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ANA Principles for Delegation [html]

CONTENTS

Purpose

The Principles for Delegation document is designed to provide overarching principles and guidelines for practice in situations where registered nurses delegate tasks to others. The purpose of this document is to define relevant principles and provide registered nurses (RNs) with practice strategies when delegating patient care to nursing assistive personnel (NAP).

The American Nurses Association (ANA) recognizes that there is a clear distinction between RN and licensed practical/vocational nurse (LPN/LVN) practice. Principles for Delegation is designated for the RN professional practice role.

ANA also recognizes that RNs practice in many settings. Principles for Delegation is intended to be useful for RNs practicing across the continuum of care. However, there are some settings for which these guidelines may not apply. These may include communitybased care settings or other settings that lack the regular presence of an RN and in which care given by others is not directed or supervised by an RN.

Notes on Terminology:

Throughout this document the terms “nurse” and “patient” are used. “Nurse” is specific to the professional registered nurse. “Patient” is used throughout the text to provide consistency and brevity. Nursing’s Social Policy Statement, Second Edition (ANA, 2003) recognized the importance of clearly identifying the recipients of professional nursing care, be they individuals, groups, families, communities or populations. The terms “patient,” “client” and “person” most often refer to individuals, while “health care consumer” can represent an individual or group. To date, professional nursing has not yet selected “health care consumer” as the term best depicting the healthy or ill recipients of professional nursing care.

Disclaimers:

This document addresses the process of delegation as it applies in most states and territories of the United States. Some states may have different definitions, regulations or directives regarding delegation. RNs must check with their state’s board of nursing to ascertain state-specific differences. The Nurse Practice Act (NPA) is the legal authority for nursing practice in each state; however, the majority of information in this document is relevant to the practice of all RNs.

Introduction

Registered nurses are accountable to the public for providing culturally competent, safe and effective nursing care for patients in a variety of settings across the continuum of health care. These settings may include hospitals, long-term care facilities, nursing homes, community and public health centers, home health agencies or schools. In each setting, RNs function as essential members of health care teams that include the consumer and may include other licensed professionals and paraprofessionals as well as assistive health care workers and informal caregivers. Consumers, who may desire to direct their own care, also may seek consultation from RNs.

RNs are accountable for supervising those to whom they have delegated tasks. RNs often delegate nursing tasks to other team members, and they are accountable for the decision to delegate and for the adequacy of nursing care to the patient, provided the person to whom the task was delegated performed the task as instructed and delegated by the delegating RN. The RN retains accountability for the outcome of delegation.

The nursing tasks or activities that may be performed by the nursing team, which may include nursing assistive personnel and other health care workers such as LPNs/LVNs under the direction of an RN, are identified according to legal parameters defined by each state in its nurse practice act and by the scope of practice and standards established by professional nursing organizations. Thus, the framework for clinical practice including delegation is determined by individual state statutes, state regulations and policy statements and by generally accepted professional nursing standards of practice.

Challenges in today’s workplace make greater demands on RNs to have the knowledge and critical thinking skills to effectively delegate to others. These challenges include the varying experience levels of RNs, the increasing use of NAP roles and the time required to effectively and safely monitor and supervise NAPs and delegated work. With a nursing shortage, the inexperienced nurse is more likely to be placed in a position of having to supervise others without sufficient mentoring. Inconsistent facility or agency expectations regarding NAP duties or tasks coupled with minimal, if any, training can lead to an unstable and, in some cases, a less qualified workforce. Sicker patients, the increased use of technology and the need to administer medications place the RN in a difficult position of juggling delivery of care with overseeing delegated work.

The dynamics of the continuously changing climate of health care and the nursing profession compel individual RNs to be vigilant and action-oriented regarding changes to address nursing practice and RN delegation.

Definitions

Accountability: The state of being responsible or answerable. Nurses, as members of a knowledge-based health profession and as licensed health care professionals, must answer to patients, nursing employers, the board of nursing and the civil and criminal court system when the quality of patient care provided is compromised or when allegations of unprofessional, unethical, illegal, unacceptable or inappropriate nursing conduct, actions or responses arise.

Amenities: Hospitality services including delivering food, meal setup, making beds, cleaning the care environment. Assignment: The distribution of work that each staff member is responsible for during a given work period.

Critical thinking: A rational reasoning process that involves applying knowledge, skills, attitudes and values for the purpose of making a decision that affects patient care. Critical thinking uses clinical and professional judgment in each phase of the nursing process.

Delegation: The transfer of responsibility for the performance of a task from one individual to another while retaining accountability for the outcome. Example: the RN, in delegating a task to an assistive individual, transfers the responsibility for the performance of the task but retains professional accountability for the overall care.

