Nursing and Delegation

Delegation: An analysis of delegation to unlicensed personal
Cheryl R. Klinkner
Ferris State University

Abstract
This paper will present an analysis on nursing delegation to unlicensed assistive personal (UAP) within the healthcare setting. Delegation is a responsibility nurses are expected to do in order to coordinate safe and timely care for their patients. With the increase in patients loads, increase in acuity of patients and an increase in shortage of nurses; there also comes an increase in delegating tasks to the UAP. Although delegation is necessary to help manage an assignment load there are barriers in preventing appropriate delegation. It is important for registered nurses (RN) to overcome those barriers and work together with the interdisciplinary team to provide top quality and safe care for all their patients.
Keywords: delegation, registered nurse, unlicensed assistive personal, barriers, interdisciplinary team, quality and safe care

Delegation: An analysis of delegation to unlicensed personal
The demands on the registered nurse (RN) in the health care setting continue to increase. Along with those demands comes the responsibility of providing safe and quality care to more complex and critical patients. With the staffing shortage and budget cuts nationwide in the health care industry there comes an increase need to delegate those tasks once completed by nurses to unlicensed assistive personal (UAP). The American Nurses Association (ANA) defines delegation as, “the transfer of responsibility for the performance of a task from one individual to another while retaining accountability for the outcome” (para. 1). As nurses, we ask ourselves why we delegate. By delegating to other health care team members: RN’s can achieve desired outcomes for their patients, have better control over their assignment load, provide timely care and improve patient safety and satisfaction. According to the Emergency Nurses Association (2010), “delegation when used effectively can be a vehicle to provide safe, timely and efficient care while allowing the registered nurse to concentrate on more complex patient care needs” (p.1).
What is stopping the delegation process? There is a fear in those who delegate; mistakes could be made, the wrong tasks could be delegated, and what would happen if the tasks did not get done. Would uncompleted tasks make the nurse look irresponsible? According to a study published in Journal of Nursing Management (2010), “41% of RN’s report no exposure to nursing delegation during their nursing curriculum, making delegation a difficult task” (p.523). In order for appropriate delegation to occur, the nurses need to understand her/his role in the delegation process. Knowing what tasks and skills can be delegated, understanding the patient load and knowing the skill set of the UAP can increase the comfort level of the RN. It is important for the nurse to only delegate tasks and skills to individuals who have the education and skill set to carry out such a responsibility. Nurses need to realize the patient loads will not get lighter, patients illnesses will not suddenly improve and by delegating to the UAP, it will not only improve job satisfaction but provide timely and appropriate care for the patient.
Theory Base Delegation is not a new concept for the nursing profession. Delegation started back with Florence Nightingale. “In 1859, Nightingale is quoted saying, but then again to look at all these things yourself does not mean to do them yourself…But can you not insure that it is done when not done by yourself (Kelly & Marthaler, 2011, p. 3). These are the same questions nurses ask themselves today. There are theories to support delegation. Not only does delegation improve safe and timely care for our patients but also improves job satisfaction of the interdisciplinary team. Individuals will be satisfied in their job if they are allowed to work to their full potential. According to Maslow’s Theory of Motivation-Hierarchy of Needs, “human beings are motivated by unsatisfied needs, and that certain lower factors need to be satisfied before higher needs can be satisfied” (Envision Software, 2012, para. 2). When bringing this into the workplace, individuals in leadership positions need to clearly understand, “lower-order needs like safety and physiological requirements have to be satisfied in order to pursue higher-level motivators along the lines of self-fulfillment” (Envision Software, 2012, para. 3). A person begins their Hierarchy of Needs by starting in the level of physiological needs. These needs are needed to live and function. The next level is the needs of safety. Having a job, life insurance, a savings account and a safe place to live accomplish the feeling of safety. Next is meeting an individuals’ esteem needs. An individual needs to feel like they belong before the next level can be reached. Once an individual is hired into a position, one wants to feel like they are a part of the team. This is the meeting an individual’s social needs. The level of esteem is very important with delegation. Esteem can be reached through delegation. An UAP can reach this level by feeling a sense of accomplishment. Having a task delegated to them, completing the task and reporting back to the RN can reach this level in the workplace (Envision Software, 2012). By fulfilling these basic motivators, an employee will move into the area of self-actualization. “Self-actualization is the quest of reaching one full potential as a person, this need is never fully satisfied; as one grows psychologically there are always new opportunities to continue to grow” (Envision Software, 2012, para. 4). Delegation can not only reach Maslow’s Hierarchy of Needs for the UAP but also for the nurse when used appropriately. The nursing theory, which was published in 1979 by Jean Watson main objective, “ is to restore the nature of caring/healing and unify with stewardship the current health care system to retain and nurtures its most precious resource, caring professional nurses and transdisciplinary care team members”(Watson Caring Science Institute and International Caring Consortium, 2008, para. 1). This nursing theory blends well with delegation. The theory of human caring is taking care of each other as health care professionals in order to provide safe and top quality care to our patients. With the increase in the nurses work load and long hours worked on the floor, the last person the nurse worries about is their self. Never taking a minute to get a drink, take a break or even to go to the bathroom. If the nurses used delegation appropriately, the care for the patient would be completed in a timely manner, staff would be utilized as designed and nurses could take 5-10 minutes to rest. By respecting one another in our roles as health care professionals and using delegation as intended, the Theory of Caring can be upheld. Not just caring for the patient but caring and supporting each other.

