critical thinking delegation and missed care in nursing practice

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Critical Thinking, Delegation, and Missed Care in Nursing Practice

Bittner, Nancy Phoenix PhD, RN, CCRN; Gravlin, Gayle EdD, RN, NEAA-BC

Authors' Affiliations: Assistant Dean and Associate Professor(Dr Phoenix Bittner), School of Nursing and Health Professions, Regis College, Weston; and Associate Chief Nurse (Dr Gravlin), Nursing Education, Research, and Professional Development, Lahey Clinic, Burlington, Massachusetts.

Corresponding author: Dr Phoenix Bittner, Regis College, 235 Wellesley St, Weston, MA 02493 ( [email protected] ).

Objective: 

The aim of this study was to understand how nurses use critical thinking to delegate nursing care.

Background: 

Nurses must synthesize large amounts of information and think through complex and often emergent clinical situations when making critical decisions about patient care, including delegation.

Method: 

A qualitative, descriptive study was used in this article.

Findings: 

Before delegating, nurses reported considering patient condition, competency, experience, and workload of unlicensed assistive personnel (UAP). Nurses expected UAP to report significant findings and have higher level knowledge, including assessment and prioritizing skills. Successful delegation was dependent on the relationship between the RN and the UAP, communication, system support, and nursing leadership. Nurses reported frequent instances of missed or omitted routine care.

Conclusion: 

Findings from this project provide insight into factors that influence delegation effectiveness. These can guide CNOs and frontline nurse leaders to focus on implementing strategies to mitigate the consequence of missed care. Ineffective delegation of basic nursing care can result in poor patient outcomes, potentially impacting quality measures, satisfaction, and reimbursement for the institution.

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Critical Thinking, Delegation, and Missed Care in Nursing Practice

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• DOI: 10.1097/NNA.0b013e31819894b7
• Corpus ID: 32907664

Critical Thinking, Delegation, and Missed Care in Nursing Practice

• N. P. Bittner , Gayle Gravlin
• Published in Journal of Nursing… 1 March 2009

96 Citations

Nurses' and nursing assistants' reports of missed care and delegation, missed nursing care and its relationship with confidence in delegation among hospital nurses, perspectives of oncology unit nurse managers on missed nursing care: a qualitative study, the hidden ethical element of nursing care rationing, factors of missed nursing care in intensive care units, delegation skills: essential to the contemporary nurse, exploring sensitive nursing issues through focus group approaches, factors impacting delegation decision making by registered nurses to assistants in nursing in the acute care setting: a mixed method study., national guidelines for nursing delegation, rationing of nursing care and nurse-patient outcomes: a systematic review of quantitative studies., 12 references, understanding the cognitive work of nursing in the acute care environment, an analysis of nurses' cognitive work: a new perspective for understanding medical errors, thinking like a nurse: a research-based model of clinical judgment in nursing., understanding the complexity of registered nurse work in acute care settings, a qualitative study.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Five rights of nursing delegation.

Jennifer M. Barrow ; Sandeep Sharma .

Affiliations

Last Update: July 24, 2023 .

• Introduction

Many definitions for delegation exist in professional literature. One of the most commonly cited definitions of the word was jointly established by the American Nurses Association and the National Council of State Boards of Nursing. These groups describe delegation as the process for a nurse to direct another person to perform nursing tasks and activities. Delegation involves at least two individuals: the delegator, and the delegatee. The delegator is a registered nurse who distributes a portion of patient care to the delegatee.

Essential Components of Delegation

Responsibility

Based on individual states’ nurse practice acts, registered nurses have a professional duty to perform patient care tasks dependably and reliably.

Authority refers to an individual’s ability to complete duties within a specific role. This authority derives from nurse practice acts and organizational policies and job descriptions.

Accountability

Accountability within the nursing context refers to nursing professionals’ legal liability for their actions related to patient care. During delegation, delegators transfer responsibility and authority for completing a task to the delegatee; however, the delegator always maintains accountability for the task's completion. The registered nurse is always accountable for the overall outcome of delegated tasks based on each state's nurse practice act provisions.

Possible legal and ethical constraints arise regarding delegation in nursing. Therefore, the American Nurses Association developed the five rights of delegation to assist nurses in making safe decisions.

Five Rights of Delegation

• Right circumstance

Right person

• Right supervision
• Right direction and communication [1]
• Issues of Concern

Five Rights of Delegation Case Study Approach

Mark is a new graduate registered nurse who has recently completed nursing orientation. He is now on his second week of non-precepted practice on a busy medical-surgical unit. During the middle of his busy night shift, Mark has several tasks that need to be completed quickly. These tasks include a linen change for a patient who just vomited, an assessment of a possibly infiltrated intravenous line, and the administration of intravenous pain medication for a patient who rates her pain 10 out of 10. Mark also needs to make hourly rounds within the next few minutes, and he is very behind on his charting. He knows he must delegate some of the tasks to his coworkers. However, Mark is unsure what he can delegate and to whom. He decides to use the five rights of delegation to help with his delegation decisions.

Right tasks

First, Mark needs to determine which tasks are right to delegate. Some questions he may ask at this time would include (1) which tasks are legally appropriate to delegate and (2) can I delegate these tasks based on this organization’s policies and procedures? Correctly answering these questions will require familiarity with institutional and nurse practice act guidance. Generally, registered nurses are responsible for assessment, planning, and evaluation within the nursing process. These actions should not be delegated to someone who is not a registered nurse. [2]

Right circumstances

After determining the right tasks for delegation, Mark considers the right circumstances of delegation. In so doing, Mark may ask the following questions: (1) are appropriate equipment and resources available to perform the task, (2) does the delegatee have the right supervision to accomplish the task, and (3) is the environment favorable for delegation in this situation? To appropriately answer these questions, it is imperative that Mark completes an assessment on each client. Patients who are or may become unstable and cases with unpredictable outcomes are not good candidates for delegation. For example, it may be appropriate for unlicensed assistive personnel to feed patients requiring assistance with the activities of daily living. However, if a patient has a high risk for aspiration and a complicated specialty diet, delegation of feeding to unlicensed assistive personnel may not be safe.

