Nursing

Nurse Delegation and Prioritization

 

Delegation and prioritization are critical aspects of becoming a nurse and, although they sound simple, are some of the most challenging topics a nurse can be tested on.  Maslow’s Hierarchy of Needs is a helpful framework when thinking about prioritization because nurses need to think of their plan of action in a similar fashion. Having an understanding of the big picture will allow nurses to take the most vital and most important actions first. It’s the basis from which they can delegate action and respond to the needs of their patients.

 

 

Review the following questions.  What order would you see the patients AND explain WHY you chose that order.  Each question is worth 5 points.

 

• After exposure to hot weather and sun, clients with signs and symptoms of heat-related ailment rush to the Urgent Care. Sort clients into those who need critical attention and those with less serious conditions.

 

1. An abandoned person who is a teacher, has altered mental state, weak muscle movement, hot, dry, pale skin; and whose duration of heat exposure is unknown.
2. An elderly traffic enforcer who complains of dizziness and syncope after standing under the heat of the sun for several hours to perform his job.
3. A comparatively healthy housewife who states that the air conditioner has been down for 5 days and who exhibits hypotension, tachypnea, profuse diaphoresis, and fatigue.
4. A sportsman who complains of severe leg cramps and nausea, and displays paleness, tachycardia, weakness, and diaphoresis.

 

WHY did you select that order?

 

 

• A client with multiple injuries is rushed to the Urgent Care after a head-on car collision. Which assessment finding takes priority?
  1. Irregular apical pulse
  2. Ecchymosis in the flank area
  3. Unequal pupils
  4. A deviated trachea

 

WHY did you select that order?

 

 

• Rachel is an Internal Medicine nurse that has been practicing for 2 years and has been upskilled to assist in the urgent care with the following patients. In what order should she see the following patients, and why?

A)     A 10-year old with a 2 cm laceration to her left arm.  The laceration is bleeding through the 4X4 gauze every 5-10 minutes.

B)     A 21-year old with complaints of a “migraine headache,” vomiting, pain (9 out of 10), and unable to open their eyes due to light sensitivity.

C)     A 62-year-old male with COPD and increased difficulty breathing for the past two hours. His family reports a recent cold and significant worsening in the past 24 hours.

D)     A 45-year-old female with chest pain that is talking on her cell phone to her son as she is being checked in (Hargrove-Huttel & Colgrove, 2014).

 

WHY did you select that order?

 

• Part 1. John is an agency nurse who is assigned to an acute care unit in a long-term care facility. He receives a report on his patients for the day. Who should he assess first after receiving report?

1. A resident with congestive heart failure (CHF) with 3+ pitting edema in their bilateral lower extremities. 
2. A resident with Parkinson’s disease (PD) that started hallucinating during the night and is sleeping now. 
3. A resident with Alzheimer’s disease (AD) that was wandering in the hallway at 2 am.
4. A resident with terminal cancer who the UAP reported has lost eight pounds since their last weight check four weeks ago.  

WHY did you select that order?

 

Part 2.  After John completes his morning assessments, he reviews the MAR and sees he has   several medications to give. Which of the following medications should be given first, and      why?

1. A) Acyclovir (Zovirax) for a resident with a diagnosis of Bell’s palsy.
2. B) Cephalexin (Keflex) for a resident with a diagnosis of a urinary tract infection (UTI).
3. C) Acetylsalicylic acid (Aspirin) for a resident with a diagnosis of cerebrovascular accident (CVA).
4. D) Neostigmine (Prostigmin) for a resident with a diagnosis of Myasthenia Gravis.

 

WHY did you select that order?

 

 

 

 

 

Delegation Activity

 

You’ve just begun your shift and, as usual, you’re off to a running start. Mr. Wong in room 730 is complaining of pain, your nursing assistant tells you. The physician at the desk wants today’s labs for Mr. Forbes in 734. Ms. Turner in room 737 has stabilized after her abdominal surgery and needs someone to accompany her as she tries to walk. Ms. Perez in 731 is due to have her blood glucose tested. The pharmacist has called the unit asking when Mr. Pearson in room 735 received his last dose of IV tobramycin.

Which of these tasks should you do yourself and which can you delegate to others? And how do you decide?

Delegation dilemmas

In today’s rapidly changing practice environment, more nurses than ever are facing delegation dilemmas. With the “redesign” of hospital patient care services-and the abandonment of the primary nursing and total patient care models prevalent in the ’80s and early ’90s-you’re probably responsible for more patients than you could possibly care for on your own. Chances are you have to delegate care tasks to unlicensed assistive personnel, who may have such titles as nursing assistant, nurse extender, or care partner. A recent survey by the American Hospital Association showed that nearly all hospitals (97%) now employ these workers. The use of UAPs figures to rise as hospitals act to preserve their bottom lines in the face of managed care’s growth and looming cuts in Medicaid and Medicare reimbursement.

