Posted in Clinicals

Delegating properly is a key nursing skill you’ll use consistently in clinical and on the job. But it doesn’t stop there. You’re likely to encounter more than a few exam questions (and NCLEX prep questions) about delegating safely and appropriately.

Why delegate?

First of all, nursing is a team sport. You’ve heard me say this time and time again. You simply cannot do everything, nor should you. By delegating appropriate tasks to others, you free yourself up to focus on the things you should be focusing on while ensuring your patients’ needs continue to be met. 

Before we dive into delegating, let’s first talk about the difference between licensed and unlicensed personnel. Licensed personnel are those who have an actual license…either an RN license or an LPN/LVN license. Unlicensed personnel are those who work in an assistive capacity, and while they may have a certification, they are not licensed. This could be a CNA (certified nursing assistant), MA (medical assistant), PCT (patient care tech), a phlebotomist or a monitor tech. 

Three levels of nursing leadership

There are essentially three levels of nursing leadership in the day-to-day clinical setting: assigning, delegating and supervising. 

Assigning refers to the process of giving the entire ownership of a task to someone else. A great example of this is when the charge nurse makes the patient assignments for the shift. The charge nurse is not in charge of the patient, he or she is assigning you ownership of the patient and you are assuming total responsibility. This is appropriate because you, as the nurse, are licensed to assume care of a patient. It would NOT be appropriate to assign a patient to a CNA. 

Delegating is the process of giving someone else responsibility for a task, but you as the licensed personnel retain accountability for it. That’s why clear communication is a key component of proper delegation. We’ll talk more about that in a bit. 

Supervising refers to the monitoring of how well others perform their duties. You will be supervising the work you have delegated to others on your team.

Let’s take a deeper dive into delegation

The first, and most important, thing to understand about delegation is that the task you delegate is dependent upon several factors, which will be different in every situation. 

  • What does the patient need?
  • What tasks can the unlicensed assistive personnel (UAP) do based on your facility’s policies and standards of practice?
  • Is the patient stable and is their condition predictable? 
  • Is the delegation appropriate at this time? What was appropriate yesterday, may not be appropriate today.

The American Nurses Association has identified the Five Rights of Delegation, which take these factors into account. These are the right task, the right circumstance, the right person, the right supervision and the right communication. 

For example, let’s say you have Mr. Roberts who came in for a hip replacement three days ago. Mr. Roberts has dementia and requires assistance with his meals, and the CNA fed him breakfast, lunch and dinner on post-op day 1 with no issues at all. However, Mr. Roberts has suffered a stroke which resulted in mild dysphagia (difficulty swallowing) and has been cleared by speech therapy to eat a modified diet. It is time for breakfast and this will be the first meal Mr. Roberts eats after having his stroke. Is it appropriate to delegate the task of feeding Mr. Roberts to the CNA who fed him yesterday? Let’s go through the decision making process using the ANA’s Five Rights:

  1. The Right Task – Is the task appropriate for delegation? Do state regulations or your hospital policies support this delegation? This includes the nurse practice act which outlines the nurse’s scope of practice.
    1. The hospital policy definitely states that the CNA can feed a patient. It is within my scope of practice, so it IS something I can delegate. But we need to go further down the decision tree.
  2. The Right Circumstance – This question asks you to consider if delegation is appropriate in this particular situation. Does the unlicensed individual have the necessary resources and supervision to perform the task? And, more importantly, is the patient’s condition predictable and stable? In other words, it is inappropriate to delegate to a UAP any task that requires assessment, clinical judgment, evaluation or problem solving. If the situation at hand involves any of those things, you can certainly delegate to another RN, but not someone who is unlicensed. 
    1. Because the stroke and modified diet are new for Mr. Roberts, I would say his response to being fed breakfast is not yet predictable. This factor alone, means it’s not an appropriate delegation. But let’s go through the whole list.
  3. The Right Person – Have you chosen the proper individual for the task? Take into account the UAP’s knowledge and competency related to the delegated task. A brand new UAP who has not yet learned how to safely reposition a patient using your facility’s lift mechanism is not the the right person to reposition your patient. As the RN or LPN, it is up to you to determine if the UAP is properly trained and has demonstrated competency.
  4. The Right Supervision – Are you able to supervise this task? This includes monitoring the UAP’s ability to perform the task well (and safely), evaluating the outcome, and intervening as necessary. Always remember that as THE licensed individual, YOU are ultimately responsible for the patient, even when tasks are delegated.
    1. If you are not available to supervise this task and monitor the outcome, then this would not be a safe delegation. Let’s say you are going to be off the unit for a couple of hours taking a patient to MRI. You will not be readily available to supervise or intervene. In this case, the delegation to an unlicensed individual would be inappropriate. I would ask one of my nurse coworkers to perform this task instead. I would still want to evaluate the outcome, but having another nurse perform the task means I’ve got someone in place who can assess and intervene appropriately.
  5. The Right Direction and Communication – When assigning a task, you must provide clear instructions to the UAP. This includes describing the task, stating the objective or goal of the task, and defining any limitations as well as your expectations. Since we already know we’re not delegating Mr. Jones’ breakfast to the UAP, let’s say you’ve assigned them the task of getting a different patient out of bed. Following the ANA’s guidelines, you wouldn’t simply ask the UAP to “Get Mr. Jones out of bed.”