Assessment of the Healthcare Environment One of the most difficult tasks an RN performs today is delegation (Weydt, 2010). Looking at the patient assignment and deciding how the work can be completed during the 8 or 12 hour shift can be overwhelming for the nurse. “Safe delegation depends on appropriate planning and execution of the delegated task” (Anthony & Vidal, 2010, p. 3). Delegation allows for the same work assigned to one RN be accomplished by more than one health care provider. Delegation helps all daily tasks be completed in a timelier manner.
Delegation is an important skill that influences clinical and financial outcomes; yet as RN’s delegation skills often are not evaluated in the same manner as other clinical skills, even though a number of nurses continue to need help in delegating appropriately. (Weydt, 2010, p. 2).
The lack of confidence nurses have regarding delegation prevents RN’s from practicing delegation in today’s health care setting.
The Board of Registration in Nursing presents the framework for delegation decision-making and accountability based on a model which identifies the five key elements of any delegated act: right task, right circumstance, right person, right direction/communication and right supervision/evaluation. (Health and Human Services Departments and Divisions [EOHHS], 2013, para. 1)
The RN needs to know the current patient assignment, understanding what each of the patients need. The RN needs to communicate clearly and delegate only appropriate tasks to other health care members and most importantly, the RN needs to follow up on the skills which were delegated. Making sure all skills were completed and documented.

