“Norma, it's 4:30,” I call out to the nursing assistant assigned to monitor the vital signs of my patients. “I'm going to take Mr. Smith's temperature.” Amidst the day's whirl of activity, I'd forgotten to review the previous temperature readings but figured Norma would have told me if anything was wrong. As I looked at the current reading, my heart sped up. It was abnormal.
“He has a fever of 102°,” I said curtly. As I wrote the number in the patient's chart, I saw that Norma had noted Mr. Smith had a low-grade temperature at 8 am. “Why didn't you tell me?” I demanded.
Norma, who was sitting hunched over a computer, looked up and said loudly, “I just didn't. Go tell the manager if you want.”
Shocked, I thought of all the dangers this high temperature potentially signaled for my patient—and what my knowledge of it earlier in the day could have accomplished. Fuming as I prepared blood culture bottles and spoke to a physician about an antibiotic order, I realized I had delegated temperature taking to Norma, not the interpretation of this value. The latter was not her responsibility. As the patient's nurse, it was mine.
THE STANDARDS OF DELEGATION
According to the American Nurses Association (ANA), “Delegation generally involves assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel while retaining accountability for the outcome.”1 The standards of this complex but common task are based on nurses’ scope of practice within each state, as specified by state boards of nursing and nursing practice acts; these standards are also guided by theoretical documents, such as the ANA's Principles for Delegation and its Code of Ethics for Nurses with Interpretive
In 2016, the National Council of State Boards of Nursing (NCSBN) published an article, “National Guidelines for Nursing Delegation,” that details the responsibilities of employers and nurse leaders, licensed nurses, and delegatees in the delegation process.3 These guidelines refer to the “Five Rights of Delegation,” a list for nurses to consider before they delegate, similar to the safety check nurses perform before administering medication (see Five Rights of Delegation).
Delegation requires much more than a checklist, however. It requires an appreciation of nuance and insight, both of which new graduates may lack. Delegation often requires skills that aren't taught in nursing school and are difficult for preceptors to teach in the clinical setting. Marjorie M. Whitman has succinctly summarized the intricacies of delegation: “Nurses must delegate the exact tasks to be done, verify that the delegatee has been trained to do the tasks correctly, and explain how and when to report the results of the tasks.”4
The process of delegation is a daunting one, so much so that the perceived potential for failure and confusion may lead new nurses to avoid delegating any tasks. The following are steps you can take to bypass barriers to delegation, establish effective delegatory relationships, and ease your transition to expert practice.
Stay within scope of practice. According to the NCSBN, nurses may delegate tasks and aspects of care, but they cannot delegate the nursing process and judgment.3 Analyze your delegatory requests in the same way you would analyze any task that has been delegated to you. Just as you would not perform a duty that falls within a physician's scope of practice, an unlicensed staff member shouldn't be asked to perform a duty within a nurse's scope of practice.
Take the time to understand your state's nurse practice act and review the NCSBN's Five Rights of Delegation as well as your institution's policies and procedures. Practice acts are located on the NCSBN website (www.ncsbn.org/npa.htm), as well as on the website of each state's board of nursing. Knowing your scope of practice will help you to understand the scope of others’ work. Currently, American nurses can be licensed as RNs, advanced practice RNs, and LPNs/LVNs, with each state's board of nursing regulating the scope of practice for each license. The educational path to an RN license is varied, with nurses having completed a range of programs, from associate's degree to accelerated bachelor's degree programs. Yet the basic elements of an RN's scope of practice do not fluctuate based on the type of educational program. By contrast, both educational levels and scope of practice vary among unlicensed assistive personnel (UAP) and LPNs/LVNs, whose practice must be supervised and is regulated by state legislation and institutional policies and procedures.
Your employer will likely not ask you to review a state practice act during orientation but should provide you with information about the institution's policies and procedures, which should align with state law. You may need to review this information when delegating, and your employer will expect you to know how to locate it in the hospital's policy and procedure manual.
Know the level of competency. Successful delegation requires that you know the level of competency of your UAP and LPN/LVN colleagues. For example, if your hospital allows assistive personnel to perform certain advanced functions, like endotracheal suctioning, make sure you know how to verify that a given colleague has gained this competency and that it's current. You can do this by checking to see if departmental records of competency exist and by observing the assistant performing the task, verifying that she or he is competent.
Communicate expectations and parameters. One of the most important aspects of delegation is communication. In instances of miscommunication and unclear communication, the delegation of duties can lead to errors or missed care. According to the Five Rights of Delegation, nurses should use two-way communication when delegating. Ask clarifying questions and verify that the delegatee understands and accepts the delegated task. Additionally, you are responsible for making sure the delegatee knows that your nursing judgment is never being delegated and that the delegatee does not have the power to change or alter her or his responsibilities without notifying you.3
This may seem like a complex concept to grasp as a new nurse, so it may help to use an abbreviated SBAR (Situation, Background, Assessment, Recommendation) report to guide delegation to your UAP colleague.5Communicating expectations using tools that you know, while also following national guidelines and those established by your institution, can provide a structure and format for delegatory conversations (see Table 1 for an example of how to do this based on the opening scenario in this article).