If a task and circumstance are right for delegation, the next “right” of delegation is the right person. Mark needs to consider if the potential delegatees have the requisite knowledge and experience to complete delegated tasks safely, especially concerning the assessed patient acuity. Before delegating a task, the registered nurse must know the delegatee’s job description and previous training. Mark may be unsure about his potential delegatee’s qualifications. Therefore, he might ask the following questions before delegating a task: (1) have you received training to perform this task, (2) have you ever performed this task with a patient, (3) have you ever completed this task without supervision, and (4) what problems have you encountered in performing this task in the past?

Right supervision              

The right supervision must be available in all delegation situations. Nurse practice acts require the registered nurse to provide appropriate supervision for all delegated tasks. In the case study, Mark must be sure that the delegatee will provide feedback after the task is complete. Following task completion, Mark is responsible for evaluating the outcome of the task with the patient. Registered nurses are accountable for evaluation and the overall patient outcomes.

Right direction and communication                

Finally, the delegator must give the right direction and communication to the delegatee. All delegators must communicate performance expectations precisely and directly. [3] Mark should not assume that his delegatee knows what to do and how to do it, even for routine tasks. Mark must consider whether the delegatee understood the assigned task, directions, patient limitations, and expected outcomes before the delegatee assumes responsibility for it. The delegatee also must comprehend what, how, and when to report back after the delegated task is complete. Delegatees also need a deadline for task completion for time-sensitive tasks. [4]

Using the five rights of delegation, Mark appropriately took care of his patients’ needs. Mark delegated the linen change to trained unlicensed assistive personnel, and he entrusted his hourly rounds to his shift charge nurse. Mark opted to assess the patient with a possibly infiltrated intravenous site first. Upon finding the site infiltrated, he assessed his patient, removed the intravenous line, and placed a warm compress on the patient’s elevated extremity. He then administered another patient’s requested pain medications after delegating new intravenous catheter placement to an intravenous-certified coworker for the patient with the infiltration. Mark was able to complete all his documentation requirements by the end of his shift.

• Clinical Significance

Reasons Delegation is Necessary for the Modern Health Care Environment

If delegation decisions are so challenging and legally charged, why should nurses delegate? Fiscal constraints, nursing shortages, and increases in patient care complexity have cultivated an environment in which delegation is necessary. If appropriately used, delegation can significantly improve patient care outcomes.

Improper Delegation

Improper delegation can negatively impact patient care while also potentially exposing the delegator to legal action. [5] All members of the health care team have valuable contributions to make toward safe, effective patient care.

Essentials of Communication

While employing the five rights of delegation in nursing practice, it is important to remember that the way the delegator asks the delegatee to perform a task can make a big difference. The delegator must use direct, honest, open, closed-loop communication to encourage teamwork and safe task performance. [6] Of the five rights of delegation, the right communication and direction are arguably the most important in ensuring good quality and safety outcomes. [7] Common delegation deficiencies for registered nurses occur when delegating tasks to unlicensed assistive personnel. These include unclear delegation directions from the registered nurse, a lack of retained accountability and follow-through, and the failure of the registered nurse to obtain the agreement of the unlicensed assistive personnel. [8]

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Disclosure: Jennifer Barrow declares no relevant financial relationships with ineligible companies.

Disclosure: Sandeep Sharma declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Barrow JM, Sharma S. Five Rights of Nursing Delegation. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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National Guidelines for Nursing Delegation

• National Council of State Boards of Nursing
• evidence-based
• nursing assignment
• • Understand evidence-based, state-of-the-art standards for delegation.
• • Explain the differences between assignment and delegation and the responsibilities of the employer, nurse leader, delegating nurse, and delegatee in the process of delegation.

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Delegation Versus Assignment

• • A delegatee is allowed to perform a specific nursing activity, skill, or procedure that is outside the traditional role and basic responsibilities of the delegatee’s current job.
• • The delegatee has obtained the additional education and training, and validated competence to perform the care/delegated responsibility. The context and processes associated with competency validation will be different for each activity, skill, or procedure being delegated. Competency validation should be specific to the knowledge and skill needed to safely perform the delegated responsibility as well as to the level of practitioner (i.e., RN, LPN/VN, UAP) to whom the activity, skill, or procedure has been delegated.
• • The licensed nurse who delegates the “responsibility” maintains overall accountability for the patient. However, the delegatee bears the responsibility for the delegated activity, skill, or procedure.
• • The licensed nurse cannot delegate nursing judgment or any activity that will involve nursing judgment or critical decision making.
• • Nursing responsibilities are delegated by someone who has the authority to delegate.
• • The delegated responsibility is within the delegator’s scope of practice.
• • When delegating to a licensed nurse, the delegated responsibility must be within the parameters of the delegatee’s authorized scope of practice under the NPA.
• • The routine care, activities, and procedures that are within the authorized scope of practice of the RN or LPN/VN or part of the routine functions of the UAP
• • The above are included in the coursework taught in the delegatee’s basic educational program.
• • Certified medication aides taught to pass out medications
• • Certified medical assistants taught to give injections.

Additional Key Definitions

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Literature Review

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• Bittner N.P.
• Scopus (72)
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• Anderson R.A.
• Hunt-McKinney S.
• Full Text PDF
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Guidelines for Delegation

• • APRNs when delegating to RNs, LPN/VNs, and UAP
• • RNs when delegating to LPN/VNs and UAP
• • LPN/VNs (as allowed by their state/jurisdiction) when delegating to UAP.
• Agency for Healthcare Research and Quality