Nursing assistive personnel (NAP): Individuals who are trained to function in an assistive role to the licensed registered nurse in providing patient care activities as delegated by the RN regardless of the title of the individual to whom nursing tasks are delegated. The term includes, but is not limited to, nurses’ aides, medication aides, orderlies and attendants or technicians.

Nursing process: The professional, systematic approach to ensuring complete care. The process consists of various steps including assessing, diagnosing, planning, implementing and evaluating the care provided.

Supervision: The active process of directing, guiding and influencing the outcome of an individual’s performance of a task. Supervision is generally categorized as on-site (the RN being physically present or immediately available while the task is being performed) or off-site (the RN has the ability to provide direction through various means of written and verbal communications). Individuals engaging in supervision of patient care should not be construed to be managerial supervisors on behalf of the employer. (See Providence Hospital on page 19.)

Policy Statements

• The authority for the practice of nursing is based on a social contract that acknowledges professional rights and responsibilities as well as mechanisms for public accountability. (Nursing’s Social Policy Statement, ANA, 2003)
  

  “Society grants the professions authority over functions vital to itself and permits them considerable autonomy in the conduct of their affairs. In return, the professions are expected to act responsibly, always mindful of the public trust. Self-regulation to assure quality in performance is at the heart of this relationship. It is the authentic hallmark of a mature profession.” (Donabedian, 1976)

• “The RN takes responsibility and accountability for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care.” (Code of Ethics for Nurses with Interpretive Statements, ANA, 2001)
  
  
• The RN assigns or delegates tasks based on the needs and condition of the patient, potential for harm, stability of the patient’s condition, complexity of the task, predictability of the outcome, and abilities of the staff to whom the task is delegated. (Nursing Scope and Standards of Practice, ANA, 2003)
  
  
• The profession defines the scope and standards of nursing practice. State nurse practice acts define the legal parameters for nursing practice, which may include delegation.
  
  
• All decisions related to delegation and assignment are based on the fundamental principles of protection of the health, safety and welfare of the public.

Principles

The following principles have remained constant since the early 1950s.

Overarching Principles:

• The nursing profession determines the scope of nursing practice.
  
  
• The nursing profession defines and supervises the education, training and utilization for any assistant roles involved in providing direct patient care.
  
  
• The RN takes responsibility and accountability for the provision of nursing practice.
  
  
• The RN directs care and determines the appropriate utilization of any assistant involved in providing direct patient care.
  
  
• The RN accepts aid from nursing assistive personnel in providing nursing care for the patient.

Nurse-related Principles:

• The RN may delegate elements of care but does not delegate the nursing process itself.
  
  
• The RN has the duty to answer for personal actions relating to the nursing process.
  
  
• The RN takes into account the knowledge and skills of any individual to whom the RN may delegate elements of care.
  
  
• The decision of whether or not to delegate or assign is based upon 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 a task is delegated.
  
  
• The RN delegates only those tasks for which she or he believes the other health care worker has the knowledge and skill to perform, taking into consideration training, cultural competence, experience and facility/agency policies and procedures.
  
  
• The RN uses critical thinking and professional judgment when following The Five Rights of Delegation:
  1. Right task
  2. Right circumstances
  3. Right person
  4. Right directions and communication
  5. Right supervision and evaluation (NCSBN 1995).
     
     
• The RN acknowledges that there is a relational aspect todelegation and that communication is culturally appropriate and the person receiving the communication is treated respectfully.
  
  
• Chief nursing officers are accountable for establishing systems to assess, monitor, verify and communicate ongoing competence requirements in areas related to delegation, both for RNs and delegates.
  
  
• RNs monitor organizational policies, procedures and position descriptions to ensure there is no violation of the nurse practice act, working with the state board of nursing as necessary.

Organization-related Principles:

• The organization is accountable for delegation through the allocation of resources to ensure sufficient staffing so that the RN can delegate appropriately.
  
  
• The organization is accountable for documenting competencies for all staff providing direct patient care and for ensuring that the RN has access to competency information for staff to whom the RN is delegating patient care.
  
  
• Organizational policies on delegation are developed with the active participation of all nurses (staff, managers and administrators).
  
  
• The organization ensures that the educational needs of nursing assistive personnel are met through the implementation of a system that allows for nurse input.
  
  
• Organizations have policies in place that allow input from nurses indicating that delegation is a professional right and responsibility.

Practice Strategies

The following practice strategies form the basis of safe and effective
delegation:

• All nurses are knowledgeable about the principles of delegation, associated risks and benefits and state laws and regulations governing their practice. In reviewing the nurse practice act in the states in which they practice, RNs ask themselves, at a minimum, the following questions:
  
  
  1. Does the nurse practice act permit delegation?
     
     
  2. What is the definition of delegation in the state of practice?
     
     
  3. Does the nurse practice act also authorize specific tasks for delegation?
     
     
  4. Does the nurse practice act list tasks that cannot be delegated, or does it authorize the RN to delegate based upon certain circumstances?
     