Both individual nurses and organized nursing have reacted to this trend with concern. Many nurses worry that they’re putting their licenses at risk in delegating care to unlicensed personnel. They’re unsure, given UAPs’ limited training, what tasks these workers may be safely delegated to perform. The difficulty of determining what can and should be delegated, without compromising quality care, has been the subject of labor law disputes, state nurses association statements, and discussions in nursing journals.

Contributing to the problem is that many nurses haven’t been prepared to assess the competence of UAPs and delegate tasks. In the AHA survey, only half of the hospitals reported offering training to nurses working with UAPs. Many nurses have only had experience working with basic certified nursing assistants, and they may be confused about new assistant roles and how to delegate appropriately to staff in these roles.

Whether we like it not, it looks like UAPs are here to stay. But you can protect your patients and yourself by learning how to delegate safely. Here I’ll suggest some questions to consider in evaluating your delegation practices-you might call it a delegation litmus test. I’ll also discuss how you can improve your delegating skills and, just as important, what you and your institution can do to make sure UAPs are competent to carry out the tasks they’ll be assigned.

You remain accountable

The American Nurses Association defines delegation as “transferring responsibility for the performance of an activity…while retaining accountability for the outcome.” The National Council of State Boards of Nursing has defined it as “transferring to a competent individual authority to perform a selected nursing task in a selected situation.” Simply put, when you delegate, you give someone else the authority to carry out a care task, but you remain accountable for the overall nursing care of the patient.

In describing how the process should take place, Ruth Hansten and Marilynn Washburn have referred to the “Four Rights” of delegation (as in the “Five Rights” of medication administration):

• • the right task (one that can be delegated, rather than falling within the nurse’s scope of practice alone);
• • the right person (one qualified and competent to do the job);
• • the right communication (a clear, concise description of the task, the objective, and your expectations); and
• • the right feedback (timely evaluation of the worker’s performance as he does the task and after he completes it).

Delegation can also be likened to some facets of the nursing process itself. After assessing the patient and planning his care, you identify which tasks someone else can perform, you assign and supervise performance of these tasks in implementing the plan of care, and, finally, you evaluate whether the task was done properly and whether it achieved the planned outcome for the patient.

While such conceptual models can help you understand delegation, your state’s nurse practice act and other professional regulations and your hospital’s job descriptions, policies and procedures, and standards should provide additional specific guidance and will specify certain restrictions.

Do you know the law?

It’s important to know your state’s nurse practice act, which delineates the scope of practice of a registered nurse. In defining nursing practice, it will identify aspects of care such as physical assessment and care planning that can be handled only by nurses. It may also cite more specific skills, such as wound care, as not delegable. Most states identify delegation and supervision of work as a responsibility of the RN in providing indirect patient care, although each state may express the criteria for delegation differently.

The practice of licensed practical or vocational nurses is also determined by state regulations. If you delegate work to LPNs or LVNs, you need to know the parameters of their practice and what functions can be legally assigned to them. In some states LPN or LVN practice is covered by a vocational nurse act, rather than a nurse practice act. This means the nurse’s practice must conform to the curriculum of her state’s LPN or LVN educational program. She can’t perform tasks that require skills or knowledge beyond what she acquired in her education, unless the task is delegated to her by an RN.

Since they aren’t licensed professionals, UAPs’ “practice” isn’t defined by state law. However, statements in the nurse practice act or state board of nursing rulings may offer insights as to what may be legally delegated to UAPs and provide guidance for job descriptions. State regulations and nursing board rules do dictate that a UAP be assigned to an RN, not directly to a group of patients. Nurses may not always understand this, because it’s not uncommon to see patients’ names and room numbers written next to the UAP staff names on assignment boards.

Are you familiar with hospital policy?

Your institution should have a job description for UAPs that spells out in detail what they can and can’t do. A job description will typically mention specific uncomplicated tasks, such as taking vital signs or positioning patients. It may also, however, list portions of more complex tasks-for example, gathering supplies for a dressing change. Make sure you’re familiar with UAPs’ job description so you assign tasks in accordance with it. Don’t assume that a UAP will know what he isn’t permitted to do.

UAP job descriptions will be based on hospital policy and procedures or by the unit’s or organization’s care standards. These must, of course, comply with state law and regulations. Nurses should have the means, whether through communication with unit managers or participation on a governance council, to influence UAPs’ job descriptions so that they follow the law and Joint Commission on the Accreditation of Healthcare Organizations criteria.

Besides knowing job descriptions, review the policies and procedures on skill requirements for specific treatments, supervision, and reporting of problems or incidents. Also be acquainted with standards of care-particularly those dealing with patient safety issues such as infection control-that may be relevant to delegation practices. Standards differ from policies and procedures both in how they’re written and how they’re implemented. They focus on care outcomes, rather than on processes or rules, assuming that nurses and other professionals have the education and experience to know how to achieve the outcomes.