Employer/Nurse Leader Responsibilities

• 1. The employer must identify a nurse leader responsible for oversight of delegated responsibilities for the facility . If there is only one licensed nurse within the practice setting, that licensed nurse must be responsible for oversight of delegated responsibilities for the facility.
• 2. The designated nurse leader responsible for delegation, ideally with a committee (consisting of other nurse leaders) formed for the purposes of addressing delegation, must determine which nursing responsibilities may be delegated, to whom, and under what circumstances . The nurse leader must be aware of the state/jurisdiction’s NPA and the laws/rules and regulations that affect the delegation process and ensure all institution policies are in accordance with the law.
• 3. Policies and procedures for delegation must be developed . The employer/nurse leader must outline specific responsibilities that can be delegated and to whom these responsibilities can be delegated. The policies and procedures should also indicate what may not be delegated. The employer must periodically review the policies and procedures for delegation to ensure they remain consistent with current nursing practice trends and that they are consistent with the state/jurisdiction’s NPA (institution/employer policies can be more restrictive, but not less restrictive).
• 4. The employer/nurse leader must communicate information about delegation to the licensed nurses and UAP and educate them about what responsibilities can be delegated . This information should include the competencies of delegatees who can safely perform a specific nursing responsibility.
• 5. All delegatees must demonstrate knowledge and competency on how to perform a delegated responsibility . Therefore, the employer/nurse leader is responsible for providing access to training and education specific to the delegated responsibilities. This applies to all RNs, LPN/VNs, and UAP who will be delegatees. Competency validation should follow education and competency testing should be kept on file. Competency must be periodically evaluated to ensure continued competency. The context and processes associated with competency validation will be different for each activity, skill, or procedure being delegated. Competency validation should be specific to the knowledge and skill needed to safely perform the delegated responsibility as well as to the level of practitioner (i.e., RN, LPN/VN, UAP) to whom the activity, skill, or procedure has been delegated.
• 6. The nurse leader responsible for delegation, along with other nurse leaders and administrators within the facility, must periodically evaluate the delegation process . The licensed nurse and/or his or her manager (if applicable) must report any incidences to the nurse leader responsible for delegation. A decision should be made about corrective action, including whether further education and training are needed or whether that individual should not be allowed to perform a specific delegated responsibility.
• 7. The employer/nurse leader must promote a positive culture and work environment for delegation.

Licensed Nurse Responsibilities

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• 2. The licensed nurse must communicate with the delegatee who will be assisting in providing patient care . This should include reviewing the delegatee’s assignment and discussing delegated responsibilities, including information on the patient’s condition/stability, any specific information pertaining to a certain patient (e.g., no blood draws in the right arm), and any specific information about the patient’s condition that should be communicated back to the licensed nurse by the delegatee.
• 3. The licensed nurse must be available to the delegatee for guidance and questions, including assisting with the delegated responsibility, if necessary, or performing it him/herself if the patient’s condition or other circumstances warrant doing so .
• 4. The licensed nurse must follow up with the delegatee and the patient after the delegated responsibility has been completed .
• 5. The licensed nurse must provide feedback information about the delegation process and any issues regarding delegatee competence level to the nurse leader . Licensed nurses in the facility need to communicate, to the nurse leader responsible for delegation, any issues arising related to delegation and any individual that they identify as not being competent in a specific responsibility or unable to use good judgment and decision making.

Delegatee Responsibilities

• 1. The delegatee must accept only the delegated responsibilities that he or she is appropriately trained and educated to perform and feels comfortable doing given the specific circumstances in the health care setting and patient’s condition . The delegatee should confirm acceptance of the responsibility to carry out the delegated activity. If the delegatee does not believe he or she has the appropriate competency to complete the delegated responsibility, then the delegatee should not accept the delegated responsibility. This includes informing the hospital leadership if he or she does not feel he or she has received adequate training to perform the delegated responsibility, is not performing the procedure frequently enough to do it safely, or his or her knowledge and skills need updating.
• 2. The delegatee must maintain competency for the delegated responsibility .
• 3. The delegatee must communicate with the licensed nurse in charge of the patient . This includes any questions related to the delegated responsibility and follow-up on any unusual incidents that may have occurred while the delegatee was performing the delegated responsibility, any concerns about a patient’s condition, and any other information important to the patient’s care.
• 4. Once the delegatee verifies acceptance of the delegated responsibility, the delegatee is accountable for carrying out the delegated responsibility correctly and completing timely and accurate documentation per facility policy . The delegatee cannot delegate to another individual. If the delegatee is unable to complete the responsibility or feels as though he or she needs assistance, the delegatee should inform the licensed nurse immediately so the licensed nurse can assess the situation and provide support. Only the licensed nurse can determine if it is appropriate to delegate the activity to another individual. If at any time the licensed nurse determines he or she needs to perform the delegated responsibility, the delegatee must relinquish responsibility upon request of the licensed nurse.

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Provider accreditation

• a. Nurses are accountable for predicting adverse outcomes.
• b. Unlicensed assistive personnel (UAP) must accept any delegated nursing activity.
• c. UAP work under the license of the delegating nurse.
• d. Nurses cannot delegate any element of the nursing process.
• a. Right reason
• b. Right person
• c. Right task
• d. Right communication
• a. Communication and collaboration
• b. Licensure and experience
• c. Training and authorization
• d. Certification and endorsement
• a. Any licensed nurse can delegate and supervise unlicensed assistive personnel (UAP).
• b. Only registered nurses can delegate and supervise UAP.
• c. All states prohibit licensed practical/vocational nurses (LPN/VNs) from delegating and supervising.
• d. Some states prohibit LPN/VNs from delegating and supervising UAP
• a. Shortage of training programs for unlicensed assistive personnel (UAP)
• b. Variation in roles and responsibilities of UAP
• c. Inconsistent use of a decision tree for delegation
• d. Lack of standardized patient handoffs
• a. Unlicensed assistive personnel (UAP) can delegate to other UAP
• b. Licensed practical/vocational nurses (LPN/VNs) can delegate to registered nurses (RNs) and UAP
• c. RNs can delegate to advanced practice registered nurses (APRNs), LPN/VNs, and UAP.
• d. APRNs can delegate to RNs, LPN/VNs, and UAP.
• a. Supervision
• b. Delegation
• c. Responsibility
• d. Accountability
• a. Delegation
• b. Supervision
• c. Assignment
• d. Authorization
• a. The health care provider
• b. The health care employer
• c. The nurse leader
• d. The nurse who delegates the activity
• a. Ensuring appropriate policies and procedures regarding delegation are in place
• b. Ensuring adequate staffing
• c. Establishing scope of practice guidelines for unlicensed assistive personnel
• d. Promoting and maintaining a positive culture
• a. Ask the UAP to observe and learn how to perform the skill
• b. Perform the activity himself or herself
• c. Contact the nursing supervisor
• d. Consult another nurse
• a. By observing the delegatee perform the activity
• b. By encouraging autonomy, creativity, and self-discipline
• c. By providing support, guidance, and instructions
• d. By assessing the staff member’s knowledge, skills, and abilities

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After being developed, the guidelines were vetted by the state boards of nursing and national nursing leaders across the United States. They were approved by the NCSBN Board of Directors.