     
  5. Does the nurse practice act include a description of the NAP role?
     
     
  6. Is there a specific definition of supervision in the nurse practice act?
     
     
  7. How does the state of practice define supervision or direction when delegating to another health care worker?
     
     
  8. Does the nurse practice act indicate consequences of inappropriate delegation?
     
     
  9. Does the nurse practice act provide guidelines for reducing delegation risks?
     
     
  10. What is the legal scope of practice for an LPN/LVN in the state of practice?
      
      
  11. What other health care worker roles, if any, are regulated by the state or nurse practice act?
      
      
  12. How are other roles regulated in relation to the RN role?
      
      
• All nurses work together to create effective policies for patient care assignments for staff, delegation and clinical supervision of team members.
  
  
• Nurses understand professional standards of practice as wellas the legal parameters for practice.
  
  
• Clear, concise job descriptions are developed for each team member, and the state board of nursing should be consulted if questions arise regarding the appropriateness of delegating particular tasks or activities.
  
  
• The profession’s foundational documents, including the Code of Ethics for Nurses with Interpretive Statements, Nursing: Scope and Standards of Practice, and Nursing’s Social Policy Statement, Second Edition; specialty nursing organization references; as well as the state nurse practice acts and other regulatory documents or position statements regarding the role of the RN in assigning care and delegating tasks are available for all nursing staff.
  
  
• Nurse leaders in administration and education play a primary and vital role in transforming the current work environment in which RNs (including advanced practice registered nurses) delegate to and supervise others.
  
  
• Nurses collaborate with institutional risk managers and legal staff to ensure comprehension of the delegation process.
  
  
• RNs educate organizational leadership and risk management staff on the process, education and training limitations of LPNs/LVNs, NAP and other health care workers and the legal responsibilities of RNs who delegate tasks.
  
  
• Language regarding RN liability related to delegation should be included in all nurse practice acts.
  
  
• RNs consider consulting with their legal counsel (organizational or personal) if there is confusion and concern regarding their legal responsibilities and risks in delegation.
  
  
• RNs are constantly vigilant and address pending legislation and regulatory changes that may affect the nurse’s ability to effectively delegate and collaborate with other stakeholders in the process.

Education

Delegation is a skill that must be taught and practiced for nurses
to be proficient in using it in the delivery of nursing care.
It is a process that involves professional development and the
application of critical thinking, and it improves with education and
experience. Delegation skills are learned and developed over time.
The RN assumes personal accountability for developing critical
thinking skills. This personal accountability is consistent with
ANA’s foundational documents, the Code of Ethics for Nurses with
Interpretive Statements (2001), Nursing’s Social Policy Statement,
Second Edition (2003) and the Nursing Scope and Standards of
Practice (2003).

• Eight steps for self-appraisal of critical thinking skills to support accountability include:
  
  
  1. Reflect on the way in which you think, and review those steps you most often miss.
     
     
  2. Learn from your mistakes and the mistakes of others.
     
     
  3. Recognize personal indicators that warn you that your thinking ability may be less than optimal, such as illness, short staffing or stress at home that reduces focus on work issues.
     
     
  4. Participate in or lead discussions of clinical scenarios.
     
     
  5. Participate in a mentorship or preceptor program, either as a participant or as a mentor or preceptor.
     
     
  6. Develop an individual educational plan based on what you have learned or identified as strengths and educational needs from reflection and feedback.
     
     
  7. Trust your intuition, or the “immediate apprehension that something is wrong without benefit of conscious reasoning.”
     
     
  8. Use a model for creative thinking and problem solving to habituate step-by-step critical thinking processes.
     
     
• RNs are educated and mentored on how to delegate and supervise others effectively, including giving and receiving feedback.
  
  
• Nurse educators are encouraged to provide programs that include the principles for delegation and address areas for needed improvement.
  
  
• The curriculum related to delegation includes the rationale for rules of delegation, the law, the profession’s position on delegation and relationship, communication, and cultural issues related to the RN and the patient, as well as the significant professional, legal and ethical responsibilities and liabilities inherent in roles in which delegation and assignment are significant.
  
  
• The first professional course in a nursing program includes a primary overview of professional standards, the nurse practice act, state board of nursing administrative rules and regulations concerning delegation and supervision, and case law regarding nurse delegation and supervision.
  
  
• Nursing curricula and the NCLEX exam include competencies related to delegation.
  
  
• RNs advocate for funding for continuing education programs and workshops to foster professional growth in the areas of delegation, supervision and communication.

