Delegation is a decision-making process that requires skillful nurse judgment. The decision to delegate should incorporate critical thinking and sound clinical decision making. The process outlined by the NCSBN (2005) starts with a preparation phase and then has a 4-step process phase. The steps are (1) assess and plan, (2) communication, (3) surveillance and supervision, and (4) evaluation and feedback.
In most cases, it is recommended that the nurse delegator and the delegate agree on the task, circumstances, and time frame and then arrange for feedback in which the delegate reports or the delegator evaluates progress toward completion of the task. One way to make certain that both delegator and delegate understand what the task is and how to complete it effectively is to follow up a verbal directive with written instructions so that each person can refer to them later. Figure 9-2 displays a sample delegation tracking form that can be generated by NAP to give to the nurse. As a vehicle for clear communication and verification of expectations and consensus, this form can be modified to be specific to each unit. The task should specify a time frame in which the entire task is to be completed. The decision to delegate needs to be consistent with the nursing process. Thus the nurse needs to ensure appropriate assessment, nursing diagnosis, planning, implementation, and evaluation in a continuous process.
Decisions to delegate need to be carefully and thoroughly evaluated. A reasonable first decision rule is to be able to delegate the care of clients whose care requirements are routine and standard. Because care is complex and variable, the competency of the delegate is critical. Once it is assessed that the person to be delegated to has the minimum competencies required for safe care and if the outcomes of care are relatively predictable, delegation is considered safe. If the client’s reaction to illness and hospitalization is not threatening to his or her mental health or sense of self, it also is relatively safe to assume that this care can be delegated to NAP. For example, a client experiencing an acute episode of hypertension would require the RN as opposed to NAP to monitor the vital signs.
In making a decision to delegate nursing tasks, the following five factors can be assessed (American Association of Critical Care Nurses [AACN], 2004):
The over-arching determinant for the decision to delegate is the legal scope of delegation as set forth in the state’s nurse practice act. With the qualifications of both the delegator and the delegate as a baseline in place, the licensed nurse enters the continuous process of delegation decision making. The situation is assessed, and a plan for specific task delegation is established, considering patient needs, available resources, and patient safety. The nurse needs to ensure accountability for the acts and process of delegation. This includes supervision of the performance of the entire task, any necessary intervention, and evaluation of the task performance and the delegation itself.
The joint ANA and NCSBN (2006) statement identified nine principles of delegation specific to the RN, including the following:
The decision of whether to delegate or assign is based on the RN’s 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 an element of care is delegated.
The RN uses critical thinking and professional judgment when following The Five Rights of Delegation promulgated by the NCSBN (1995) as follows:
When determining the right task (element of care) to delegate, the nurse determines whether the element of care falls within the guidelines of established agency policies and procedures, the ANA Code of Ethics, and legal regulations for practice. The nurse then must consider whether the element of care can be delegated to any other staff members.
The right circumstance to perform the element of care indicates the delegate has the available resources, equipment, safe environment, and supervision to complete the task correctly.
The right person has the education and competency to perform the element of care. The right delegate, then, is legally acceptable to complete the element of care.
The right direction/communication of delegated elements of care will be a clear, concise description of the task, including its objective, limits, and expectations. The nurse allows for clarification without the fear of repercussions.
The right supervision of an element of care includes appropriate monitoring, intervention, evaluation, and feedback as deemed necessary. A process should be in place for the delegate to report to the RN both that the task was completed and the client’s response.
In addition to the five rights, the following three organizational principles are to be considered:
The five rights can quickly help analyze whether a delegation decision will most likely result in a safe outcome. To facilitate the delegation process in a way that will ensure the client’s personal health needs are addressed and the nurse’s professional goals are achieved, effective communication techniques must be used (Marthaler, 2003). Box 9-1 outlines a personal checklist for the delegator to use for self-evaluation.
True delegation is real to the delegate. Delegators let delegates go on their own but only after instilling in them the highest standards of performance and adherence to a shared vision. The delegate then functions within the standards set by the delegator, who has given authority to do the job, make independent decisions, and be responsible for seeing that the job is done well. True delegation trust is earned over time. Effective delegation requires that the delegate have the authority to accompany the responsibility. The delegator monitors the element of care completion and is alert for variances or other problems.
The essence of the element of care being delegated is often overlooked. Recognition of the potential vulnerability of the client, and thus the presence of an inherently moral element to health care practice, has raised concerns in relation to proper moral regard and respect for clients (Niven & Scott, 2003). This means that nursing judgment about which elements of care are to be delegated requires consideration of the client’s unique individual needs at that point in time. For example, obtaining vital signs on a client who is dying may be a reasonable delegation to NAP. However, because a nurse has spent much time explaining the process of the “do-not-resuscitate” status to the family, a trusting relationship has been established. The client’s or family members’ preferences for treatment/care need to be considered in delegating care activities.
Safety is a major facet of delegation, addressed over the years by The Joint Commission’s (TJC) Hospital National Patient Safety Goals. For example, The Joint Commission’s 2007 Patient Safety Goal Requirement 2E, Implement a standardized approach to “hand-off” communications (TJC, 2007), is applicable to delegation. Its provisions include the opportunity to ask and respond to questions. This assists in determining whether delegation can safely occur when a responsible delegator is not physically present.
