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International Journal of Nursing Education Scholarship

Volume 3, Issue 1 2006 Article 15

Nursing EDGE: Evaluating Delegation Guidelines in Education


Deborah Henderson Pamela Sealover Sandy Jones Tim Blake Vicki Sharrer Sally Fusner Stacie Sweet

Ohio University - Zanesville, hendersd@ohio.edu Ohio University - Zanesville, millerp3@ohio.edu Ohio University - Zanesville, sharrer@ohio.edu Ohio University - Zanesville, fusner@ohio.edu Ohio University - Zanesville, joness3@ohio.edu Ohio University - Zanesville, sweets@ohio.edu Ohio University - Zanesville, blaket@ohio.edu

Copyright c 2006 The Berkeley Electronic Press. All rights reserved.

Nursing EDGE: Evaluating Delegation Guidelines in Education


Deborah Henderson, Pamela Sealover, Vicki Sharrer, Sally Fusner, Sandy Jones, Stacie Sweet, and Tim Blake

Abstract
Delegation, an important concept for nursing students to learn and practice, is central to registered nurse (RN) performance, and important on the NCLEX-RN examination. Nursing faculty members from an ADN program designed a descriptive study to evaluate planned versus actual delegation in the curriculum, and a second study to evaluate an intervention on delegation. Study One assessed the presence of delegation in each nursing course. Statistical analysis compared the planned implementation with the results for student denitions of delegation, and identication of the ve rights of delegation based on the National Council of State Boards of Nursing (NCSBN) denition and ve rights. Study one results are shared. Study Two utilized a comparison of pre-to-post intervention measures. Students were asked to complete eight steps of a delegation exercise and determine what could be delegated to an unlicensed assistant, and what should be completed by the RN. Answers were coded and entered into SPSS. Statistical analysis compared each students ability to correctly identify the ve rights of delegation prior to the exercise, against the ability to correctly answer ve questions two weeks post exercise. Signicant improvement (p< 0.05) occurred on each measure. Recommendations are discussed. KEYWORDS: delegation, nursing curriculum, nursing faculty, nursing education

Henderson et al.: Nursing Education Delegation Guidelines

Todays nurses face numerous challenges in providing quality care. Current changes and trends in health care include high patient acuity, registered nurse shortages, an increased need for registered nursing services and increased use of unlicensed personnel. Consequently, nursing faculty are being called upon to prepare nursing graduates in the art and skill of delegation. Delegation is not a new concept but one dating back to Florence Nightingale. The National Council of State Boards of Nursing (NCSBN) defines delegation as transferring to a competent individual authority to perform a selected nursing task in a selected situation (NCSBN, 1995, p. 1). The majority of State nurse practice acts specifically address delegation for the registered nurse (RN). Delegation is considered by NCSBN (1995) to be an entry-level nursing practice skill for RNs. Furthermore, according to the American Nurses Association Position Statement On Registered Nurse Education Relating To The Utilization of Unlicensed Assistive Personnel (ANA, 1992), curricula for all RN programs should include content on supervision, delegation, assignment and legal aspects regarding nursings utilization of assistive personal (p. 1). Delegation has become important enough that the concept is included on the national licensure exam for RNs (NCSBN). Even though delegation is considered an entry-level activity, many new graduates cite a lack of academic preparation for this role (Conger, 1999). In a study of 87 RNs, Parsons (1998) found that only 41% had been taught delegation skills in nursing school. This suggests a need for nurse educators to evaluate current curricular content to ensure that delegation is taught and practised by nursing students. The purpose of this study, therefore, was to undertake an evaluation of delegation in an undergraduate nursing curriculum. Since it was determined that delegation was not meeting the learning outcomes of the curriculum, an intervention was implemented to further evaluate student knowledge and ability to use delegation in clinical practice. LITERATURE REVIEW The NCSBN (1995) published five rights of delegation which include the right:

task: one that is delegable for a specific patient circumstances: where the appropriate patient setting, available resources, and other relevant factors are considered person: which means delegating the right task to the right person to be performed on the right patient

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International Journal of Nursing Education Scholarship

Vol. 3 [2006], No. 1, Article 15

direction and communication: that includes clear, concise description of the task, including its objective, limits, and expectations, and supervision and evaluation: which includes appropriate monitoring, evaluation, intervention, as needed, and feedback.