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DOI: https://doi.org/10.1016/S2155-8256(16)31035-3

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Delegation in Nursing: How to Build a Stronger Team

5 min read • September, 07 2023

If you want something done right, you need to do it together. As a nurse leader, it can often feel like you have too many tasks on your plate and need more time to complete them all safely and effectively. That's where delegation in nursing comes in.

Keep in mind that delegating tasks isn't the same as assigning them. Assigning a task refers to giving a specific responsibility to a team member with the skill set to accomplish it safely and effectively. Examples include taking vitals, documenting patient information, and administering meds. When nurses assign a task, they're ultimately responsible for its outcome.

So, what is delegation in nursing, and how does it differ? When you delegate a task, you transfer accountability to a qualified team member to safely perform a specific task or activity. A registered nurse may delegate certain functions to a Licensed Practical Nurse (LPN), Unlicensed Assistive Personnel (UAP), or other licensed healthcare member on the team. That person assumes the authority to make decisions. However, the person who delegated the task is still responsible for the overall process and should offer guidance, support, and an honest assessment of the individual's performance.

Why Is Delegation Important in Nursing?

Registered nurses have many responsibilities. Nursing shortages, technological advances, increasing complexity in patient care, and continuous changes in healthcare have made delegating in nursing essential. This time-management skill can help ensure your patients are safely cared for — and may improve outcomes if used appropriately. Nurturing your delegation skills isn't only useful for you but also for your patients and your staff.

Potential benefits of delegation in nursing include:

• Empowering employees
• Decreasing burnout
• Increasing commitment
• Improving job satisfaction

When you delegate, you show your staff that their talents and contributions are valuable to the team, your patients, and the organization. By trusting them, your employees will likely take on greater responsibilities and be more willing to learn new skills to enhance their professional growth.

Delegating Tasks in Nursing

Delegating requires you to entrust the authority and responsibility of a specific task to other staff members. Before delegating, consider the type of care needed, the circumstances, staff competence, and the functions permitted within each staff member's scope of practice. Effective communication and critical thinking skills are necessary to  determine how and what to delegate .

How to Improve Delegation Skills

Effective delegation is a skill that can take time to master, but it's essential for effective leadership and staff growth. Fortunately, ANA developed  Principles for Delegation by Registered Nurses to Unlicensed Assistive Personnel (UAP) . This document provides strategies for RNs to draw from when determining which tasks to delegate.

The  Five Rights of Delegation  Include:

1. Right task Consider which tasks are legally appropriate to delegate and permitted by your organization's policies. Not all tasks can be delegated. If there isn't a designee with the proper skill set, you could open yourself up to mistakes and safety issues. Avoid delegating tasks that:

• Require specific nursing judgment and decision-making skills
• Fall outside the caregiver's scope of practice, the nurse practice act, or state regulations
• Violate the organization's policies and procedures
• Expose private or personal information about co-workers or patients that should not be shared

2. Right circumstance Assess the care complexity of the patient’s needs before delegating the task to ensure appropriate resources, equipment, and supervision are available. For example, if the patient is at high risk for aspiration, a task such as feeding them may not be appropriate to delegate to a UAP.

3. Right person Identify and match the individual who can best complete the job based on ability. Validate their capabilities by determining if they have the knowledge, skills, and time to complete the task. You can evaluate their confidence level by asking if they've encountered problems in the past while performing the job and if they've completed it without supervision.

4. Right supervision The Nursing Practice Act requires you to provide appropriate supervision for all tasks delegated to your team members. Make sure they give you feedback after each job gets completed. Remember, you're responsible for evaluating the outcome of these tasks and overall patient outcomes.

5. Right direction and communication Clear communication is essential to ensure the designated individual understands the delegated task. They need to know what it entails, when it needs to be completed, details regarding documentation, and what the patient's limitations and expected outcomes are. Confirm these factors before allowing the staff member to assume responsibility. Assure them they can complete the delegated task successfully and safely, offer advice and support, and emphasize the opportunity for growth.

Evaluate and Provide Feedback

Once a task has been completed, evaluate the outcome and identify areas for improvement. Share feedback with the team member and acknowledge their achievements while providing constructive feedback.

Effective delegation involves ongoing collaboration, communication, and trust. You can deliver safe, quality care that benefits your staff, patients, and the organization by evaluating outcomes and making necessary adjustments.

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Developing Delegation Skills

Published: 31 March 2020

There is no doubt that delegation skills are needed in healthcare. At its worst, delegation can be used as a form of abdication, but at its best, delegation can provide enormous benefits resulting from the optimum use of human resources (Wheeler 2001).

What Does it Mean to Delegate?

Gillen and Graffin (2010) suggest that several definitions of delegation can be found within nursing literature, but they all share the same emphasis - that even though the work is done by a junior member of staff, the accountability and responsibility remain with the delegator, who needs to ensure the work is assigned appropriately.

As the Royal College of Nursing (2015) clearly states, nurses must be accountable for their decisions to delegate tasks and duties to other people. For the delegating nurse, this means:

• You must establish that anyone you delegate to can carry out your instruction.
• You must confirm that the outcome of any delegated task meets the required standards
• You must make sure that everyone you are responsible for is supervised and supported.

Delegation should also only take place when it is in the best interests of the person receiving the care, and when a holistic assessment of need has been undertaken by the nurse who delegates. Employers also have a responsibility to ensure that practitioners to whom nurses delegate tasks have the appropriate education, training and skills to carry out those tasks.

However, the nurse who delegates the task retains the responsibility to judge the appropriateness of the delegation by:

• Reassessing the condition of the patient at appropriate intervals and determining that it remains stable and predictable
• Observing the competence of the caregiver and determining that they remain competent to perform the delegated task safely and effectively
• Evaluating whether or not to continue delegation of the task.

Essential Components of Delegation

Matching the right person with the right expertise for the right job is a complex professional skill requiring sophisticated clinical judgment and the willingness to have final accountability for patient care (Weydt 2010). Yet, done well, delegation can significantly improve patient care outcomes.