Know who to delegate to. Most of the time, nurses will delegate to UAP or LPNs. These staff play a vital role in caring for patients, and it's our duty as nurses to be familiar with their legal scope of practice.1 New nurses should also consider the value of turning to other RNs for help, even if delegation to UAP is an option. A good rule of thumb is to first ask yourself, “If I don't ask for help right now, will my patients be safe?” You can then determine what would best serve the situation: additional assistance or additional nursing assessment? For example, if one of your patients is in intractable pain, another is having a reaction to a new antibiotic, and another needs water and a toilet break, don't be afraid to ask a nursing colleague if she can determine the cause of your first patient's pain. There is no substitute for a nursing assessment when there is an increase in a patient's pain. Asking your colleague for assistance allows you to focus on managing your other patient's reaction to the antibiotic. You can then ask assistive personnel to attend to the patient who needs assistance with toileting. It's important to consider that the right person for the job, in some circumstances, may be another nurse.1
Know when to delegate (not always, not never). Just because unlicensed personnel are available to perform basic functions and care and to assist with activities of daily living doesn't mean you should delegate every one of these tasks. A nurse's best assessment can be the one she or he performs while providing a bed bath, for instance. Similarly, wounds can be assessed when assisting with incontinence care. In another example, helping a patient to walk down the hall offers dual benefits: it allows you to build your relationship with the patient while also providing an opportunity to conduct a fall risk assessment.
Florence Nightingale likened a good nurse to one who could distinguish the call bell of her patient from that of others.6 Responding to call lights, providing water pitchers and meals, and assisting with trips to the bathroom are duties too often automatically delegated to nursing assistants. RNs risk becoming removed from the intimate physicality of our jobs and miss out on the way these responsibilities sharpen our assessment skills and help us to prevent emergencies if we are always on the sidelines.
This is not to say nurses should never delegate. There are instances in which nurses must bring their expert knowledge, skills, and labor to tasks that non-RN colleagues simply cannot perform. For example, if pulmonary edema is worsening in one of your patients, it may be necessary to ask a nursing assistant to help clean another patient, who is incontinent. Hearing “Why don't you change her?” from a nursing assistant may prove challenging. But if it's your practice to work alongside your assistant, you will find that her or his pushback will lessen when you firmly delegate.
Make a practice of using simple responses drawn from established communication tools, such as the Agency for Healthcare Research and Quality's CUS (Concerned, Uncomfortable, Safety) tool, which is part of its TeamSTEPPS program.5 By using these words intentionally, you highlight the facts and focus on the importance of the delegated task: “I am concerned about spending my time on this task right now. I am uncomfortable with the way my other patient is breathing. I am concerned about her safety and need to assess her further. Thank you for completing this work. As soon as I think the patient has stabilized, I will assist you.” In doing so, you communicate that both your work and the work of your unlicensed colleague is important to your patients’ safety.
Be open to learning and teaching opportunities. The interaction described above promotes teaching opportunities, in which the nurse helps the assistant to gain valuable clinical knowledge. Nurses must also be open to learning from such interactions. Although some practices we see carried out by our unlicensed colleagues may be incorrect or unsafe, others might genuinely help our patient care. In care settings other than the hospital, such as in the home, RNs may see patients only weekly or during emergencies. Nursing assistants often provide these patients with around-the-clock assistance. It's thus important to learn how to interpret and appreciate their feedback, which can inform your assessment and the care to these patients you provide.
Troubleshoot pitfalls and barriers. As a new nurse, many of your delegatory relationships may be with colleagues who are older than you. They may have different educational and cultural backgrounds, as well as varying levels of experience. At times, you may encounter communication barriers or resistance to your delegation efforts. Keep in mind that although a nursing assistant with 25 years of experience is an invaluable resource, you have expert knowledge of clinical care and the ability to analyze clinical evidence.
Take advantage of cultural and in-service training programs, which can provide you with a better understanding of the diverse health care workforce and effective delegation strategies. Pausing to consider a person's background and cultural mores is never the wrong step. In my experience, relationships are often born from the simple question, “So, where are you from?” asked with genuine interest.
Also, weigh the complexity of the delegated task. If it makes the delegatee uncomfortable, or if you don't fully understand whether a task should be delegated, step back and ask for help from a colleague. More experienced nursing colleagues can serve as leaders in these instances and should direct you to institutional policy and best practice resources.
If resistance persists, don't hesitate to ask for support from your nurse manager. Sometimes the most effective tactic is to convene a meeting with the assistant and your supervisor as soon as possible. A third party can serve as an important sounding board in a delegatory relationship. In addition, your supervisor is responsible for maintaining an ongoing understanding of your relationship with your unlicensed colleague and for helping you find ways to improve this relationship.
It is important to understand that working relationships and delegatory instructions are not intended to achieve dominance or control. They are for the benefit of the patient. If communication problems or cultural or behavioral issues get in the way of patient care, it's important to immediately address this barrier with your colleague or supervisor.
Show your appreciation. To enter into any delegatory relationship is to begin a conversation that should start with a respectful request, continue with encouragement, and end with gratitude and praise. Leaving praise out of a delegatory relationship—or any working relationship—will sour it quickly. Intentional and effective praise calls out specific behaviors, giving weight to the worth of your delegatee's work. In the opening scenario, for instance, I didn't offer praise to Norma for her assistance. Ideally, I would have checked the temperature readings she'd recorded earlier in the day and then said, “Norma, thank you so much for keeping a close eye on Mr. Smith's temperature today; because of you, we caught a change in his temperature trend as early as possible and got this information to the physician right away.”
Expressing appreciation also establishes that you are a leader in this delegatory relationship. As such, you must engage in heathy practices to inspire engagement and team building. By rolling up your sleeves, getting your hands dirty, and giving your UAP colleagues credit for their contributions to the team, you'll show that you value their work and rely on their unique assistance.