Care Provision

Elements essential for effective delegation include:

1. Emphasis on professional nursing practice
   
   
2. Definition of delegation, based on the nurse practice act and regulations
   
   
3. Review of specific sections of the law and regulations regarding delegation, identification of disciplinary actions related to inappropriate delegation
   
   
4. Emphasis on tasks/functions that cannot be delegated nor routinely delegated
   
   
5. Focus on RN judgment for task analysis and decision to delegate
   
   
6. Determination of the degree of supervision required for delegation
   
   
7. Identification of guidelines for lowering risk related to delegation
   
   
8. Development of feedback mechanisms to ensure that task is completed and to receive updated data to evaluate the outcome.

Consistent with the Code of Ethics for Nurses with Interpretive Statements (ANA, 2001), the nurse must not engage in practices prohibited by law or delegate to others activities prohibited by practice acts of other health care personnel or by other laws. RNs determine the scope of their practice in light of their education, knowledge, competence and extent of experience. The RN is frequently called upon to carry out components of care delegated by other health care professionals as part of the client’s treatment regimen. When accepting a delegated assignment from another healthcare professional, if the RN concludes that she or he is inadequately prepared to carry out a specific function, the RN has the responsibility to refuse that work and to seek alternative sources for care based on concern for the client’s welfare. In that refusal, both the client and the RN are protected, inasmuch as the RN is accountable for the continuous care of patients in health care settings. The RN does not accept delegation of interdependent functions if they are so extensive as to prevent the RN from fulfilling the responsibility to provide appropriate nursing care to clients (ANA, 1995).

Delegation Model

The RN assesses the patient and the person to whom the task will be delegated (delegatee) before delegating a task:

• Will the patient receive quality nursing care if the task is delegated? Should the task be delegated? How much supervision will the person doing the task require?
  
  
• Is the person to whom the task is being delegated competent to do the task? Is she or he functionally able to perform the task based on other assignments? Can the person perform the task without adverse patient occurrence?

The RN communicates clearly the task being delegated, in a concise manner, for a specific patient. Communication includes both written and oral components. The RN has the responsibility for clinical supervision of the person doing the task. If the RN identifies that the task to be delegated requires too much supervision, then the task should not be delegated. The RN monitors the patient and evaluates the outcome of the delegated task and anticipates a potential change of plan based on clinical judgment. The RN considers barriers and benefits to delegating a specific task. If the task is technical or includes primarily provision of daily amenities such as delivery of meals, there is a benefit to delegation, so the RN is then able to complete other professional duties and manage her or his time more effectively doing what only an RN can do. The RN considers cultural barriers — staff or patients might have cultural biases that need to be addressed in order to complete the delegated task. The task being delegated by an RN must be a function that is of a technical assistive nature (a clinical task that can be taught, such as drawing blood on stable patients, feeding or ambulating patients) or provides amenities to the patient (such as hospitality services, including delivering food, setting up meals, making beds, cleaning the care environment) and must not require critical thinking or professional judgment. The RN holds the delegatee responsible for completing the task and for reporting any changes in the patient’s condition.

The RN does not delegate the nursing process. However, selected components of the nursing process may be delegated as follows:

The RN is accountable for the delegation decision, the process and the ongoing monitoring of the outcomes of nursing care.

Research

• Mechanisms and partnerships are created in which RNs in all roles and settings are encouraged to contribute to the development of a valid and reliable body of knowledge about practices associated with delegation and assignment.

Summation

The scope and standards of nursing practice serve as the foundation for legislation and regulatory policy-making. Scopes of practice, standards of practice, nurse practice acts and legal regulations guide the development of institutional policies and procedures. Using skills, knowledge and professional judgment, the registered nurse
determines appropriate nursing practice based on the scope of practice, standards of practice, nurse practice act, legal regulation and institutional policies and procedures. RNs know the context of their practice, including:


The state practice act and their professional scope of practice, standards and code of ethics.

• The organization’s policies and procedures related to delegation.
  
  
• The RN is urged to seek guidance and appropriate direction from supervisors or mentors when considering decisions about delegatio

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Congress on Nursing
Practice and Economics
Workgroup

Karen A. Ballard, MA, RN
Joan M. Caley, MS, CNS, APRN-BC, CNAA-BC
Imatrude Grant, MS, RN
Anne M. Hammes, MS, RN, CNAA
Saul Josman, MN, RN, APRN-BC
Mary A. Maryland, PhD, RN, APN
Lorna Samuels, BSN, RN, C
Jeanne Surdo, BSN, MA, RN
Susan Tullai-McGuiness, PhD, RN

ANA Staff

Mary Jean Schumann MSN, RN, MBA, CPNP
Rita Munley Gallagher, PhD, RN
Winifred Carson-Smith, Esq
Vernice Woodland, BA

American Nurses Association

8515 Georgia Avenue, Suite 400
Silver Spring, MD 20910-3492
(301) 628-5000 Phone • (301) 628-5001 Fax
www.NursingWorld.org


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