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chapter 7
Delegation and Prioritization of Client Care
OBJECTIVES
After reading this chapter, the student should be able to:
■ Define the term delegation.
■ Define the term prioritization.
■ Differentiate between delegation and prioritization.
■ Define the term nursing assistive personnel.
■ Discuss the legal implications of making assignments to other health-care personnel.
■ Discuss barriers to successful delegation.
■ Make appropriate assignments to team members.
■ Apply priority setting guidelines to patient care.
OUTLINE
yourself. If you do it, it is by so much the better certainly than if it were not done at all. But can you not insure that it is done when not done by your- self ? Can you insure that it is not undone when your back is turned? This is what being in charge means. And a very important meaning it is, too.
The former only implies that just what you can do with your own hands is done. The latter that what ought to be done is always done. Head in charge must see to house hygiene, not do it herself ” (p. 17).
Today, nurses find that there is more nursing needed than nurses available to deliver the care.
Changes in demographics, improved life expec- tancy, and newer, more complex therapies continue to generate an increased demand for nursing care.
Changes in the health-care law compound this need, requiring nurses to learn how to work effec- tively with other members of the health-care deliv- ery team, particularly nursing assistive personnel.
Knowing how and when to delegate are critical skills for nurses entering the profession today and in the future.
Definition of Delegation
In 2005, the American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN) approved papers regarding del- egation in nursing practice (NCSBN, 2006). Previ- ously the ANA (1996) defined delegation as the reassigning of responsibility for the performance of a job from one person to another. The NCSBN describes delegation as the transferring of authority.
Both organizations agree that this means the reg- istered nurse (RN) has the ability to request another person to do something that this individual may not usually be permitted to do. However, registered nurses maintain accountability for supervising those to whom tasks are delegated (ANA, 2005).
Nightingale referred to this delegation responsibil- ity when she implied that the “head in charge” does not necessarily carry out the task but still sees that it is completed.
Assignments and Delegation
Making or giving an assignment is not the same as delegation. In an assignment, power is not trans- ferred (the directive to do something not necessar- ily described as part of the job, does not occur).
Both the NCSBN and the ANA define an assign- ment as the allocation of duties that each staff
member is responsible for during a specific work period (2006). Assignments relate to situations where an RN directs another individual to do something that the person is already authorized to do. For example, the RN assigns the NAP the responsibility of taking vital signs on three patients.
The NAP is already authorized to take vital signs.
However, if the RN directed the NAP to check the amount of drainage on a fresh postoperative abdominal dressing, this would be considered del- egation because the RN retains responsibility for this action. Matching the skill set of the appropri- ately educated health-care personnel with the needs of the client and family defines the difference between delegation and assignment (Weydt, 2010).
The individual state nurse practice acts define the legal boundaries for professional nursing prac- tice (www.ncsbn.org). Individual nursing organiza- tions also set standards of practice for their specialties that fall within the guidelines of the nurse practice acts. Nurses need to understand the guidelines and provisions of their state’s nurse prac- tice acts regarding delegation of patient care (Cipriano, 2010). However, according to the ANA, specific overlying principles remain firm regarding delegation. These include the following:
■ The nursing profession delineates the scope of nursing practice.
■ The nursing profession identifies and supervises the necessary education, training, and use of ancillary roles concerned with the delivery of direct client care.
■ The RN assumes responsibility and
accountability for the provision of nursing care and expertise.
■ The RN directs care and determines the appropriate utilization of any ancillary personnel involved in providing direct client care.
■ The RN accepts assistance from ancillary nursing personnel in delivering nursing care for the client (ANA, 2005, p. 6).
Nurse-related principles are also designated by the ANA. These are important when considering what tasks may be delegated and to whom. These prin- ciples are:
■ The RN has the duty to be accountable for personal actions related to the nursing process.
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■ The RN considers the knowledge and skills of any ancillary personnel to whom aspects of care are delegated.
■ The decision to delegate or assign is based on the RN’s judgment regarding the following:
the condition of the patient; the competence of the members of the nursing team; and the amount of supervision that will be required of the RN if a task is delegated.
