Being a newly Registered Nurse entails a lot of challenges, how we deal with our clients and effectively communicating what their needs are in a multi-cultural setting gives us these difficult tasks of rendering proper and appropriate health care. RNs (Registered Nurses) are known to provide care from womb to tomb, without preference to age, gender, race, religion and status. RNs need to understand the importance for them to know by heart, what are the tasks they can delegate to their co-workers because problem could arise if tasks are delegated inappropriately and clients would be the one to suffer the consequences. Delegation of activities will be relied more heavily due to decreasing workforce and increasing workload that’s why nurses should understand fully the different guidelines on how one can appropriately apply delegation in their professional practice.
The role of RN in the delegation process takes unprecedented importance. The independent licensee of the RN imposes a legal accountability on the part of the nurse to the patient/recipient of care. This becomes a primary responsibility, with the accountability to other disciplines or the employer being secondary. Because the RN is responsible for the practice of other lesser skilled licensed or unlicensed nursing personnel (i.e., Enrolled Nurses and Unlicensed Health Care Worker), it is imperative that registered nurses understand the guidelines and parameters set for delegation and training. All RNs and midwives must be willing to accept accountability and responsibility when undertaking activities within their individual scope of practice after considering: legislation or restriction of practice, professional standards of practice, current evidence for practice, individual knowledge skill and competence and contextual/organizational support for practice [Nursing Board of Victoria (NBV) 2007].
The responsibility of the RN prevails whatever the employment setting or status of employment and that legal accountability cannot be removed or assumed by another individual or by the employer. We can never work alone, thus we are always a part of a multidisciplinary healthcare team and this is where the issues of delegation come into place.
I. Definition of delegation and application in clinical setting
The Queensland Nursing Council (2005) defined delegation as ‘conferring of authority on a person to a person to perform activities. In the same way, delegation is conferment of authority to an individual who is not authorized to perform a particular task autonomously but can do so under direct or indirect supervision (Nursing & Midwifery Board of South Australia 2005). Direct supervision means that the RN is actually present during performance of the delegated task, observing and guiding the person who is being supervised while indirect supervision is provided when the RN does not directly observe the person performing the delegated task but should be easily contactable by phone or electronic devices when the need arises [Royal College of Nurses, Australia (RCNA) 2005].
Delegated task can either be new, meaning that the delegated task is not normally part of their role or established, which means that the task has already been done before and no change in context was made [Queensland Nursing Council (QNC) 2005d, sec. D 7.0; Nursing Board of Tasmania (NBT) 2006, pp.5-6]. As a Registered Nurse working as part of the healthcare team, we cannot do away of the process of delegating tasks to other health practitioners be it to another Registered Nurse (RN), Enrolled Nurse (EN), or an Unlicensed Health Care Worker (HCW). It is both beneficial to the health care team and the client because if properly and accurately done, it speeds up the process of rendering the care needed by the client without sacrificing the quality of care being given. Health professionals should always remember that delegation of tasks are made not just to ease one’s workload but are made to meet the clients need and to ensure that the right person is available at the right time to provide the right care to the client [Australian Nursing & Midwifery Council (ANMC) 2007].
There are tasks that an RN cannot delegate to Enrolled Nurses and Unregulated Health Workers. According to the QNC (2005d, p. 4), care planning and delegation of activities from a nursing care plan cannot be delegated, some aspects of drug administration by Enrolled Nurses which are restricted by the council as per the Health (Drugs and Poisons) Regulations 1996 and tasks as defined by the Nursing Act 1992 to be solely exclusive for RNs or midwives.
Registered nurses have the right to clarify, validate and support their professional judgment when it disagrees with an employer or supervisor’s direction, facilitate resolution of disagreement with an employer or supervisor and help resolve disagreement whether it is appropriate to advance their practice through accepting a delegation (QNC 2005c).
II. Role and Responsibilities of Nurses in Delegating Tasks
Only RNs may delegate nursing acts, functions or tasks. A registered nurse that delegate nursing acts, functions, or tasks should first determine whether it is within the RNs scope of practice, that the individual is qualified, competent and has the necessary skills to perform the task safely, that the RN delegating the task is available to directly or indirectly supervise the individual and evaluate the result after the delegated task was performed and that the RN should always remember that only the task is delegated and not the ultimate responsibility and accountability that goes with it. As stated in the ANMC (2007), RNs should understand the requirements for delegation and supervision of practice an example of which is by accepting delegated tasks only if it is within one’s scope of practice and by raising concerns about inappropriate delegation with relevant organizational or regulatory personnel. Activities delegated by a RN cannot be re-delegated to another professional or healthcare worker (QNC 2005a).
