DELEGATION OF CLIENT CARE

1
DELEGATION OF CLIENT CARE
2
Objectives

• Define the term delegation
• Define the term unlicensed assistive personnel
• Understand the legal implications of making
• assignments to other healthcare personnel
• Recognize barriers to successful delegation
• Make appropriate assignments to team members

3
DELEGATION
4
Definition of DelegationAccording to the
AmericanNurses Association (ANA)

• The reassigning of responsibility for the
  performance of a job from one person to another.
  (ANA Registered Professional Nurses and
  Unlicensed Assistive Personnel, ed 2. ANA,
  Washington, DC, 1996.)

5
Concepts of Delegation

• Is not a new concept
• Moses was instructed to identify 70 elders so
  they would share the burden of the nation and the
  people would no longer have to carry the burden
  by themselves.
• Florence Nightingale discussed delegation in
  her Notes on Nursing in 1859.
• Delegation is a process that transfers to a
  competent individual the authority to perform a
  selected nursing task in a specific situation

6
CONCEPTS OF DELEGATION

• The responsibility for the task is transferred.
• Accountability remains with the person who is
  delegating tasks.
• Delegation may be either direct or indirect.

7
DIRECT DELEGATION

• Usually verbal direction
• The registered nurse (RN) decides which staff
  member is capable of performing a specific task

8
INDIRECT DELEGATION

• Contained in a listing of tasks that has been
  approved and established by an institution
• Tasks permitted may vary with different
  institutions

9
ASSIGNING TASKS

• The RN may assign a more skilled individual to
  perform specific tasks.
• The RN may not assign an individual to perform a
  task that is outside that individuals job
  description or scope of practice.

10
DELEGATION VERSUS SUPERVISION
11
SUPERVISION

• Usually more direct than delegation
• Requires directly overseeing the work or
  performance of others
• Includes checking in with individuals throughout
  the day
• May entail the delegation of tasks and
  activities (i.e., the nurse manager performs both
  delegation and supervision)

12
NURSING PROCESS ANDDELEGATION
13
Compare Delegation Process to the Nursing Process

• Assessment
• Delegation
• Planning
• Implementation
• Monitoring
• Evaluation

14
ASSESSMENT

• Is the foundation of the delegation process, just
  like the nursing process or any scientific
  process
• Assess patient needs.
• Without accurate and thorough
  assessment, there can be no delegation
• Set patient goals.
• Match staff members who have appropriate skills
  to care for that patient.

15
PLANNING

• Planning prevents future problems.
• Mentally identify the person who is best suited
  for the task or activity.

16
IMPLEMENTATION

• Assign staff members who have the appropriate
  level of expertise that is necessary to deliver
  the patient care and perform the activities.

17
FIVE RIGHTS

• Right task
• Right concern
• Right person
• Right direction/communication
• Right supervision

18
AS AN RN YOU SHOULD ALWAYS ASK-

• Can this task be delegated safely?
• Is there anything about the clients condition
  orthe environment which would preclude this
  assistant from performing the task as
  delegated? Every client is different
  and the same activity may differ in each
  situation
• Is the task within the scope of practice of
  the individual I am asking to perform it?

19
Have I communicated clearly and directly what is
expected in the performance, reporting and
documentation of this task?Will I be
available and accessible to this individual while
he/she completes the delegated task?Do I
have the requisite skills to assist the
individual in completing the task as delegated?
20
ASSESSMENT RED FLAGS

• Complex nursing activity
• Unidentified client needs
• Requisite knowledge and skills missing
• Insufficient opportunity to train
• Insufficient opportunity to monitor/supervise

21
DELEGATION PROCESS

• Communication of task to be elegated
• Mutual agreement
• Transfer of Authority

22

• Communication of the specific task
• Generally do not use the term assignment when
  dealing with unlicensed assistants.
• Assignment is defined as designating nursing
  activities to be performed by an individual
  consistent with his/her licensed scope of
  practice. Since assistants do not have a legal
  scope of practice, they cannot accept assignments
  but they can accept delegated tasks.