■ The RN uses critical thinking and professional judgment when following the Five Rights of Delegation delineated by the National Council of State Boards of Nursing (NCSBN) (Box 7-1).
■ The RN recognizes that a relational aspect exists between delegation and communication.
Communication needs to be culturally appropriate, and the individual receiving the communication should be treated with respect.
■ Chief nursing officers are responsible for creating systems to assess, monitor, verify, and communicate continuous competence requirements in areas related to delegation.
■ RNs monitor organizational policies,
procedures, and job descriptions to ensure they are in compliance with the nurse practice act, consulting with the state board of nursing as needed (ANA, 2005, p. 6).
Delegation may be direct or indirect. Direct del- egation is usually “verbal direction by the RN del- egator regarding an activity or task in a specific nursing care situation” (ANA, 1996, p. 15). In this case, the RN decides which staff member is capable of performing the specific task or activity. Indirect delegation is “an approved listing of activities or tasks that have been established in policies and procedures of the health care institution or facility”
(ANA, 1996, p. 15).
Permitted tasks vary from institution to institu- tion. For example, a certified nursing assistant (CNA) performs specific activities designated by the job description approved by the particular health-care institution. Although the institution
delineates tasks and activities, this does not mean that the RN cannot decide to assign other person- nel in specific situations. Take the following example:
Ms. Ross was admitted to the neurological unit from the neuroscience intensive care unit. She suf- fered a right hemisphere intracerebral bleed 2 weeks ago and has a left hemiplegia. She has difficulty with swallowing and receives tube feedings through a percutaneous endoscopic gastrostomy (PEG) tube;
however, she has been advanced to a pureed diet. She needs assistance with personal care, toileting, and feeding. A physical therapist comes twice a day to get her up for gait training; otherwise, the primary health-care provider wants Ms. Ross in a chair as much as possible.
Assessing this situation, the RN might consider assigning a licensed practical nurse (LPN) to this client. The swallowing problems place the client at risk for aspiration, which means that feeding may present a problem. Based on education and skill level, the LPN is capable of managing the PEG tube feeding. While assisting with bath ing, the LPN can perform range-of-motion exercises to all the client’s extremities and assess her skin for breakdown. The LPN also knows the appro priate way to assist the client in transferring from the bed to the chair (Zimmerman and Schultz, 2013).
Supervision
The term supervisor implies that an individual holds authority over others (National Labor Rela- tions Act [NLRA], 1935). While nurses supervise others on a daily basis, they do not necessarily hold
“authority” over those they supervise. Therefore, it is important to differentiate between supervision and delegation (Matthews, 2010). Supervision is more direct and requires directly overseeing the work or performance of others. Supervision includes checking with individuals throughout the day to see what activities they completed and what they may still need to finish. When one RN works with another, then supervision is not needed. This is a collaborative relationship and includes consulting and giving advice when needed.
The following gives an example of supervision:
A NAP has been assigned to take all the vital signs on the unit and give the morning baths to eight
1. Right task 2. Right circumstances 3. Right person
4. Right direction/communication 5. Right supervision/evaluation box 7-1
The Five Rights of Delegation
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patients. Three hours into the morning, the NAP is far behind in the assignment. At this point, it is important that the RN discover the reason the NAP has not been able to complete the assignment.
Perhaps one of the clients required more care than expected, or the NAP needed to complete an errand off the unit. Reevaluation of the assignment may be necessary.
Individuals who supervise others also delegate tasks and activities. Chief nursing officers often delegate tasks to associate directors. This may include record reviews, unit reports, or client acu- ities. Certain administrative tasks, such as staff scheduling, may be delegated to another staff member, such as an associate manager. The delega- tor remains accountable for ensuring the activities are completed.
Supervision sometimes entails more direct evaluation of performance, such as performance evaluations and discussions regarding individual interactions with clients and other staff members.
Regardless of where you work, you cannot assume that only those in the higher levels of the organization delegate work to other people. You, too, will be responsible at times for delegating some of your work to other nurses, to technical personnel, or to other members of the interprofessional team.
Decisions associated with this responsibility often cause some difficulty for new nurses. Knowing each person’s capabilities and job description can help you decide which personnel can assist with a task.