The Joint Commission’s (2013) National Patient Safety Goal to maintain and communicate accurate patient medication information (NPSG.03.06.01) is an example of an effort to collect, reconcile, and communicate medication use to enhance patient safety. It speaks to the complexity and fluidity of care and how discrepancies in communication affect safety, especially in the context of multidisciplinary and team-based care systems where gaps can occur.
Communication is a major factor in missed care results of delegation. Research has shown no relationship between leadership style and delegation confidence, although there is an interaction between educational preparation and clinical nursing experience (Saccomano & Pinto-Zipp, 2011). There is, however, a bundle of best practices for delegation and supervision skills that includes planning assignments, including NAPs in shift handoffs and rounding, check-in points, evaluation of organizational practices about delegation and supervision, and coaching and mentoring (Gravlin & Bittner, 2010; Hansten & Jackson, 2009).
Delegation to unlicensed staff is common in long-term care (LTC) and assisted living settings. Thus delegation is a major strategy for care delivery. UAPs can be certified nursing assistants, personal care workers, or other types of unlicensed personnel. Lightfoot (2011) outlined the following eight principles for RN delegation:
Delegating nursing responsibilities is an important tool for managing workloads in a medical facility. By assigning tasks to other employees, nurses can focus on other responsibilities that may require more detailed attention. Learning the importance of delegation in nursing and how to improve your delegation skills can help you effectively transfer tasks to others to ensure desirable outcomes. In this article, we explore why delegation is important in nursing and provide tips for improving your delegation skills.
Delegation in nursing is important because it maintains accountability while assigning tasks to staff members. Often, the person delegated to accomplish a task may have other duties, and the delegated task can be outside their normal responsibilities. When delegating in nursing, there are some procedures to keep in mind. The National Council of State Boards of Nursing (NCSBN) outlines five rights of delegation:
Right task: The delegated task falls under the individual's job description of knowledge of the expectations.
Right circumstance: The patient who the delegate is working with is in a stable condition and not prone to fluctuations in their health or physical state.
Right person: When delegating tasks, a nurse makes sure the delegate has the knowledge and skills to perform the task properly.
Right direction and communication: To help the individual understand their task, the nurse gives explicit instructions and expectations, along with answering questions about any procedures.
Right supervision and evaluation: The nurse assigning the task remains available to supervise and make corrections as needed to ensure a desirable outcome.
Delegation can help nurses effectively manage their many responsibilities. It's a method for making their caseload more manageable while still ensuring patients receive the care they need. When used effectively, delegation can help save nurses time and provide other benefits such as:
Building skills in delegates
Allowing nurses to focus on more challenging tasks
Creating strong working relationships and motivating teamwork
Promoting the most effective utilization of staff
Improving resident and family satisfaction
Discovering potential in other employees
While both delegation and assignment involve transferring a task to another individual, there are a few differences between the two. When assigning a task, it usually is something within an individual's job description. This means they already have the proper education and training to perform the duty. However, when you delegate a task, it may be something beyond an individual's job description. Another difference between delegating and assigning tasks is that when you delegate a task, you are still responsible for the outcome, whereas when you assign a task, you also assign responsibility for the result.
Here are some tips to help you improve your delegation skills for nursing:
Be willing to yield some control: In order to delegate some of your tasks, be willing to let go of some of your control. You can still be active in monitoring the progress of the task, but it may take less of a hands-on approach as the individual performs the task for you.
Match abilities with tasks: Get to know your team members so you know what their strengths and weaknesses are. This can help when choosing who to delegate a task to so you assign it to the right person. Evaluate factors such as education, skillset and license status when determining delegation of tasks.
Identify potential problems: Before delegating, consider potential problems that may occur when transferring responsibilities to someone, such as a lack of confidence in doing the task. Try to come up with ways to overcome these challenges to prepare for when they occur.
Set reasonable goals: Clearly communicate the goal of the task to the individual you are delegating your assignment to. This helps them understand what they are working toward and what you expect from them. Consider making timelines or setting deadlines to help the delegate stay on schedule.
Delegate responsibilities fairly: When choosing who to delegate your assignment to, be fair in your decision. Try to delegate to various employees, rather than the same individual every time. Also, consider the tasks you delegate and try not to repeat undesirable tasks, such as bathing patients.
Consider delegation throughout your shift: As soon as you notice you won't be able to accomplish a particular task, find someone to delegate the assignment to. If possible, try to delegate throughout your shift to spread the number of delegations out.
Be thankful and respectful: Be sure to thank those who completed your delegated tasks. Showing respect to those helping you can help you develop a positive relationship and lead to greater success in your delegation in the future.
Develop critical thinking skills: Because delegation and critical thinking work together, it's helpful to improve your critical thinking skills. Being able to think through complex situations can help you make better decisions when delegating and find solutions when problems arise.
Practice being patient: Since delegation often involves employees performing an unfamiliar task, it may take some time for them to understand how to do it correctly. Be patient through the process as the individual develops their skills and knowledge.
Give advice and affirmation: Since the delegate may perform a task outside of their normal responsibilities, it's helpful to provide them with advice on how to succeed. Provide them with any necessary resources or training to help them succeed at the job duty and let the delegate know to alert you if a problem occurs while performing the task.
Learn through experience: To become better at delegating, use experimental learning. As you gain more experience in delegation, you may become more comfortable assigning others responsibilities and learn what works best.
Evaluate how the delegate did: After the delegate completes the task, review how they did and how the patient responded to their help. When evaluating, consider any opportunities for improvement in the future.
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