Registered nurses should provide guidance, support, assistance and clinically focused supervision, ensure that the person to whom the delegation is being made understands their accountability and is willing to accept the delegation, they should reflect on one’s own practice, provide competency assessment of the individual who will accept the delegated task and evaluate the outcome of the delegated task (ANMC 2007; QNC 2005a).
Accountability goes hand in hand when delegating tasks to other health care personnel. RNs carries with them a very big responsibility when delegating tasks to another member of the team because the RN retains the accountability and must see to it that the person to whom the task is being delegated to is competent enough to perform such task so as not to compromise the quality and safety of the care provided. RNs who delegates health care tasks are accountable to the State where they are registered, to their employer, and to their clients for their own actions and decisions. The RN must see to it that only those that can be performed safely to the patient be delegated, and it is critical that there is a clear and effective communication between the two parties. Expectations and outcomes are to be set so as to have an exact basis of evaluation if the delegated tasks are successfully performed to that of the accepted level of standard. Responsibility can be delegated to others so that the person to whom a task is delegated to remains responsible of the action while the accountability remains with the one who delegated the task. The independent license of the RN imposes a legal accountability on the part of the nurse to the patient/recipient of care. This becomes a primary responsibility, with the accountability to other disciplines or the employer being secondary. Because the RN is responsible for the practice of other lesser skilled licensed or unlicensed nursing personnel (i.e., Enrolled Nurses, Unregulated Health Care Workers), it is imperative that registered nurses understand the guidelines and parameters set for delegation and training. Liability cannot be delegated & a nurse’s registration is at risk if he or she delegates a task inappropriately. Appropriate delegation begins with knowing what skills can be delegated. There are published guidelines which helps nurses in delegating tasks in accordance with the RN’s legal scope of practice, an example of these are the five rights of delegation (National Council of State Boards of Nursing, 1995) wherein the fundamental basis of public protection should be the basis of all decisions related to delegation of nursing activities can be used as a mental checklist to assist nurses clarify critical elements of the decision-making process. The RN’s final responsibility is to evaluate whether assistants performed a task properly and whether desired outcomes where realized. RNs should use the principles of delegation to guide them in deciding whether a particular task can be delegated or not.
III. Principles of Delegation
According to the Australian Nursing Federation (2004, p. 1), each state and territory in Australia governs the practice of registered nurses and midwives through published nursing and midwifery acts and that the ANF’s purpose of publishing the guideline is to ‘clarify the role and obligation of the RNs and midwives when delegating aspects of nursing and midwifery care, guide RNs and midwives through the issues to be considered in delegating aspects of nursing and midwifery care and to clarify the role and obligations of employers in the delegation of aspects of nursing and midwifery care by nurses and midwives.
The principle of delegation should be used when considering delegating an activity to another health care provider. The following are the principles of delegation as stated in the Nurses Board of Victoria (NBV), Guidelines: Delegation and Supervision for Registered Nurses and Midwives (2007, p. 4): RNs should always remember that the primary motivation in delegating tasks is to meet the health needs and improve health outcomes of clients, it must be consistent with the acceptable standards of nursing and the policy of the service providers, that the delegated task is based on appropriate planning and consultation, delegated tasks should only be accepted if the person to perform the ask is deemed competent after proper assessment by an authorized personnel, the RN should see to it that he/she is accountable not only for their decision to delegate but also in monitoring the delegated individual’s standard of performance and that the activity delegated should presently be part of the RNs current role. Likewise, the delegating nurse has also the responsibility to apply the five rights of delegation, namely: (1) the right task; (2) the right circumstances; (3) the right person; (4) the right direction or communication; and (5) the right supervision (Crisp and Taylor 2005, p.366). If either one of these rights are missing, the task being delegated is considered to be unsafe and can result to negative outcomes.
Delegation is different from allocation or assignment which involves asking another person to care for one or more consumers on the assumption that the required activities of consumer care are normally within that person’s responsibility and scope of practice (ANMC 2007; NBV 2007, p.4). When a patient is admitted during your tour of duty, and you are the nurse on deck, this means that the patient will then be allocated to you on the assumption that the required activities for consumer care are normally within your responsibility and scope of practice and you must holistically take care of all the needs of the patient while in the case that the admitted patient was assigned to another RN which then delegates a task to you, like getting the patient’s initial vital signs, the accountability and overall responsibility remains with the admitting RN with you sharing the responsibility of the outcome of the task.