Numerous authors have utilized the NCSBN five rights of delegation (KellyHeidenthal & Marthaler, 2005; Lemone & Burke, 2004; NCSBN; Tappan, Weiss, & Whitehead, 2004). In the Position Statement on Unlicensed Assistive Personnel (UAP) (ANA 1992), delegation is defined as transferring responsibility for the performance of an activity while retaining accountability for the outcome. This definition has also been used by numerous authors (Kelly-Heidenthal & Marthaler, 2005; Curtis & Nicholl, 2004; Lemone & Burke, 2004; Tappen, Weiss, & Whitehead, 2004). Further outlined in the position statement is that the RN must use professional judgment to determine the appropriate activities to delegate. This determination is based on the concept of protection of the public and includes consideration of the needs of patients, the education and training of nurses and assistive staff, the level of supervision required, and staff workload. The ANA statement also identifies which tasks should not be delegated, i.e., health counseling, teaching or independent, specialized nursing knowledge, skill or judgment that requires analysis of evidence or data. Other sources that may impact the RNs delegation authority include: professional organizations and the Joint Commission on the Accreditation of Healthcare Organizations (Fisher, 1999). Eason (2000) has identified four As of delegation: assessment, assignment, authority, and accountability. Williams and Cooksey (2004) added that tasks which are repetitive and supportive can be delegated to unlicensed assistive personnel (UAP). Curtis and Nicholl (2004) have applied Culp and Smiths (1997) six stages of delegation for self management: (a) what to delegate, (b) selecting delegates, (c) assigning tasks, (d) assessing and discussing, (e) executing the task, and (f) completion of the task, while Hansten and Jackson (2004) defined delegation as transferring to a competent individual authority to perform a selected nursing task in a selected situation (p. 1). Parsons (1998) described results of a job satisfaction survey involving 87 RNs, 30 days following a structured teaching intervention on delegation and decision making. Registered nurses with higher delegation scores on the Nursing Assessment Decision Grid reported high levels of job satisfaction relative to decision making and ability to promote within the organization.

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Henderson et al.: Nursing Education Delegation Guidelines

Factors that hinder effective delegation have been described by Curtis and Nicholl (2004), notably working in a hierarchy, doubting delegatees abilities, difficulties delegating, inadequate staffing, dustbin (unpleasant tasks) delegation, under-delegating, over-delegating (dumping), and resistance to delegation. They reported that effective delegation, on the other hand, requires skills such as sensitivity to the capabilities of team members ability to communicate clearly and directly; knowledge of the stages involved in effective delegation; and a vision of how delegation can benefit delegators, delegatees, and wards or organizations (p. 4-6). BRIEF OVERVIEW OF UNDERGRADUATE NURSING PROGRAM The nursing curriculum is divided into a three-level, six quarter, associate degree (AD) nursing program. Students study incrementally, fundamentals of nursing, assessment, communication, medical and surgical alterations that affect nursing care, mental health, maternity and pediatric nursing, emergency nursing, leadership and management, and role transition from student nurse to RN. Licensed practical nurses (LPNs) have the option to enter the program at level two following successful completion of LPN transitions courses, which include topics such as nursing process, communication skills, delegation, medical-surgical content, and legal/ethical concepts. In level one, there is an absence of reading assignments, of objectives dealing with delegation or evidence of delegation on the clinical evaluation tool. The concept of delegation is not covered in class, clinical, or included in the curriculum content map. In all level two courses, there is also no evidence of assigned reading on delegation, while a description of delegation is in the required medical surgical text. Outcome objectives do not include delegation. Students are evaluated as to whether or not they demonstrate accountability for their own care and care delegated. The concept of delegation is not evaluated on written exams in level two. However, level three covers the five rights of delegation as described by NCSBN, and delegation is included in the curriculum content map. Outcome objectives are included in assigned readings and are assessed on course exams. It is also a topic for class discussion, in which students complete small group projects based on mock scenarios, and read the State Board of Nursing rules and regulations on delegation. Furthermore, delegation is included as a clinical course objective required for successful course completion. Research Questions The following research questions guided study one.

