Delegation & Prioritization

Work Reality

With the increasing shortage of nurses,

complex advance technology and
increasing acuity of patients condition,
nursing assistive personnel
(administrators, RNs, LVNs, CNAs, UAPs)
should work effectively to pave way for
safe delivery of health care.

Delegation

the transfer of responsibility for

the performance of an activity
from one individual to another
while retaining accountability for
the outcome.

transferring to a competent
individual the authority to
perform a selected nursing task
in a selected situation.
National Council of State Boards
of Nursing, 1995, p.2

Delegation
is a complex skill
requiring sophisticated
clinical judgment and
final accountability for
patient care.
Grumet (2005)

Assignment
describes the
distribution of work
that each staff
member is to
accomplish on a
given shift or work
period.
NCSBN, 2005 p. 193

typically developed by nurse manager

or charge nurse from the previous
shift.

Principles of Delegation

by NCSBN and ANA......09-12-2006

The RN takes responsibility and

accountability for the provision of
nursing practice.

The RN directs care and determines the

appropriate utilization of any assistant
involved in the direct patient care.

Principles of Delegation

by NCSBN and ANA......09-12-2006

The

RN may delegate components of

care but does NOT delegate the
nursing process itself. The practice
pervasive functions of assessment,
planning, evaluation, and nursing
judgment CANNOT be delegated.

Principles of Delegation

by NCSBN and ANA......09-12-2006

The

decision whether or not to delegate or

assign is based upon the RNs judgment
concerning the:
- condition of the patient
- the competence of all members of the
nursing team and
- the degree of supervision that will be
required of the RN if a task is delegated.

Principles of Delegation

by NCSBN and ANA......09-12-2006

upervision

the provision of guidance and

oversight of a delegated nursing
task.

ANA refers to onsite supervision

NCSBN refers to direct supervision
Both have to do with physical presence and immediate availability of the
supervising nurse

Principles of Delegation

by NCSBN and ANA......09-12-2006

The

RN delegates only those tasks

for which she or he believes the other
health care worker has the
knowledge and skill to perform,
taking into consideration training,
cultural competence, experience and
facility/agency policies and
procedures.

Principles of Delegation

by NCSBN and ANA......09-12-2006

The

RN individualizes communication
regarding the delegation to the nursing
assistive personnel and client situation and the
communication should be clear, concise,
correct and complete. The RN verifies the
comprehension with the nursing assistive
personnel and that the assistant accepts the
delegation and the responsibility that
accompanies it.

Principles of Delegation

by NCSBN and ANA......09-12-2006

Communication
must be two-way
process. Nursing
assistive personnel
should have the
opportunity to ask
questions and/or for
clarification of

Principles of Delegation

by NCSBN and ANA......09-12-2006

The RN uses critical

thinking and
professional
judgment when
following the Five
Rights of Delegation,
to be sure that the
delegation or
assignment is:

Principles of Delegation

RIGHT
S

by NCSBN and ANA......09-12-2006

Principles of Delegation

by NCSBN and ANA......09-12-2006

RIGHT
S

Task

one that is delegable for

a specific patient

Principles of Delegation

by NCSBN and ANA......09-12-2006

RIGHT
S

Circum
stance

appropriate patient setting,

available resources, and other
relevant factors considered

Principles of Delegation

by NCSBN and ANA......09-12-2006

RIGHT
S

Person
right person is delegating the
right task to the right
person to be performed on
the right person

Principles of Delegation

by NCSBN and ANA......09-12-2006

RIGHT
S

Direction
Communicatio
&
n
clear, concise description of the
task, including its objective, limits
and expectations

Principles of Delegation

by NCSBN and ANA......09-12-2006

RIGHT
S

Super
vision

appropriate monitoring, evaluation,

intervention as needed and feedback

Principles of Delegation

by NCSBN and ANA......09-12-2006

Chief

Nursing Officers
are accountable for
establishing
systems to assess,
monitor, verify and
communicate
ongoing competence
requirements in areas
related to delegation.

Principles of Delegation

by NCSBN and ANA......09-12-2006

There

is both
individual
accountability
and
organization
accountabilit
y for
delegation.

Principles of Delegation

by NCSBN and ANA......09-12-2006

Organizational

Sufficient staffing
accountability for
with appropriate
delegation relates mix;

to providing
sufficient
resources,
including:

Principles of Delegation

by NCSBN and ANA......09-12-2006

Organizational

accountability for
delegation relates
to providing
sufficient
resources,
including:

Documenting competencies for

all staff providing direct patient
care and for ensuring that the RN
has access to competence
information for the staff to whom
the RN is delegating care;

Principles of Delegation

by NCSBN and ANA......09-12-2006

Organizational

accountability for
delegation relates
to providing
sufficient
resources,
including:

Organizational policies on
delegation are developed with the
active participation of all nurses and
acknowledge that delegation is a
professional right and
responsibility.