23

• The outcome of assignment and delegation is the
  same (the nursing activity is completed), the
  decision making process is similar, but the
  authority to perform the activity must be
  transferred to the assistant, while the licensed
  nurse already has legal authority.

24

• Mutual agreement
• by both the person delegating and the
  assistant that the task is to be delegated and
  that there is acceptance of the task to be
  performed by the assistant.

25

• Transfer of the authority to perform the task
  from the delegator to the assistant
• The nurse must still retain the
  accountability for its completion and for the
  outcomes of the task.
• The source of authority is always
  legal (nursing license) and may be managerial
  (position description),
• Managerial authority
  cannot supersede legal authority.

26

• A common use of the term assignment is to
  designate the overall workload, including
  delegation and assignment.
• Do not confuse the general use of the term to
  list the workload for which all staff members are
  responsible with the legal use of the term that
  designates nursing activities.

27
DELEGATION

• WHO will do
• WHAT by
• WHEN and
• HOW, WHERE, and
• WHY it will be done
• No delegation can be complete without the above

28
DIRECTIONS

• Priority of activity
• Expected timeliness
• Guidelines for consulting mid activity
• Reportable conditions
• Guidelines for reporting task completion
• Role as delegator and supervisor

29

• Use of written and visual resources may be used
  to reinforce direction
• The communication style of the nurse and that
  of the assistant directly affects the working
  relationship.
• Repeat the directions
• Look at the priority of activities
• Provide a checkpoint throughout the process

30
IN COORDINATING ASSIGNMENTS, REMEMBER

• Plan your time around these activities
• Do high-priority activities first
• Determine which activities are best done in a
  cluster
• Remember that you are still responsible for
  activities delegated to others
• Consider your peak energy time when scheduling
  optional activities

31
DELEGATION RED FLAGS

• Refusal to accept delegation
• Incomplete directions
• Failure to confirm expectations
• Failure to communicate
• Your delegation may be inappropriate

32
CHANGE IN HEALTH CARE ENVIRONMENT

• In the 1990s the nursing shortage, health care
  reform, an increased need for nursing services,
  and demographic trends brought about changes
• The ANA defines an unlicensed assistive
  personnel.
• Remember, certification differs from licensure

33
DELEGATION PROCESS-MONITORING

• This one frequently causes the most problems
• It is easy for someone to forget to check in

34
SUPERVISION

• Provision of guidance or direction, evaluation
  and follow up by the licensed nurse for a process
  and the outcomes of a delegated task.
• Supervision includes monitoring the
  performance, intervening if necessary, and
  ensuring that proper documentation of the task is
  completed.

35

• DEGREE OF SUPERVISION REQUIRED DEPENDS ON
• Client needs
• Stability of the client
• Competency of the assistant
• Nature of the task
• Available supervision

36
MONITORING RED FLAGS

• Change in other clients condition with impact on
  workload
• Failure of assistant to report unexpected events
  or client outcomes
• Work completed incorrectly
• Work not completed
• Inadequate direction from delegator
• Inadequate or lack of monitoring from delegator

37
The occurrences indicate that the delegation may
be inappropriate and that the delegation decision
should be revisited to insure that the 5 Rights
still apply
38
EVALUATION

• THIS IS YOUR FOLLOW-UP
• Oversee the care and activities provided by the
  employees.
• Determine if patient care needs have been met.
• Allow for feedback. Evaluation of the delegator
  / assistant should be done
• Evaluation is often the missing link in the
  delegation process

39
DESIRED OUTCOMES

• Protection of client safety
• Achievement of desired client outcomes
• Reduction of health care costs
• Access to appropriate levels of health care
• Decreased nursing liability

40
INAPPROPRIATE DELEGATION

• MAY RESULT FROM
• Inadequate resources
• Conflict of employee policies and law
• Inappropriate employer direction
• Lack of knowledge about delegation
• Failure to accept accountability for nursing
  care provided

41
CORRECTIVE ACTION

• Educate and train
• Restate expectations
• Return skill demonstration
• Identify specific checkpoints
• Increase frequency of check ins
• Evaluate directions