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International Journal of Nursing Education Scholarship

Vol. 3 [2006], No. 1, Article 15

Are level one students able to define delegation incorporating a minimum of two of the five rights of delegation? Are level two students able to define delegation incorporating a minimum of three of the five rights of delegation? Are level three students able to define delegation incorporating a minimum of five of the five rights of delegation?

The following research question was posed for study two. Is there a change in students ability to identify the five rights of delegation pretest to post test? METHODOLOGY Study One The NCSBN definition (1995) of delegation is used to evaluate student knowledge of the delegation process. Nursing faculty examined when delegation was introduced and how it was integrated throughout the curriculum. A descriptive study was conducted in 2005 which included 210 associate degree nursing students in southeastern Ohio, 11 of whom were advanced placement LPNs. In the first study, 210 student surveys were collected: 40% (n = 83) from level one; 50 % (n = 106) from level two; and 9 % (n= 19) from level three (see Table 1). Assessed was the presence of delegation in each nursing course. Data were coded and loaded into SPSS. Statistical analysis compared the planned implementation with the results for student definitions of delegation, and for identification of the five rights of delegation based on the NCSBN definition.. Statistical analyses included frequencies and chi-squares. For the definition of delegation to be correct, level one students were to identify two of the five rights of delegation; level two, three of the five rights; and level three, five of the five rights. Each definition was examined using predetermined criteria, and coded as right or wrong. All surveys were coded by a second researcher and results compared. Discrepancies were discussed by the research group to finalize coding as right or wrong. The five rights of delegation were also coded as right or wrong, and validated by the same process as for the definition of delegation.

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Henderson et al.: Nursing Education Delegation Guidelines

Table 1 Results of Study One Level 1 N=83 (2 items)


Right Wrong

Level 2 N=107 (3 items)


Right Wrong

Level 3 N=20 (5 items)


Right Wrong

Total N=210
Right Wrong

Definition Delegation right task right person right circumstance right direction/ communication right supervision /evaluation

38 45.8% 26 31.3% 26 31.6% 8 9.6% 13 15.7%

45 54.2% 57 68.7% 57 68.7% 75 90.4 70 84.3%

5 4.7% 33 30.8% 42 39.3% 7 6.5% 4 3.7%

102 95.3% 74 69.2% 65 60.7% 100 94.3% 103 96.3%

0 0% 16 80% 17 85% 10 50% 12 60%

20 100% 4 20% 3 15% 10 50% 8 40%

43 167 20.5% 79.5% 75 135 35.7% 64.3% 85 125 40.5% 59.5% 25 185 11.9% 88.1% 29 181 13.8% 86.3%

15 18.1%

68 81.9%

16 15%

91 85%

13 65%

7 4.2%

44 21%

166 79%

Study Two A descriptive study conducted during Fall quarter 2005 included level three students, and some level two students from Study One (n=24). A comparison of pre-post intervention measures was employed. The pretest, in which students were asked to write the five rights of delegation, was administered four weeks after class content on delegation was discussed. Additionally, students completed an intervention that included eight steps of a delegation simulation, whereby they determined what could be delegated to an unlicensed assistant and what should be completed by an RN. A coding procedure to quantify each answer into right or wrong had been determined according to whether students delegated appropriately and if they under-delegated. Faculty assessment of the coding of each students response ensured agreement. Coded data were loaded into SPSS and frequencies were calculated.