Responsibilities are two-fold during the nursing delegation process. The nurse is ultimately responsibility for the patients care and all the tasks/skills which are delegated during the shift regarding the assignment. But the UAP is taking the responsibility for the task when they accept the delegation. The UAP takes ownership of the task/skill which needs to be completed. The RN is the care holder of the accountability in delegation. The RN needs to be accountable for the delegation process. Even though the nurse may delegate appropriate tasks to UAP it is the RN’s responsibility to be accountable and follow up to make sure the delegated task was done correctly. The delegation task gives the RN authority to delegate appropriate tasks as long as the 5 rights are met. Delegation gives authority to the RN but authority comes with accountability and responsibility. According to the National Council of State Boards of Nursing (2005), “The RN may delegate components of care, but does not delegate the nursing process itself. The functions of assessment, planning, evaluation and nursing judgment cannot be delegated” (p.2). By using the 5 rights to delegation and assigning appropriate skills/tasks to the UAP, the RN will not only decrease their stress level but improve patient care and satisfaction.
Implications and Consequences Delegation when done appropriately has no bad outcome for the RN, UAP or patient. To make delegation easy, the RN needs to know their assignment, know their patients, know what type of care the patients will require, understand what tasks can be delegated to make the work load equal and clearly communicate those tasks. Clear communication is what will prevent any mistakes from happening and ultimately provide the best possible care for the patient. The RN needs to clearly communicate the task to the UAP. The nurse should not only explain the task but the importance of the task. Why the task needs to be done and how quickly. This assists the UAP in understanding the why portion of the delegation which helps with prioritizing their day. Understanding why a blood sugar should be done immediately instead of at the end of the day is important. Once the nurse has clearly communicated the delegated task, this would be the time for the UAP to speak up if they are uncomfortable with the task. If the task is out of the UAP skill set, a conversation would need to take place between the UAP and the RN so the task is redirected to the correct staff or clarified. Once the task is assigned and the UAP accepts the task, than the RN believes the task will be completed as delegated. “When delegation occurs with trust, respect and a mutual exchange of information and ideas, it provides an environment for team cohesiveness and strengthens outcomes beneficial for the patient and the institution” (Saccomano & PintoZipp, 2011, p. 524).
According to studies done regarding delegation, RN’s benefit from delegation. When nurses delegate appropriately, the RN has time to complete activities which cannot be delegated. By using the interdisciplinary team to its fullest potential, the daily work can be completed in a timely fashion providing safe and quality care. “Effective delegation improved nurse’s job satisfaction, reduced burnout, enhanced time management and clarified accountability” (McInnis & Parsons, 2009, p. 469).
Studies have also been done regarding the UAP and delegation. UAP report an improvement in their skill level and knowledge. “Assistive personal reported that effective delegation by the RN improved their skills and knowledge, which enhanced their ability to achieve job promotion” (McInnis & Parsons, 2009, p. 469). Delegation also builds confidence in the UAP giving them a sense of accomplishment in their job and feeling like a part of the health care team. Delegation has had a positive impact on evaluation by supervisors. By accepting delegated tasks, responsibility is shown in the UAP’s job role giving them a higher evaluation than those who do not accept the delegated tasks (McInnis & Parsons, 2009). Since the health care industry continues to thrive in today’s society delegation will not go away. The number of patients continues to rise and the number of staff continues to get smaller so the need for delegation will continue to grow. By providing staff with appropriate skills and guidelines for delegation, the nurse will be confident not only in delegation but also in the RN role.
Recommendations for Quality and Safety Improvements
RN’s know not every skill can be delegated, but how to improve delegation skills needs some work. “The ability to delegate, assign and supervise are critical competencies for the 21st century nurse” (American Nurses Association and National Council of State Boards of Nursing [ANA & NCSBN], 2005, p. 1). These skills are hard to learn as a nursing student but are expected upon graduation. “Studies have concluded age and experience play an important part in effective nursing delegation” (Kaernested & Bragadottir, 2012, p. 14). If delegation is expected straight out of nursing school then the framework for delegation needs to begin there. “The situation of delegation demonstrates a need for educating RNs in the areas of leadership as well as clinical competency and exemplifies a situation that may be alleviated by required continuing education programs during the nursing employment” (Saccomano & PintoZipp, 2011, p. 524). Not only do nurses need to be competent in their skill set but also in what skills to delegate.
The American Nurses Association has developed Standards of Practice for Nursing. “The standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process” (American Nurses Assocation [ANA], 2010, p. 9). This nursing process involves many standards of care. According to the ANA (2010), “the registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes” (p. 9). The ANA identifies Planning as their 4th Standard of Nursing. The RN needs to plan their assignment accordingly so she/he may utilize the entire interdisciplinary team in providing patient care. The RN needs to be familiar with her UAP and know their skill set. UAP’s are competent in different skills depending on their area of work. By using the UAP for appropriate tasks, the RN not only frees up time to complete un-delegated tasks but also provides top quality care for the patient in a timely manner.
Communication is ultimately the key to delegation. The 11th Standard of Professional Nursing Practice is communication. “The registered nurse communicates effectively in all areas of practice” (ANA, 2010, p. 11). By communicating clearly with the health care team, all tasks can be accomplished without hesitation. For nurses who struggle with communication; practice improves the situation. Some hospitals provide crucial conversation classes to improve communication between team members. By clearly communicating with the team all tasks can be competed effectively.
Nurses continue to lack the skill set for delegation due to a lack of education. Education is the 8th Standard. “A registered nurse attains knowledge and competence that reflects current nursing practice” (ANA, 2010, p. 11). A RN should continue to participate in workshops or simulation experiences to improve delegation skills. If there are no educational opportunities available within the hospital as a RN it is our responsibility to seek out other experiences. Simulation is an experience which can benefit the RN and the UAP. Together, the RN and UAP could provide top quality care while participating in simulation scenarios. These simulation experiences help build trust, encourage clear communication and help the RN understand the skill set of the UAP. Not only does simulation experiences enhance education for the health care team but promotes and practices safe care for the patient.

Conclusion Delegation is about working together to accomplish what more than one person cannot do alone. With the changes in the health care industry and the increase responsibilities of the RN, delegation is here to stay. By knowing how to delegate safely and appropriately, the RN will make sure every task is carried out in a safe manner. By understanding the role of the UAP, delegation will be an asset not only to the nurse but to the entire interdisciplinary team. Safe delegation not only improves staff satisfaction but promotes quality and safe patient care.