Barrow and Sharma (2019) note the need for the three key components of responsibility, authority and accountability to be in place if delegation is going to be successful. They describe the ' five rights of delegation ' as:

• Right circumstance
• Right person
• Right supervision
• Right direction and communication.

Others in the wider team must also be informed of the delegation, whilst the delegator should provide ongoing evaluation so that any difficulties can be eliminated (Eveleigh 2018).

How to Delegate Safely

In theory, the delegation of roles and responsibilities should be a win-win situation, creating manageable workloads while also providing patients with the care they need.

For delegation to be safe and successful, the tasks allocated must be appropriate for the skill level of the delegate. In addition to having the necessary skills and experience to work safely, they must also be able to show that they have clearly understood the task. Furthermore, they must be adequately supervised and supported to ensure a high standard of care.

As Eveleigh (2018) notes, if these elements are in place, the practitioner is not accountable for the decisions and actions of the person performing the delegated task. The person delegated then becomes accountable because:

• They have the ability (knowledge and skills) to undertake the activity or intervention
• They accept the responsibility for performing the activity
• They have the authority to perform the activity because it is within their job description
• They take social, ethical, legal and contractual accountability and are responsible for the tasks they accept.

Eveleigh (2018) also offers the following checklist to help practitioners decide if it is safe to delegate:

• Is it in the patient’s best interests to delegate this duty to another member of staff?
• Have you considered the wider situation and not just the duty itself?
• Have you thought about the clinical risks?
• Do you have the authority and appropriate clinical knowledge to delegate the duty?
• Does the person you are delegating to have the appropriate knowledge, skills and competence to perform the task?
• Does the duty lie within the other person’s job description?
• Can you provide support and supervision to the other person?
• Can you check that the outcome meets the required clinical standard?

Barriers to Delegation

The three key elements in the act of delegation include the delegator , the delegate , and finally, the situational context .

As Gillen and Graffin (2010) make clear, any of these elements, or a combination of any of them, can become a barrier to the delegation process, though most can be overcome with effective education and training. For example:

Barriers relating to delegators include:

• Their preference to work alone
• Lack of experience or insecurity
• Lack of confidence in subordinates
• Desire for control
• Lack of organisational or managerial skills
• Unwillingness to develop subordinates and help them grow in their roles.

Barriers that may arise from the perspective of the delegated practitioner include:

• Lack of experience
• Lack of competence
• Avoidance of responsibility
• Lack of organisational skills
• Excessive amounts of work.

Barriers that may arise as a result of the situational context include:

• The critical nature of decisions
• The urgency of those decisions
• Confusion relating to responsibility
• Authority and understaffing.

Critical Thinking Skills

Delegation and critical thinking skills naturally go hand-in-hand. They both require nurses to process large amounts of information and think through complex and often emergent clinical situations whilst making critical decisions about patient care, including delegation.

To gain a better understanding of this process, Bittner and Gravlin (2009) conducted a study to investigate how nurses use critical thinking to delegate care. They found that before delegating, nurses reported considering the patient’s condition, competency and experience, and the workload of the junior member of staff. They also expected the delegating nurse to report significant findings and have higher-level knowledge, including assessment and prioritising skills.

Yet, whilst all of these qualities are important, the real key to successful delegation was the relationship between the delegating nurse and the person assigned the task. In other words, successful delegation was ultimately about good communication and nursing leadership. Even so, Bittner and Gravlin (2009) reported that there were frequent instances of missed or omitted routine care that had been delegated.

Like anything else, delegation skills have to be practised to be perfected. Otherwise, standards of care can suffer and valuable resources mismanaged. As Weydt (2010) notes, resources will surely continue to shrink and care demands will surely continue to rise, increasing the risks of inappropriate delegation.

Knowing when, how and to whom you can delegate requires a deep understanding of the task at hand, as well as confidence in the process of delegation. All of this has to be balanced with the skills, experience and existing workloads of the people available.

Achieving the right balance is crucial because delegating too much may result in a loss of control while failing to delegate or not delegating enough can lead to missed or inadequate care and a demotivated or uncooperative team (Wheeler 2001). Yet, when delegation is done well, everybody wins .

• Bittner, N & Gravlin, G 2009, 'Critical Thinking, Delegation, and Missed Care in Nursing Practice', JONA: The Journal of Nursing Administration , vol. 39 no. 3, pp.142-146, viewed 28 March 2020, https://journals.lww.com/jonajournal/Abstract/2009/03000/Critical_Thinking,_Delegation,_and_Missed_Care_in.10.aspx
• Eveleigh, M 2018, 'Safe Delegation Techniques For Practice Nurses', Nursing in Practice , 1 August, viewed 28 March 2020, https://www.nursinginpractice.com/professional/safe-delegation-techniques-for-practice-nurses/
• Gillen, P & Graffin, S 2010, 'Nursing Delegation in the United Kingdom', The Online Journal of Issues in Nursing , vol. 15 no. 2, viewed 28 March 2020 http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No2May2010/Delegation-in-the-United-Kingdom.html
• Royal College Of Nursing 2015, Accountability and Delegation , RCN, viewed 28 March 2020, https://www.rcn.org.uk/professional-development/accountability-and-delegation
• Weydt, A 2010, 'Developing Delegation Skills', The Online Journal of Issues In Nursing , vol. 15 no. 2, viewed 28 March 2020, https://ojin.nursingworld.org/table-of-contents/volume-15-2010/number-2-may-2010/delegation-skills/
• Wheeler, J 2001, 'How to Delegate Your Way to a Better Working Life', Nursing Times , vol. 97 no. 36, p.34., viewed 28 March 2020, https://www.nursingtimes.net/roles/nurse-managers/how-to-delegate-your-way-to-a-better-working-life-06-09-2001/

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Critical thinking, delegation, and missed care in nursing practice.