So the big
question is
WHO CAN DO
WHAT?????

Registered Nurse
Admission assessment
IV meds
Blood products
Initiation of Care Plan
Client Teaching
Unstable Clients
Acute Diseases

Licensed Vocational Nurse

Vital signs
Uncomplicated skills
Stable clients
Chronic diseases
Oral/SQ/IM medications
Teaching: Initiated by the RN
Dressing changes

Nursing Now!
2009 4th ed by Joseph Catalano Chapter 15 p. 299

Strategies for
Success
For the NCLEX-RN
Examination 2010
by Silvestre
Chapter 10 p. 115

Unlicensed Assistive Personnel

Vital Signs
Feeding
Bathing
Ambulation
Client transport
Grooming
Hygiene measures
Positioning
ROM exercises
I&O

Keep this in mind

Avoid using agency policies

and procedures and agency
position descriptions to
answer the question,
UNLESS the question
provides information to do
so, because they are
specific to do so.

Considerations in Delegation

The RN assigns or delegates tasks based

on the:
- needs and condition of patient
- potential for harm
- stability of patients condition
- complexity of task
- predictability of the outcomes
- abilities of the staff to whom the task is
delegated
- and the context of other patient needs

Barriers to Effective
Delegation

Internal barriers

External barriers

Internal Barriers

Lack of experience in delegating

Lack of confidence in others
Demanding perfectionism
Poor organizational skills
Fear of not being liked by
everyone
Micromanaging management
style

External Barriers

Unclear policies about delegation

Policies that do not tolerate
mistakes
Management-by-crisis model
facility
Lack of competence
Unclear delineation of authority and
responsibility

Prioritization
deciding which
needs or problems
require immediate
action and which
ones could be
delayed until a
later time because
they are not
urgent.

More on Prioritization
It also includes
evaluating and weighing
each competing task or
process with the
following
Is it lifecriteria:
threatening
or potentially life
threatening if the
task is not done?

Would another client

be endangered if I do
this now or leave this
task for later?

More on Prioritization

Is this task or process

essential to client or
staff safety?

Is this task or process

essential to the
medical or nursing
plan of care?
(Hansten and Jackson, 2004, pp. 163164)

More on Prioritization
A nurse is caring for a patient with
the diagnosis of pneumonia. Health
care provider prescribed Levaquin
1 gm IV every day and D5W one
liter to run at 125 ml/hr upon
admission. The nurse reviews the
patients clinical lab results for the
day and performs a physical
assessment. What should the
nurse do first?
1. Notify the health care
provider.
2. Continue formulated care
plan.
3. Monitor patients status every
shift.
4. Encourage the patient to turn
every two hours.

CHART
Vital
Signs:
0700:
T=98.6 F
P=78
R=17
BP= 119/70

Lab Results:

Day 1
Na = 147
BUN = 22
WBC =
12K/mm3
NE%= 72% (H)

1100:
T=97.9 F
P=84
R=19
BP= 125/80

Day 3
Na = 140
BUN = 20
WBC =
11K/mm3
NE%= 12% (H)

Three Levels of Priority Setting

(Critical Thinking and Clinical Judgment , by Rosalinda Alfaro-Lefevre (2004)

1
First Level: ABC plus
vital signs

2
Second Level:
Includes issues such
as mental changes,
untreated medical
issues, acute pain,
acute elimination
problems, abnormal
laboratory results
and risks

3
Third Level: Long
term issues in health
education, rest,
coping

What about NCLEX-RNs stance on

delegation?

Delegating to the
right person
requires that the
nurse be aware of
the qualifications
of the delegatee:
appropriate
education, training,
skills, experience
and demonstrated
and documented
competence.

Remember the
nursing process:
assessment,
diagnosis, planning
and evaluation (any
activity requiring your
nursing judgment)
MAY NOT be
delegated to UAP.
Delegated
activities fall within
the implementation
phase.

What about NCLEX-RNs stance on

delegation?

UAPs generally
DO NOT perform
invasive or sterile
procedures.

The RN is
accountable for
adhering to the
three basic aspects
of supervision when
delegating to the
other health care
personnel such as
LVNs, graduate
nurses,
inexperienced
nurses, student

What about NCLEX-RNs stance on

delegation?

Priorities often center on which client

should be assessed FIRST by the
nurse.
Ask yourself:
Which client is most critically ill?
Which client is most likely to
experience a significant change in
condition?
Which client requires assessment by
an RN?

What about NCLEX-RNs stance on

delegation?

The nurse manager needs to analyze all

the desired outcomes involved when
assigning rooms for clients or assigning
client care responsibilities.

A client with an infection should not be

assigned to share a room with a surgical or
immunocompromised client.

A nurses client care management should

be based on the nurses abilities, the
individual clients needs and the needs of
the entire group of assigned clients.
SAFETY AND INFECTION CONTROL are high
priorities.