Using reflective practice, the RN should then evaluate their individual contribution to the achievement of patient outcomes, if he or she was able to properly apply the scope of nursing practice decision-making framework in delegating tasks to other health care professionals and if patients are properly allocated based on individual skills, experience and competency of the receiving person. Reflective practice also helps nurses establish what they have learned from the experience of providing nursing care and responding to patient needs and is important for novice RNs as it helps them identify areas in their practice that they need to improve ensuring that they make better choices and decisions in the future (NBWA 2004).
According to Usher & Holmes (2005, p.110), ‘self awareness is the foundation skill upon which reflective practice is based’. Self awareness offers RNs an opportunity to see themselves in certain situations and how they affected the situation and the situation affected them (Atkins 2000 cited in Usher, K & Holmes, C 2005).
IV. Professional competence, delegation and clinical effectiveness
Competence is an individual’s ability to effectively apply knowledge, understanding, skills, and values within a designated scope of practice at a standard acceptable to the client and others who has the same experience and background (ANMC 2005, p. 8). Critical thinking, or the practice of questioning, is necessary so that practitioners integrate relevant information from various sources, examine assumptions, and identify relationships and patterns (Parker & Clare 2000 cited in Usher, K & Holmes, C 2005).
Health care organizations have made dramatic advances and transformations during the last few decades, resulting in rapid growth of technology and theory. If nurses are to deal effectively with complex change, increased demands and greater accountability, they must become skilled in higher level thinking and reasoning abilities and this is where the use of critical thinking becomes vital in examining simple and complex situations in nurses’ day to day responsibilities. RNs who are critical thinkers practice sound clinical judgement by practicing critical thinking skills to investigate and reflect on all aspects of a clinical observation or problem in order to decide on an appropriate course of action based on factual evidence rather than conjecture and is able to arrive at a reasoned conclusion that can be justified. The process of critical thinking will enhance the ability of nurses to properly identify and assess the need of delegating tasks to other health care professionals and to determine if they carry with them the professional competence needed to efficiently perform the assigned task which would definitely result in clinical effectiveness by delivering the care plan and attending to the needs of the client faster rather than performing the care plan alone even if the task is legally delegable. (Simpson & Courtney 2002).
V. Interpersonal Relationships between team members during delegation of tasks
Registered nurses work within the health care team to properly address the different complex health care needs of clients and each of the team member’s knowledge and contribution is valued and respected.
Interpersonal relationship is the association or connection between unit managers & staff nurses within a nursing unit & interpersonal relationships within team members during delegation of tasks should be built on trust.
Acceptance, care, feeling, integrity, & respecting the values all revolved on trust, thus, trust building should be the focus of every activity within an organization. Interpersonal relationships are built through effective communication skills, listening to each member queries and actively participating during supervision of a delegated task builds confidence on their part. An interpersonal relationship is a dynamic system that changes continuously wherein social associations, connections, or affiliation between two or more people are present. Effective delegation forces you to spend time with your employee thus developing your interpersonal relationship. This holds true to RN’s who personally see to it that each member of the team to whom different tasks are delegated will continually grow as their experiences and skills develop in time, building the confidence, competency & a collaboratively harmonious interpersonal relationship needed to properly and effectively care for each patient within their jurisdiction. Working in partnership and cooperation with other members of the health care team for the benefit of the clients receiving health service where delegation of a nursing intervention is not required means that a collaborative relationship exists between the health care team. It is then important to maintain & enhance relationships among employees by creating a social environment in which the team can attain their goals.
In summary, delegation is a process wherein new RN’s must be able to understand to avoid any professional & legal dilemma that may arise due to ignorance. There are tasks that the RN cannot delegate (QNC 2005a), aspects of nursing care like assessment of the client, planning on how to provide care, & evaluation of the expected outcome was met after implementation and these should be strictly followed. Allocation of accountability in QNC (2005d, p. 15), states that RNs and midwives are accountable for delegation decisions and for the standard of care provided but if the RN or midwife ensured that the delegation decisions and level of supervision were appropriate, they would not be held accountable for inappropriate or unauthorized actions by another care provider. It is the role & responsibility of the RN to see to it that the person to whom the task is being delegated to have the necessary education, experience & skill to perform competently. It is important that a harmonious interpersonal relationship between team members are present because this would be the basis of a therapeutic, collaborative approach in rendering the best care possible to clients assigned to them.