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International Journal of Nursing Education Scholarship

Vol. 3 [2006], No. 1, Article 15

The posttest was administered 2 weeks following the clinical simulation. Students answered five questions on their final examination, which focused on a specific right from the five rights of delegation. Each pretest right was matched with the same posttest right for data analysis. RESULTS Study One: Delegation Definition When asked to define delegation in nursing, 20% of all students defined delegation correctly according to faculty-determined criteria (see Table 1). Forty-six percent (38 of 83) of level one students correctly defined delegation, compared to 5% (5 of 107) of level two, and 0% (0 of 20) of level three. Level three students had the highest percentage of the components of the delegation definition (i.e., right task 80%, right person 85%, right circumstance 50%, right direction/communication 60%, right supervision/evaluation 65%). Level one students had the second highest percentage on four of the delegation definition components (right task 31%; right circumstance 10%; right direction/ communication 16%; right supervision/evaluation 18%). Level two had the lowest percentages of correct answers for four of the five rights (right task 31%; right circumstance 7%; right direction/communication 4%; and right supervision/evaluation 15%). Level two had the second highest percentage only for the right person (39%) in the delegation definition. Five Rights of Delegation Significant results were obtained on chi square tests for each of the five rights of delegation (p<.05). When incorporating the five rights, level three students had the highest percentage of correct answers (n = 20): right task (80%), right person (85%), right circumstance (50%), right direction/communication (60%) and right supervision/evaluation (65%). Level one students had the next highest percentage of correct answers on four of the five rights (n = 83): right task (31.3%), right circumstance (9.6%), right direction/communication (15.7%) and right supervision/evaluation (18.1%). Level two students had the lowest percentage of correct answers (n = 107) on right task (30.8%), right circumstance (6.5%), right direction/communication (3.7%) and right supervision/evaluation (15%) but the second highest percentage of correct answers for right person (39.3%).

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Henderson et al.: Nursing Education Delegation Guidelines

Study Two Results Two cases that had missing data were eliminated. One student did not complete the course and was also eliminated. This resulted in a sample size of 21. Results indicated that all students omitted identifying at least one of the five rights in the definition of delegation. However, there was a significant increase from pre to post intervention for each of the five rights (see Table 2). Table 2 Five Rights of Delegation Five Rights N = 21 Right task Right person Right circumstance Right direction Right supervision PreIntervention 14 (67%) 14 (67%) 9 (43%) 5 (24%) 9 (43%) Postintervention 20 (95%) 20 (95%) 19 (91%) 18 (86%) 20 (95%) Significance 0.03 0.03 0.000 0.000 0.001

The follow up chi-square test results demonstrated a decline in students ability to define delegation from level one to level two, and from level one to level three. While the expectation of defining delegation increased across levels, correct answers decreased significantly (p < .05). For right task, right person, and right supervision, the direction of significant results were unexpected. Instead of improving as students progressed through the curriculum, their correct answers declined. The follow-up chi-square indicated improvement in correct answers for right circumstance from level one to level three, and level two to level three. However, the difference in group size may have confounded the statistical analysis, since levels one and two were much larger than level three. Furthermore, the content on delegation had not been covered nor assessed for level three students.

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International Journal of Nursing Education Scholarship

Vol. 3 [2006], No. 1, Article 15

DISCUSSION From the results of study one it was apparent that the concept of delegation was not implemented as planned in level two of the program. However, delegation was covered as planned during level three. For level one students, the criteria for the correct delegation definition was set at two of the five rights of delegation. When students were asked to list the five rights of delegation, several listed the five rights of medication administration instead. This was a concern as there may have been a coding error since the right time of medication administration was coded as being the correct response for right circumstance of delegation. Credit had also been given for right person, even though it was obvious students were listing the five rights of medication administration. This is an obvious limitation of the study. Furthermore, it was found that integration of the concept of delegation was not being implemented across curricular levels as per the curriculum plan. The criteria for level three students were set at a higher expectation, with five of the five components of delegation necessary in order to be coded correctly. In study two, a significant improvement occurred with level three students being able to identify each of the five rights of delegation (post intervention). The majority of students (20 of 21) stated delegation exercises should be introduced earlier in the program (beginning at level two). They also acknowledged that the delegation exercise would have been more difficult to complete without classroom discussion and/or a precepted learning experience. RECOMMENDATIONS While a limitation of this study is the small sample size and only one setting, thereby limiting generalizability of findings, several recommendation are worthy of mention. Replication of this study using a larger sample size, and several nursing education institutions would be worthwhile. Additionally, refinement, as well as reliability and validity testing of the survey tools, are necessary. The NCSBN definition of the five rights should be adopted by educators in nursing education programs since the assessment of entry level nurses knowledge of delegation will be determined by NCSBN. It is also recommended that because of few resources available for teaching delegation skills, published reliable interventions and simulations for nurse educators would be valuable.

