, that what they delegated, that the individual is doing it. So again, as leaders, the RN must determine how much supervision is needed for the individual delegate, just as we determined the degree of observation needed for each patient based on our assessment and the patient's need.
So matching the right person with the right task is that third step in circular process of delegation. for the right person after you have determined that the task can be delegated matching the task to the right person involves nursing selection selecting the right task for a competent person in each situation so we've already discussed how we determine the correct task but how do we select the right person on the right situation so like for example so the same logic applies when you've heard in report that a patient Mr. Smith is unstable. In your current care delivery system on your unit, the LPN and LVN may handle the second set of vital signs, vital sign data in a post-operative intensive care unit after the initial bedside handoff that you attended with the nurse in the post-anesthesia care unit.
So what we're saying is that that patient, you know, what tasks can be delegated to the right person at the right time as well. So it's depending on that plan of care and the healthcare team and then the outcomes, the expected outcomes. And so it's important to delegating, you know, what that right information is or that right task to delegate to that LPN and when. Again, the RN is accountable for the total nursing care of the patient, for determining the situation in which delegation will be used, and for the selection of the right person to do the right task in addition to the periodic inspection and follow-up.
those they supervise. Remember that the building blocks of state practice regulations, job descriptions, skill records, and competency checklists in your organization and department with clear communication with your delegate about their abilities, observing observation of their skills, and ongoing evaluation of the results of their work will allow you to allow you to be certain you have created a functioning team with the right tasks. under the right circumstances, being assigned to the right person. Moving on to the right direction in communication. How clear you make your initial direction will be the cornerstone in determining the success of your delegated task and ultimately the performance of your team.
The bottom line, which is whether the patient outcome was achieved, hinges on your ability to provide initial direction that clearly defines your expectations. of the delegate of the delegate in performance of that assigned task the use of the four c's is it clear is it concise correct and complete so clear does the team member understand what i am saying concise have i confused the direction by giving too much unnecessary information correct is the direction according to policy procedure job description and the law complete Does the delegate have all the information necessary to complete the task? Finally, the right supervision and evaluation. The National Council of State Board of Nursing reminds us that nurses must monitor the work that he or she has delegated or assigned, discovering the quality of the task completing and the patient's results, proper documentation, and follow should be accomplished. Follow-up is crucial to complete the process and to keep patients safe.
However, many nurses have shared that discomfort with giving and receiving feedback for their co-workers. So it's important to give good feedback. So there's a critical thinking box, box 14.6 on page 344 that says feedback formula.
So ask for others' individual input first, then give credit. for the effort, share your perceptions with each other, explore different points of view focusing on shared outcomes, ask the other individual's input to determine what steps may be necessary to make certain desired outcomes are achieved, agree on the plan for the future including time timeline for follow-up and revisit the plan and results achieved. So it's very important to provide You know, it's a collaborative effort to working as a team. giving feedback, receiving feedback, coming up with a plan all together, and again, to helping that patient. It's patient-centered care.
So positive feedback, informative feedback, and practice using the feedback formula, you know, and remembering of following up the three most important points. Ask the other person's input first, give credit for accomplishments and efforts, and ask the other individuals to come up with steps for resolving the issue. Realizing that All situations are different.
So nursing assessment and professional judgment are necessary for clinical delegation. And so that proper evaluation, it's important because as a team, one, as a nurse, we can't do everything. We have a team to provide effective quality patients, high patient satisfaction and safety for our patients in our team.
So you have to be able to delegate. to know how to delegate who to delegate knowing the person's strengths knowing their weaknesses follow-up documentation all of these things are very important and then you know in every situation is different but you have to practice this feedback and feedback is very important as well good positive feedback is important for evaluation and then it allows for the person for all of you everybody involved to learn and grow In conclusion, the delegation process summed up. The right task under the right circumstance to the right person with the right direction and communication under the right supervision and evaluation. That's the importance of, you know, that delegation in the clinical setting. And delegation is important.
Don't be fearful of delegating. But you just got to delegate what is appropriate to delegate to the right person, to the right direction. And. provide good, concise, clear communication, and then always follow up, supervise, and then give that feedback.
On the next 10 slides are questions, five questions with their answers. Please go through and review the questions so you can better understand or evaluate how well you understand delegation in the clinical setting.