• Clinical Competence
• Communication
• Decision Making
• Health Knowledge, Attitudes, Practice
• Nursing Assessment
• Nursing Process
• Patient Care
• Gayle Lorraine Gravlin EdD, RN, NEA-BC

APRN National Guidelines for Nursing Delegation

National Guidelines for Nursing Delegation

Effective Date: 04/01/2019 Status: Replaces ANA 2010 Written by: ANA – NCSBN Jointly Adopted by: ANA Board of Directors / NCSBN Board of Directors

I. Purpose Delegation is an essential nursing skill. Building on previous work of National Council of State Boards of Nursing (NCSBN) and the American Nurses Association (ANA), this joint statement reflects an effort to standardize the nursing delegation process based on research findings and evidence in the literature and is applicable to all levels of nursing licensure (advanced practice registered nurse [APRN], registered nurse [RN], licensed practical/vocational nurse [LPN/VN]) where the nurse practice act (NPA) is silent. These guidelines can be applied to: • APRNs when delegating to RNs, LPN/VNs and assistive personnel (AP) • RNs when delegating to LPN/VNs and AP • LPN/VNs (as allowed by their state/ jurisdiction ) when delegating to AP. Note: These guidelines do not apply to the transfer of responsibility for care of a patient between licensed health care providers (e.g., RN to another RN or LPN/VN to another LPN/VN), which is considered a handoff (Agency for Healthcare Research and Quality, 2015).

Introduction Health care is continuously changing and necessitates adjustment for evolving roles and responsibilities of licensed health care providers and assistive personnel. The abilities to delegate, assign and supervise are critical competencies for every RN. It is important to note that states/ jurisdictions have different laws and rules/ regulations about delegation, and it is the responsibility of all licensed nurses to know what is permitted in their state. When certain nursing care needs to be delegated, it is imperative that the delegation process and the state NPA be clearly understood so that it is safely, ethically and effectively carried out. The decision of whether or not to delegate or assign is based upon the RN’s judgement 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. The difference between delegation and assignment has been a source of debate for years. Definitions

Accountability: “To be answerable to oneself and others for one’s own choices, decisions and actions as measured against a standard…” (American Nurses Association, 2015, p. 41).

Delegated Responsibility: A nursing activity, skill or procedure that is transferred from a licensed nurse to a delegatee.

Delegatee: One who is delegated a nursing responsibility by either an APRN, RN or LPN/VN (where states NPA allows), is competent to perform it and verbally accepts the responsibility. A delegatee may be an RN, LPN/VN or AP.

Delegator: One who delegates a nursing responsibility. A delegator may be APRN, RN, or LPN/VN (where state NPA allows).

Assignment: The routine care, activities and procedures that are within the authorized scope of practice of the RN or LPN/VN or part of the routine functions of the AP.

Licensed Nurse: A licensed nurse includes APRNs, RNs and LPN/VNs. In some states/jurisdictions, LPN/ VNs may be allowed to delegate.

Assistive Personnel (AP): Any assistive personnel trained to function in a supportive role, regardless of title, to whom a nursing responsibility may be delegated. This includes but is not limited to certified nursing assistants or aides (CNAs), patient care technicians, CMAs, certified medication aids, and home health aides (formerly referred to as ‘‘unlicensed” assistive personnel [UAP]).

When performing a fundamental skill on the job, the delegatee is considered to be carrying out an assignment. The routine care, activities and procedures assigned are those which would have been included in the delegatee’s basic educational program. A licensed nurse is still responsible for ensuring an assignment is carried out completely and correctly. Delegation is allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and not routinely performed. This applies to licensed nurses as well as AP. Regardless of the current role of the delegatee (RN, LPN/ VN or AP), delegation can be summarized as follows: • A delegatee is allowed to perform a specific nursing activity, skill or procedure that is outside the traditional role and basic responsibilities of the delegatee’s current job. • The delegatee has obtained the additional education and training, and validated competence to perform the care/delegated responsibility. The context and processes associated with competency validation will be different for each activity, skill or procedure being delegated. Competency validation should be specific to the knowledge and skill needed to safely perform the delegated responsibility as well as to the level of practitioner (i.e., RN, LPN/VN, AP) to whom the activity, skill or procedure has been delegated. The licensed nurse who delegates the “responsibility” maintains overall accountability for the patient. However, the delegatee bears the responsibility for the delegated activity, skill or procedure.

Page 2 of 10 • The licensed nurse cannot delegate nursing judgment or any activity that will involve nursing judgment or critical decision making. • Nursing responsibilities are delegated by someone who has the authority to delegate. • The delegated responsibility is within the delegator’s scope of practice. • When delegating to a licensed nurse, the delegated responsibility must be within the parameters of the delegatee’s authorized scope of practice under the NPA. Regardless of how the state/jurisdiction defines delegation, as compared to assignment, appropriate delegation allows for transition of a responsibility in a safe and consistent manner. Clinical reasoning, nursing judgement and critical decision making cannot be delegated. The delegation process is multifaceted. It begins with the administrative level of the organization including: determining nursing responsibilities that can be delegated, to whom, and what circumstances; developing delegation policies and procedures; periodically evaluating delegation processes; promoting positive culture/ work environment. Then the licensed nurse must be responsible for determining patient needs and when to delegate, ensure availability to delegate, evaluate outcomes of and maintain accountability for delegated responsibility. Finally, the delegatee must accept activities based on their competency level, maintain competence for delegated responsibility and maintain accountability for delegated activity.

Page 3 of 10 Five Rights of Delegation

Right task: The activity falls within the delegatee’s job description or is included as part of the established written policies and procedures of the nursing practice setting. The facility needs to ensure the policies and procedures describe the expectations and limits of the activity and provide any necessary competency training.

Right circumstance: The health condition of the patient must be stable. If the patient’s condition changes, the delegatee must communicate this to the licensed nurse, and the licensed nurse must reassess the situation and the appropriateness of the delegation.

Right person: The licensed nurse along with the employer and the delegatee is responsible for ensuring that the delegatee possesses the appropriate skills and knowledge to perform the activity.

Right directions and communication: Each delegation situation should be specific to the patient, the licensed nurse and the delegatee. The licensed nurse is expected to communicate specific instructions for the delegated activity to the delegatee; the delegatee, as part of two-way communication, should ask any clarifying questions. This communication includes any data that need to be collected, the method for collecting the data, the time frame for reporting the results to the licensed nurse, and additional information pertinent to the situation. The delegatee must understand the terms of the delegation and must agree to accept the delegated activity. The licensed nurse should ensure that the delegatee understands that she or he cannot make any decisions or modifications in carrying out the activity without first consulting the licensed nurse.