42
EVALUATION RED FLAGS

• Failure to evaluate delegation effectiveness
• Failure to evaluate the delegator/assistant
  relationship
• Failure to learn from work experience

43
COORDINATING ASSIGNMENTS
44
METHODS TO HELP ORGANIZECARE

• Critical pathways
• Computerized information sheets
• Personalized worksheets
• Delegation tree

45
TIPS FOR ORGANIZING CARE

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

46

• THE NEED FOR DELEGATION

47
CHANGES IN THE HEALTH-CARE ENVIRONMENT

• A nursing shortage
• Health-care reform
• An increased need for nursing services
• Demographic trends
• Use of unlicensed assistive personnel

48
UNLICENSED ASSISTIVE PERSONNEL (NA)

• Trained to assist the nurse
• Perform tasks delegated by the nurse
• Under the RNs direct supervision
• May or may not be certified

49

• Delegation of Unlicensed Assistive Personnel

50
TASKS

• Unlicensed assistive personnel perform numerous
  tasks such as
• Taking vital signs
• Demonstrating skills learned through special
  training (e.g., drawing blood or administering an
  electrocardiogram ECG)
• Measuring intake and output
• Performing nonnursing duties

51

• SAFE DELEGATION

52
CRITERIA FOR SAFE DELEGATION

• Potential for harm
• Complexity of the task
• Problem solving and innovation are necessary to
  complete the task or activity
• Ability of the individual
• Fairness of the task

53

• TASK-RELATED CONCERNS

54
ACCOUNTABILITY

• Being answerable for the actions or omissions
  of self or others in the context of delegation.
• Accountable to
• Self
• Clients
• Employer
• Licensing Board
• Profession

55
NURSES ACCOUNTABILITY

• For Decision to delegate
• Ultimate accountability for the management and
  provision of nursing care
• Delegated task
• Client outcomes

56
ASSISTIVE PERSONNEL ACCOUNTABILITY
FOR

• Decision to accept delegation
• Performance

57
ASSISTIVE PERSONNEL ACCOUNTABILITY
TO

• Self
• Delegating Nurse
• Employer

58
PRIMARY CONCERN

• Does the individual assigned to the task have the
  ability to perform it?

59
OTHER TASK-RELATED CONCERNS

• Employees abilities
• Priority of various tasks
• Employees level of efficiency
• Appropriateness of the assigned task

60
RELATIONSHIP-ORIENTEDCONCERNS

• The RN should consider the following when
  assigning tasks to employees
• Fairness
• Learning opportunities
• Health
• Compatibility
• Preferences

61

• Is the workload evenly distributed
• One might have less physical work to do, yet
  have the work may require more emotional care
• Discuss with your team decisions you have made
  that may be considered unfair
• If possible, allow the team to participate in
  making decisions regarding assignments.

62

• Assign so your staff will be stimulated and
  motivated to learn
• Rotate your members through more difficult jobs
• Work at helping your team to develop better
  working relationships
• Explain your rationales and decisions

63
SUMMARY OF PROFESSIONALEXPECTATIONS

• Respect from others
• A reasonable workload
• Appropriate wages
• Determining his or her own priorities
• Ask for what he or she wants
• Be accountable
• Give and receive information in a professional
  manner

64

• DELEGATION
• BARRIERS

65
BARRIERS

• Level of experience
• Licensure
• Quality of care
• Having to assign work to others

66
REMEMBER-THE FIVE RIGHTS OFDELEGATION

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

67

• CONCLUSION

68
POINTS TO CONSIDER

• Delegation is not new.
• Delegation is essential for good working
  relationships.
• Organizational skills are a prerequisite for
  delegation.
• An understanding of patient needs is essential
  for appropriate delegation.

69
THE RN MUST UNDERSTAND

• The states Nurse Practice Act
• The capabilities of each staff member
• The tasks that may be delegated
• His or her accountability when delegating tasks

70
REMEMBER TO

• Communicate continuously
• Value all team member contributions
• Develop trust between co-workers
• Learn from experience