CHAPTER 9 DELEGATION OF CLIENT CARE

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CHAPTER 9DELEGATIONOF CLIENT CARE
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OBJECTIVES

• Define delegation and unlicensed assistive
  personnel.
• Identify the rights of delegation and the
  implications of each.
• Understand the legal implications of making
  assignments to other healthcare personnel.
• Discuss the process of delegation and the
  coordination of assignments.

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Objectives

• Differentiate delegation from work allocation.
• Outline how delegation benefits the patient,
  staff and the organization.
• Valuate the need for delegation using the Seven
  Components of the Delegation Decision-Making
  Grid, NCSBN Five Factors for Determining if
  Client Care Activity Should be Delegated, AACN.
• Examine the criteria for safe delegation.

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OBJECTIVES

• Discuss the task related and relationship-oriented
  concerns of delegating.
• Identify and discuss barriers to delegation.
• Identify the basic rights of individuals in the
  workplace.
• Differentiate direct and indirect client care
  activities.
• Describe ways to facilitate performance of tasks
  by the delegatee.

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OBJECTIVES

• Compare delegation in professional practice as it
  relates to responsibility, accountability and
  authority.
• Illustrate critical thinking when making
  assignments and delegating tasks.
• Illustrate how to communicate assignments and
  delegated tasks and recognize barriers to
  successful delegation.
• Differentiate the models of care delivery -
  Functional, Team, Total Client Care

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OBJECTIVES

• Apply delegation concepts, and critical thinking
  to client scenarios and NCLEX-style questions.
• Illustrate critical thinking when making
  assignments and delegating tasks.
• Illustrate how to communicate assignments and
  delegated tasks and recognize barriers to
  successful delegation.
• Apply delegation concepts, and critical thinking
  to client scenarios and NCLEX-style questions.

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DEFINITION

• The reassigning of responsibility for the
  performance of a job from one person to another.
  (ANA, 1996)

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Concepts of Delegation

• The responsibility of the task is transferred.
• Accountability remains with the delegator.
• Delegation may be direct or indirect.

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Direct Delegation

• Usually verbal direction
• RN decides which staff member is capable of
  performing a specific task

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Indirect Delegation

• Contained in an approved listing of tasks
  established by an institution
• Permitted tasks may vary from institution to
  institution

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CONSIDERATIONS

• Whether the client's condition is stable and
  predictable
• The nature and complexity of the nursing task
• The risk to the client if the task is done
  inappropriately or incorrectly
• The necessary knowledge, skills and abilities
  needed to perform the task

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Considerations Cont.

• The competency of the unlicensed assistive
  person
• Whether the outcome anticipated is stable and
  predictable
• The number of unlicensed assistive personnel that
  can safely be supervised by the licensed nurse.

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The Five Rights of Delegation

• Right task
• Right circumstances
• Right person
• Right direction/communication
• Right supervision/evaluation

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Right TaskWhat can the nurse not delegate?

• Initial nursing assessment and follow-up
  assessments if nursing judgment is indicated
• Decisions and judgments about client outcomes
• Determination and approval of a client plan of
  care
• Interventions that require professional nursing
  knowledge, decisions, or skills
• Decisions and judgments necessary for the
  evaluation of client care
• Note Nurse cannot delegate own accountability
  for patient outcome.

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Right Circumstance

• Relate to patient condition
• To delegate task, outcome must be reasonable,
  predictable, and the task must not require
  ongoing assessment or critical decision making

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Right Person

• RN accountable and responsible for meeting
  patient needs
• Delegated care (to UAP) should be for stable
  patients
• Competencies basic nursing skills that include
  standard reoccurring procedures
• Appropriate assignment predictable outcomes
• Abilities Performs care for routine
  procedures---feeding, bathing, routine
• VSs, transferring patient

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Right Direction Communication

• Communicate expectations
• Evaluate whether or not instructions are
  understood
• 4 Cs of Communication
• Is it Clear?
• Is it Concise?
• Is it Correct?
• Is it complete?

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Right Supervision and Evaluation

• Monitoring
• Guidance
• Direction
• Feedback

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Red Flags

• Complexity of nursing activity
• Unidentified client needs
• Missing requisite knowledge and skills
• Insufficient opportunity to train
• Insufficient opportunity to monitor

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Assigning Tasks

• The RN may assign a more skilled individual to
  perform a task
• The RN may not assign an individual to perform an
  activity outside of a job description or the
  scope of practice
• Consider the following situation

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• Mr. Ross was admitted to the neurological unit
  from the Neuro ICU. She suffered a grade II
  subarachnoid hemorrhage 2 weeks ago and has a
  left hemiparesis. She has difficulty with
  swallowing and receives tube feedings through a
  PEG tube however, she has been advanced to a
  pureed diet. She needs assistance with personal
  care, toileting, and feeding. A PT comes BID to
  get her up for gait training otherwise, the
  physician wants her in a chair as much as
  possible.