Right supervision and evaluation: The licensed nurse is responsible for monitoring the delegated activity, following up with the delegatee at the completion of the activity, and evaluating patient outcomes. The delegatee is responsible for communicating patient information to the licensed nurse during the delegation situation. The licensed nurse should be ready and available to intervene as necessary. The licensed nurse should ensure appropriate documentation of the activity is completed.

Source: NCSBN. (1995, 1996)

Page 4 of 10 Guidelines for Delegation Employer/Nurse Leader Responsibilities

1. The employer must identify a nurse leader responsible for oversight of delegated responsibilities for the facility. If there is only one licensed nurse within the practice setting, that licensed nurse must be responsible for oversight of delegated responsibilities for the facility.

Rationale: The nurse leader has the ability to assess the needs of the facility, understand the type of knowledge and skill needed to perform a specific nursing responsibility, and be accountable for maintaining a safe environment for patients . He or she is also aware of the knowledge, skill level and limitations of the licensed nurses and AP. Additionally, the nurse leader is positioned to develop appropriate staffing models that take into consideration the need for delegation. Therefore, the decision to delegate begins with a thorough assessment by a nurse leader designated by the institution to oversee the process.

2. The designated nurse leader responsible for delegation, ideally with a committee (consisting of other nurse leaders) formed for the purposes of addressing delegation, must determine which nursing responsibilities may be delegated, to whom and under what circumstances. The nurse leader must be aware of the state/jurisdiction’s NPA and the laws/rules and regulations that affect the delegation process and ensure all institution policies are in accordance with the law .

Rationale: A systematic approach to the delegation process fosters communication and consistency of the process throughout the facility.

3. Policies and procedures for delegation must be developed. The employer/nurse leader must outline specific responsibilities that can be delegated and to whom these responsibilities can be delegated. The policies and procedures should also indicate what may not be delegated. The employer must periodically review the policies and procedures for delegation to ensure they remain consistent with current nursing practice trends and that they are consistent with the state/jurisdiction’s NPA (institution/employer policies can be more restrictive, but not less restrictive).

Rationale: Policies and procedures standardize the appropriate method of care and ensure safe practices. Having a policy and procedure specific to delegation and delegated responsibilities eliminates questions from licensed nurses and AP about what can be delegated and how they should be performed.

4. The employer/nurse leader must communicate information about delegation to the licensed nurses and AP and educate them about what responsibilities can be delegated. This information should include the competencies of delegatees who can safely perform a specific nursing responsibility.

Rationale: Licensed nurses must be aware of the competence level of staff and expectations for delegation (as described within the policies and procedures) in order to make informed decisions on whether or not delegation is appropriate for the given situation. Licensed nurses maintain accountability for the patient. However, the delegatee has responsibility for the delegated activity, skill or procedure.

Page 5 of 10 Employer/Nurse Leader Responsibilities (continued)

5. All delegatees must demonstrate knowledge and competency on how to perform a delegated responsibility. Therefore, the employer/nurse leader is responsible for providing access to training and education specific to the delegated responsibilities. This applies to all RNs, LPN/VNs and AP who will be delegatees. Competency validation should follow education and competency testing should be kept on file. Competency must be periodically evaluated to ensure continued competency. The context and processes associated with competency validation will be different for each activity, skill or procedure being delegated. Competency validation should be specific to the knowledge and skill needed to safely perform the delegated responsibility as well as to the level of practitioner (i.e., RN, LPN/VN, AP) to whom the activity, skill, or procedure has been delegated.

Rationale: This ensures that competency of the delegatee is determined not only at the beginning of the delegation process, but on an ongoing basis, as well.

6. The nurse leader responsible for delegation, along with other nurse leaders and administrators within the facility, must periodically evaluate the delegation process. The licensed nurse and/or his or her manager (if applicable) must report any incidences to the nurse leader responsible for delegation. A decision should be made about corrective action, including if further education and training are needed, or if that individual should not be allowed to perform a specific delegated responsibility.

Rationale: Patient safety should always be the priority for a health care setting. If any compromises in care are noted, immediate action must be taken. Gravlin and Bittner (2010) identified that evaluation of the effectiveness of the delegation process and resolution of any issues is critical to delegation.

7. The employer/nurse leader must promote a positive culture and work environment for delegation.

Rationale: A positive culture nurtures effective communication and collaboration in order to create an environment supportive of patient directed care.

Page 6 of 10 Licensed Nurse Responsibilities

Any decision to delegate a nursing responsibility must be based on the needs of the patient or population, the stability and predictability of the patient’s condition, the documented training and competence of the delegatee, and the ability of the licensed nurse to supervise the delegated responsibility and its outcome, with special consideration to the available staff mix and patient acuity. Additionally, the licensed nurse must consider the state/jurisdiction’s provisions for delegation and the employer’s policies and procedures prior to making a final decision to delegate. Licensed nurses must be aware that delegation is at the nurse’s discretion, with consideration of the particular situation. The licensed nurse maintains accountability for the patient, while the delegatee is responsible for the delegated activity, skill or procedure. If, under the circumstances, a nurse does not feel it is appropriate to delegate a certain responsibility to a delegatee, the delegating nurse should perform the activity him/herself.

1. The licensed nurse must determine when and what to delegate based on the practice setting, the patients’ needs and condition, the state/jurisdiction’s provisions for delegation, and the employer policies and procedures regarding delegating a specific responsibility. The licensed nurse must determine the needs of the patient and whether those needs are matched by the knowledge, skills and abilities of the delegatee and can be performed safely by the delegatee. The licensed nurse cannot delegate any activity that requires clinical reasoning, nursing judgment or critical decision making. The licensed nurse must ultimately make the final decision whether an activity is appropriate to delegate to the delegatee based on the Five Rights of Delegation (NCSBN, 1995, 1996).

Rationale: The licensed nurse, who is present at the point of care, is in the best position to assess the needs of the patient and what can or cannot be delegated in specific situations.

2. The licensed nurse must communicate with the delegatee who will be assisting in providing patient care. This should include reviewing the delegatee’s assignment and discussing delegated responsibilities, including information on the patient’s condition/stability, any specific information pertaining to a certain patient (e.g., no blood draws in the right arm), and any specific information about the patient’s condition that should be communicated back to the licensed nurse by the delegatee.