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Henderson et al.: Nursing Education Delegation Guidelines

Delegation as a concept and process should be introduced early in nursing curricula through assigned readings and followed by application in classroom and clinical settings. Nurse educators should make a conscious effort to incorporate delegation throughout the curriculum, and measurable, simple to complex learning opportunities implemented in all nursing courses. Additionally, since the process used to evaluate delegation, particularly in Study One, was found to be an effective tool for faculty evaluation of any curricular concept, this process could be expanded for content coverage, curricular threads, and educational outcomes. Finally, quarterly or semester prepost tests might provide more definitive statistical analyses when used with groups of varying sizes. This could also provide more specific information on students knowledge and progress at particular stages in the nursing program, and decisions could be made for improving content delivery. SUMMARY Nurse educators need to present information about delegation early in the curriculum, increase emphasis on application of delegation as students progress, and adopt measurable methods to track success in using delegation. Currently, there is a paucity of resources for teaching delegation, hence these should be developed and disseminated. Delegation is a concept that has become more important in the role of RNs. Therefore, nurse educators should respond by incorporating this knowledge and skill application in nursing curricula. REFERENCES American Nurses Association (ANA) (1992). Registered nurse utilization of unlicensed assistive personnel. American Nurses Association Position Statement. American Nurses Association (ANA) (1992). Registered nurse education relating to the utilization of unlicensed assistive personnel. American Nurses Association Position Statement. Conger, M. (1999). Evaluation of an educational strategy for teaching delegation decision making to nursing students. Journal of Nursing Education, 38, 419-423. Curtis, E. & Nicholl, H. (2004). Delegation: A key function to nursing. Nursing Management, 11(4), 26.

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International Journal of Nursing Education Scholarship

Vol. 3 [2006], No. 1, Article 15

Culp, G. & Smith, A. (1997). Six steps to effective delegation. Journal of Management in Engineering, 13(1), 30-31. DeLaune, S. C. & Ladner, P. K. (2002). Fundamentals of Nursing; Standards & Practice (2nd ed.). New York: Delmar Thomson Learning. Eason F.R. (2000). The four "A's of delegation. Advance for Nurses Carolina/Georgia, 2(23), 11-13. Fisher, M. (1999). Do your nurses delegate effectively? Nursing Management,30(5), 53. Hansten, R. I. & Jackson, M. (2004). Clinical Delegation Skills: A Handbook For Professional Practice. Massachusetts: Jones and Bartlett. Harrington, N. & Terry, C. (2003). LPN to RN Transitions: Achieving Success in Your New Role (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Kelly-Heidenthal, P. & Marthaler, M. T. (2005). Delegation of Nursing Care. New York: Thomson Delmar Learning. Lemone, P. & Burke, K. (2004). Medical Surgical Nursing: Critical Thinking in Client Care. New Jersey: Prentice Hall. National Council of State Boards of Nursing (1995). Delegation: Concepts and decision making process. National Council Position Paper. Ohio University Curriculum Outcome Objectives (1999). Ohio University Zanesville/Chillicothe Associate Degree Nursing Program NLN Accrediting Commission Site Visit Self Study. 15(3). Parsons, L. (1998). Delegation skills and nurse job satisfaction. Nursing Economics ,16(1), 18-27. Tappen, R.M., Weiss, S.A. & Whitehead, D.K., (2004). Essentials of Nursing Leadership and Management. (3rd ed.). Philadelphia: F. A. Davis. Williams, J.K. & Cooksey, M.M. (2004). Navigating the difficulties of delegation; Learn to improve teamwork in the unit by delegating duties appropriately. Nursing 2004, 34(9), 32.

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