References
American Nurses Assocation and National Council of State Boards of Nursing. (2005). Joint Statement on Delegation. Retrieved from https://www.ncsbn.org/Joint_statement.pdf
American Nurses Association. (2010). Standards of Professional Nursing Practice. In Scopes and Standards of Practice: Nursing (2nd ed., pp. 31-62). Silver Spring, MD: Nursebooks.
Anthony, M., & Vidal, K. (2010, May). Mindful Communication: A Novel Approach to Improving Delegation and Increasing Patient Safety. Online Journal of Issues in Nursing, 15(2). http://dx.doi.org/10.3912/OJIN.Vol15No2May02
Emergency Nurses Association. (2010). Delegation by The Emergency Registered Nurse. Retrieved from http://www.ena.org/SiteCollectionDocuments/Position%20Statements/Delegation%20by%20the%20Emergency%20Nurse.pdf
Envision Software. (2012). Maslow’s Theory of Motivation- Hierarchy of Needs. Retrieved February 2, 2013, from http://www.envisionsoftware.com/articles/Maslows_Needs_Hierarchy.html#Safety_Needs
Health and Human Services Departments and Divisions. (2013). Five Rights of Delegation. Retrieved from http://www.mass.gov/eohhs/provider/licensing/occupational/nursing/nursing-practice/advisory-rulings/unlicensed-assistive-personnel/five-rights-of-delegation.html
Kaernested, B., & Bragadottir, H. (2012, January). Delegation of registered nurses revisited: attitiudes towards delegation and preparedness to delegate effectively. Nursing Science, 32(1), 10-15.
Kelly, P., & Marthaler, M. (2011). Nursing Delegation, Setting Priorities, and Making Patient Care Assignments (2nd ed.). Clifton Park, NY: Delmar.
McInnis, L., & Parsons, L. (2009, December). Thoughtful Nursing Practice: Reflections on Nurse Delegation Decision-Making. The Nursing Clinics of North America, 44(4), 461-470.
Saccomano, S., & PintoZipp, G. (2011). Registered nurse leadership style and confidence in delegation. Journal of Nursing Management, 19, 522-533.
Vogelsmeier, A. (2011, October). Medication Administration in Nursing Homes: RN Delegation to Unlicensed Assistive Personnel. Journal of Nursing Regulation, 2(3), 49-53.
Watson Caring Science Institute and International Caring Consortium. (2008). http://watsoncaringscience.org/about-us/wcsi-fact-sheet/
Weydt, A. (2010, May 31). Developing Delegation Skills. The Online Journal of Issues in Nursing, 15(2). http://dx.doi.org/

References: American Nurses Assocation and National Council of State Boards of Nursing. (2005). Joint Statement on Delegation. Retrieved from https://www.ncsbn.org/Joint_statement.pdf American Nurses Association Anthony, M., & Vidal, K. (2010, May). Mindful Communication: A Novel Approach to Improving Delegation and Increasing Patient Safety. Online Journal of Issues in Nursing, 15(2). http://dx.doi.org/10.3912/OJIN.Vol15No2May02 Emergency Nurses Association Envision Software. (2012). Maslow’s Theory of Motivation- Hierarchy of Needs. Retrieved February 2, 2013, from http://www.envisionsoftware.com/articles/Maslows_Needs_Hierarchy.html#Safety_Needs Health and Human Services Departments and Divisions Kaernested, B., & Bragadottir, H. (2012, January). Delegation of registered nurses revisited: attitiudes towards delegation and preparedness to delegate effectively. Nursing Science, 32(1), 10-15. Kelly, P., & Marthaler, M. (2011). Nursing Delegation, Setting Priorities, and Making Patient Care Assignments (2nd ed.). Clifton Park, NY: Delmar. McInnis, L., & Parsons, L. (2009, December). Thoughtful Nursing Practice: Reflections on Nurse Delegation Decision-Making. The Nursing Clinics of North America, 44(4), 461-470. Saccomano, S., & PintoZipp, G. (2011). Registered nurse leadership style and confidence in delegation. Journal of Nursing Management, 19, 522-533. Vogelsmeier, A. (2011, October). Medication Administration in Nursing Homes: RN Delegation to Unlicensed Assistive Personnel. Journal of Nursing Regulation, 2(3), 49-53. Watson Caring Science Institute and International Caring Consortium. (2008). http://watsoncaringscience.org/about-us/wcsi-fact-sheet/ Weydt, A