Rationale: Communication must be a two-way process involving both the licensed nurse delegating the activity and the delegatee being delegated the responsibility. Evidence shows that the better the communication between the nurse and the delegatee, the more optimal the outcome (Corazzini, Anderson, Mueller, Hunt-McKinney et al., 2013). The licensed nurse must provide information about the patient and care requirements. This includes any specific issues related to any delegated responsibilities. These instructions should include any unique patient requirements. The licensed nurse must instruct the delegatee to regularly communicate the status of the patient.

Page 7 of 10 Licensed Nurse Responsibilities (continued)

3. The licensed nurse must be available to the delegatee for guidance and questions, including assisting with the delegated responsibility, if necessary, or performing it him/herself if the patient’s condition or other circumstances warrant doing so.

Rationale: Delegation calls for nursing judgment throughout the process. The final decision to delegate rests in the hands of the licensed nurse as he or she has overall accountability for the patient.

4. The licensed nurse must follow up with the delegatee and the patient after the delegated responsibility has been completed.

Rationale: The licensed nurse who delegates the “responsibility” maintains overall accountability for the patient, while the delegatee is responsible for the delegated activity, skill or procedure.

5. The licensed nurse must provide feedback information about the delegation process and any issues regarding delegatee competence level to the nurse leader. Licensed nurses in the facility need to communicate, to the nurse leader responsible for delegation, any issues arising related to delegation and any individual that they identify as not being competent in a specific responsibility or unable to use good judgment and decision making.

Rationale: This will allow the nurse leader responsible for delegation to develop a plan to address the situation.

Delegatee Responsibilities

Everyone is responsible for the well-being of patients. While the nurse is ultimately accountable for the overall care provided to a patient, the delegatee shares the responsibility for the patient and is fully responsible for the delegated activity, skill or procedure.

1. The delegatee must accept only the delegated responsibilities that he or she is appropriately trained and educated to perform and feels comfortable doing given the specific circumstances in the health care setting and patient’s condition. The delegatee should confirm acceptance of the responsibility to carry out the delegated activity. If the delegatee does not believe he or she has the appropriate competency to complete the delegated responsibility, then the delegatee should not accept the delegated responsibility. This includes informing the nursing leadership if he or she does not feel he or she has received adequate training to perform the delegated responsibility, is not performing the procedure frequently enough to do it safely, or his or her knowledge and skills need updating.

Rationale: The delegatee shares the responsibility to keep patients safe and this includes only performing activities, skills or procedures in which he or she is competent and comfortable doing.

Page 8 of 10 Delegatee Responsibilities (continued)

2. The delegatee must maintain competency for the delegated responsibility.

Rationale: Competency is an ongoing process. Even if properly taught, the delegatee may become less competent if he or she does not frequently perform the procedure. Given that the delegatee shares the responsibility for the patient, the delegatee also has a responsibility to maintain competency.

3. The delegatee must communicate with the licensed nurse in charge of the patient. This includes any questions related to the delegated responsibility and follow-up on any unusual incidents that may have occurred while the delegatee was performing the delegated responsibility, any concerns about a patient’s condition, and any other information important to the patient’s care.

Rationale: The delegatee is a partner in providing patient care. He or she is interacting with the patient/family and caring for the patient. This information and two-way communication is important for successful delegation and optimal outcomes for the patient.

4. Once the delegatee verifies acceptance of the delegated responsibility, the delegatee is accountable for carrying out the delegated responsibility correctly and completing timely and accurate documentation per facility policy. The delegatee cannot delegate to another individual. If the delegatee is unable to complete the responsibility or feels as though he or she needs assistance, the delegatee should inform the licensed nurse immediately so the licensed nurse can assess the situation and provide support. Only the licensed nurse can determine if it is appropriate to delegate the activity to another individual. If at any time the licensed nurse determines he or she needs to perform the delegated responsibility, the delegatee must relinquish responsibility upon request of the licensed nurse.

Rationale: Only a licensed nurse can delegate. In addition, because they are responsible, they need to provide direction, determine who is going to carry out the delegated responsibility, and assist or perform the responsibility him/herself, if he or she deems that appropriate under the given circumstances.

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• Gravlin, Gayle EdD, RN, NEA-BC
• Phoenix Bittner, Nancy PhD, RN, CCRN

Objective: Measure RNs' and nursing assistants' reports of frequency and reasons for missed nursing care and identify factors related to successful delegation.

Background: Routine nursing tasks were identified as the most commonly occurring omissions. Reasons for omissions included poor utilization of staff resources, time required for the nursing interventions, poor teamwork, ineffective delegation, habit, and denial.

Methods: Quantitative, descriptive design.

Results: Widespread reports of missed care included turning, ambulating, feeding, mouth care, and toileting. Frequently reported reasons were unexpected increase in volume or acuity, heavy admission or discharge activity, and inadequate support staff. Factors affecting successful delegation were communication and relationship, nursing assistant competence and knowledge, and attitude and workload.

Conclusion: Nurse leaders must focus on implementing strategies to mitigate factors and the consequences of care omissions, including poor patient outcomes. An analysis of point-of-care delivery system failures and ineffective processes is essential.

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Nurses' and nursing assistants' reports of missed care and delegation

Affiliation.

• 1 Nursing Education, Research & Professional Development, Lahey Clinic, Burlington, Massachusetts, USA.
• PMID: 20661063
• DOI: 10.1097/NNA.0b013e3181e9395e

Objective: Measure RNs' and nursing assistants' reports of frequency and reasons for missed nursing care and identify factors related to successful delegation.

Background: Routine nursing tasks were identified as the most commonly occurring omissions. Reasons for omissions included poor utilization of staff resources, time required for the nursing interventions, poor teamwork, ineffective delegation, habit, and denial.

Methods: Quantitative, descriptive design.

Results: Widespread reports of missed care included turning, ambulating, feeding, mouth care, and toileting. Frequently reported reasons were unexpected increase in volume or acuity, heavy admission or discharge activity, and inadequate support staff. Factors affecting successful delegation were communication and relationship, nursing assistant competence and knowledge, and attitude and workload.

Conclusion: Nurse leaders must focus on implementing strategies to mitigate factors and the consequences of care omissions, including poor patient outcomes. An analysis of point-of-care delivery system failures and ineffective processes is essential.

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