    Instead, you may say something like, “I’d like you to get Mr. Jones out of bed to the chair using his walker and ambulating no more than a distance of 4 feet. Once he’s in the chair, set up his lunch tray and please alert me if he shows any difficulty with the activity or complains of shortness of breath. He did fine this morning, so I don’t anticipate him having any significant difficulty.”

    See how that second statement is much clearer and sets the UAP up for success with this task? It is also a good idea to ask the UAP if s/he has any questions before moving on with the assigned delegation.

You’ve delegated a task. Now what?

Now it’s lunch time and since Mr. Roberts did fine with breakfast, you’ve delegated his meal to the CNA. Here’s what we need to do to make sure this delegation continues to be appropriate for both Mr. Roberts and your CNA.

  • First, we’re going to ensure the CNA is capable of performing the task. Have we observed this particular CNA feeding patients before? Is there a special class CNAs must take prior to feeding patients with swallowing difficulty? Let’s make sure we have the right person performing this task. This is part of the ANA’s guidelines of ensuring you have selected the right person for the task. 
  • Second, we’re going to make sure the CNA knows to alert you if there is any unexpected outcome. These outcomes could include any difficulty with swallowing, any coughing, any significant change in vital signs, difficulty breathing or changes in level of consciousness. This is part of providing effective communication and clear direction.

Once the task is complete, you still have work to do. You need to evaluate how the patient responded to the intervention, how well the CNA performed the task, and identify any opportunities for improvement that you could share with the CNA. 

Now, let’s talk a little bit about assigning

As mentioned earlier, a charge nurse making a patient assignment is an excellent example of this type of nursing management. The charge nurse will not assume responsibility for the patient. Instead, it falls upon the individual this task is assigned to…the RN or LPN. A lot of factors will come into play with making assignments, such as staffing ratios and skills of nurses on the unit. For example, if a patient requires CRRT (continuous renal replacement therapy), the charge nurse cannot assign that patient to a nurse who has not completed training and demonstrated competency in managing this form of dialysis.

What if you feel your assignment is unsafe?

When a nurse feels he or she has been given an inappropriate or unsafe patient assignment, there are steps to take. If you were to refuse the assignment without following the proper steps, this could be considered patient abandonment and could cost you your license and your job.

So, if you feel you have been given an unsafe assignment, the first thing to do is bring the matter to the attention of the charge nurse. Perhaps the charge nurse has paired you with a patient who requires 1:1 supervision with a patient who is hemodynamically unstable. This would be a very unsafe assignment. By going to the charge nurse, you can discuss a changenso that your assignment becomes safe. For example, pairing the unstable patient with one who does not require 1:1 supervision would be much safer.

If the charge nurse were to refuse to change your assignment, you would then go up the chain of command. In most cases that would be someone like the ANM (assistant nurse manager) or director of your unit. After that it would be the house supervisor, or even the nursing director. 

If you still do not have a safe resolution to your patient assignment concerns, you can submit an ADO (assignment despite objection) form and submit a copy to your supervisor, one to your union rep (if you have one) and keep a copy for yourself. If an assignment is truly unsafe, and your employer does not rectify the situation, this form is your documentation that your employer has not corrected a potentially dangerous situation. It is an effort to protect yourself personally should there be an adverse outcome for the patients in question.

Let’s go through a couple of scenarios to solidify these concepts.

Your patient has recently had his hip replaced and has not yet gotten out of bed. It is the morning after surgery and the MD has ordered the patient to be OOB (out of bed) for meals. His breakfast tray comes, but you are busy giving discharge instructions for another patient. Do you delegate this task? 

I would say no. The only person I would trust getting this patient out of bed without my direct supervision would be the physical therapist. I would not delegate this task to a CNA because it doesn’t meet the criteria for a safe delegation. Though he is stable, his condition is unpredictable since he hasn’t gotten out of bed yet. I would want to be there for that first transfer from bed to chair to determine the patient’s response and ensure his safety. 

You take your patient’s blood sugar and notice that it is 49 and the patient is complaining of feeling lightheaded, nauseous and “jittery.” She is following commands and is able to swallow. You need to give pain medication in another room. Do you delegate to the CNA to get this patient some juice? 

No. Why not? First of all, this patient’s condition is not stable and is unpredictable. While giving the patient some juice is an appropriate action, this patient is symptomatic and her condition needs to be evaluated by the RN. This would not be an appropriate delegation.

So there you have it! Your quick and easy guide to delegating like a pro!

Get this on audio in podcast episode 120 on the Straight A Nursing Podcast.

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References

American Nurses Association. (2013). ANA’s principles for delegation by Registered Nurses to unlicensed assistive personnel (UAP). Nursesbooks.org The publishing program of ANA. https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principlesofdelegation.pdf

WojciechowskiMichele, M. (2019, February 6). The risks of wrongful delegation. Daily Nurse. https://dailynurse.com/the-risks-of-wrongful-delegation/