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Delegation vs Supervision

• Supervision usually more direct than delegation
• Requires directly overseeing the work or
  performance of others
• Could include reevaluation

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The Nursing Process and Delegation

• Assessment
• Assess client needs
• Set client-specific goals
• Match the personnel with the appropriate skills
  to care for the client

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• Planning
• Mentally identify who is best suited for the task
  or activity
• Planning prevents later problems
• Implementation
• Assign the appropriate personnel who have the
  level of expertise necessary to deliver the care
  or carry out the activities

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• Evaluation
• Oversee the care or activities
• Determine if client care needs have been met
• Allow for feedback

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Coordinating AssignmentsMethods to Help
Organize Care

• Care plans
• Clinical (Critical) pathways
• Computerized information sheets
• Personalized worksheets

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Tips for Organizing Care

• Plan time around activities that must be
  performed at a certain time
• Perform high-priority activities first
• Cluster activities that may be performed together
• Consider your peak time when performing optional
  activities

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The Need for Delegation

• Changes in the Health-Care Environment
• Nursing shortage
• Health-care reform
• Increased need for nursing services
• Demographic trends
• Use of unlicensed assistive personnel

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Unlicensed Assistive Personnel (UAPs)

• Individuals trained to function in an assistive
  role to the nurse
• Perform delegated tasks
• Under direct supervision of the RN
• May or may not be certified

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Decision -Making Grid

• Method to evaluate activities being considered
  for delegation
• Level of client acuity
• Level of UAP capability
• Possibility for injury
• Number of times the skill has been performed by
  the UAP
• Level of decision making needed for the activity
• Clients ability for self care

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Examples of Tasks

• Vital signs
• Skills learned through special training
• Blood drawing
• ECGs
• Measuring intake and output
• Non-nursing duties

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• The nurse cannot delegate
• Initial nursing and follow-up assessments if
  nursing judgment is indicated
• Decisions and judgments about client outcomes
• Determination and approval of a client plan of
  care
• Interventions that require a professional nursing
  knowledge, decisions, or skills
• Decisions and judgments necessary for the
  evaluation of client care

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Five Factors for Determining if Client Care
Activity Should be Delegated

• Potential for harm to the patient
• Complexity of the nursing activity
• Problem-solving and innovation necessary to
  complete the task or activity
• Predictability of outcome
• Extent of interaction

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When should the nurse intervene?

• A task not completed in a timely manner
• The implementation of a task/function/activity
  not meeting expectations
• Change in a clients condition
• Alertness to subtle signs and symptoms (which
  allows nurse and assistant to be proactive,
  before a clients condition deteriorates
  significantly)
• Awareness of assistants difficulties in
  completing delegated activities early rather than
  later
• Questions asked by the assistant inform the nurse
  of the assistant's level of understanding and may
  alert the nurse that the assistant needs
  additional training

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Primary task-related concern

• Ability
• Priorities
• Efficiency
• Appropriateness

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Relationship-Oriented Concerns

• Fairness
• Learning opportunities
• assignments
• Compatibility
• Preferences

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Obstacles to Delegating

• Inadequate experience and education
• I can do it better
• Lack of skill
• Confidence in UAP
• Need to feel indispensable
• Fear of losing authority
• Lack of time

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Obstacles to accepting delegation

• Fear of criticism
• Lack of self-confidence
• Lack of time

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LPN vs RN roles
NP Phase LPN RN
Assess Gather data ID strengths Gather extensive data Group analyze data ID resources
Nsg Dx n/a Draw conclusionsUse judgment Assign Nsg Dx
Planning Contributes Short/long-term goals Establish Priorities Collaborate/refer
Implement Provide basic care measures, teaching, documents Manage patient care perform/ delegate, teaching, referrals, collaborate team members, Document
Evaluate Eval effects of care Evaluate plans overall effectiveness, analyze new data, modify plan
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Delegating to LPN

• Competencies Technical skills
• Appropriate assignment Stable patient with
  predictable outcomes
• Abilities More complex care than UAP sterile
  technique, medication administration

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Models of Care Delivery
Major Concept Advantages Disadvantages
Functional Division of tasks with clearly defined roles Efficient, economical, productive Fragmented care
Team RN team leader supervises ancillary staff More holistic RN must take time to delegate
Primary RN maintains 24 hour responsibility for client Emphases on accountability and client satisfaction Extremely costly primary nurse must be capable of meeting all client needs
Total Care One RN with total responsibility for care Continuity of care Costly no efficient use of staff
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The Five Rights of Delegation

• Right task
• Right circumstances
• Right person
• Right direction/communication
• Right supervision/evaluation

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In Conclusion, Points to Consider

• Delegation is not new
• Delegation is essential today
• Organizational skills are a prerequisite for
  delegation
• Understanding client needs is essential for
  appropriate delegation

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The RN Needs to

• Be knowledgeable in relation to own State Nurse
  Practice Act
• Be aware of the capabilities of each staff member
• Understand/know the tasks that may be delegated
• Understands the concept of accountability in
  delegation

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• RN cannot give responsibility away for
  assessment, evaluation, and knowledge base needed
  for nursing judgment
• RN assignment---the unstable patient with the
  least predictable outcome.