For example, a policy and procedure may state that a UAP is supervised by the RN and then define the steps of the delegation process. A standard may state, “The RN is accountable for task completion and determines the degree of supervision appropriate to the UAP and particular task.” Many hospitals have found that as they implement clear, outcome-focused practice standards, they need fewer policies and procedures.

Standards can define not only the role of UAPs but also what level of performance is expected of them. A standard might say, for example, “The Level I UAP independently gathers, documents, and reports specific vital signs data.”

In many hospitals, professional or shared governance councils, particularly the practice council, are empowered to establish and maintain care standards for both the professional and technical- or support-level nursing staff. Councils base institutional standards on those of professional nursing, the state nurse practice act, state department of health regulations, statements from the ANA, and the JCAHO criteria.

Whether in policy statements or practice standards, certain issues should be addressed-the levels of nursing staff from UAPs to RN, the staff mix, what training assistive staff must receive, and how it should be carried out.

Is the worker competent to perform the task?

Practice and job descriptions, policies and procedures, and standards alone don’t guarantee that a UAP or other worker will have sufficient training and ability to perform job duties proficiently and safely. Before delegating a task, you need to know whether the worker is capable of carrying it out.

The JCAHO requires written documentation of staff competence. A training program can help ensure competence. An effective program comprises training in various kinds of skills, not just in the rote performance of basic care tasks (see Important Skills for UAPs on page 46).

Communication skills such as conflict resolution and listening are important, since UAPs are expected to understand directions and won’t necessarily be experienced in doing so. Because UAPs have to make decisions, such as when to call or report information to an RN, training should also cover decision-making skills. Critical thinking skills, too, are necessary-UAPs, for example, must be able to recognize when the potential for harm to a patient exists.

Some may view such training as too expensive in a time of budgetary constraints. But ensuring that UAPs are competent is crucial to the success of a restructured nursing staff. Misunderstandings about roles and miscommunications, as well as subpar performance of tasks, can lead to mistakes that put patients at risk and may ultimately prove costly to the institution.

Taking part in the training of UAPs and the continual refining of their skills can diminish the fear of working with unlicensed staff as well as familiarize you with what they can do. And UAPs are more likely to communicate openly and report information quickly if you create an environment of cooperation and trust.

A staff empowerment model can help involve clinical RNs who will supervise support staff in the design of their jobs and later evaluation. At Sharp Memorial Hospital, where I used to work, the acute care clinical practice and education councils shared responsibility for overseeing nursing assistant competence, from directing orientation programs to review and evaluation of individual workers and their job descriptions. Over several years, the skill mix evolved from one UAP (called a basic nursing assistant or NA) on a shift to approximately one UAP for every two RNs, and the UAP role expanded. It was essential to periodically update the job description (such as by creating level I and level II roles) to reflect the greater scope of UAPs’ work.

Governance councils provided a unit-based and divisional system for bedside RNs to quickly identify job design problems and concerns and to work with nursing managers in making skill-mix decisions while addressing budget goals. Working through shared governance, clinical RNs were able to articulate the need for well-trained assistants, and to see that this need was addressed and appropriate training provided.

You may not get involved in UAP training. But you should at least know how long your UAP’s training program was, what he was trained to do, and how he fared when his skills were tested. Documentation of training, however, doesn’t guarantee that every UAP will be capable of every task included in the job description. You have to be certain that a UAP has the skills and knowledge necessary to perform a task you assign. If you’re at all unsure, watch the person do it or demonstrate it to him and have him do a return-demonstration before he does it on his own.

What are the patient’s needs?

Whether it’s appropriate to delegate a care task-even one a UAP is fully capable of performing-depends also on the patient’s condition and the level of care he requires. Your critical thinking skills are challenged as you look at the patient in all his complexity-his spiritual needs, emotional state, and cognitive function as well as clinical condition and physiologic status.

Generally, the more stable the patient, the more likely that you’ll be able to delegate aspects of his care. For example, a UAP can be assigned to take vital signs in a patient who’s recovering well from elective surgery. With a critically ill patient, however, you may want to monitor vital signs yourself because you’re more likely to immediately detect a downturn in the patient’s condition. Similarly, you may be less likely to delegate tasks when a patient requires complex treatment or monitoring devices, such as infusion pumps or multiparameter monitors, unless the UAP is familiar with these devices.

A less obvious situation is when a task that could be delegated is intertwined with a nursing responsibility. You might choose to bathe a patient yourself if it allows you to assess her skin integrity more closely. You might even choose to perform this task because it gives you a chance to offer a troubled patient emotional support.

Are you communicating effectively?

Effective communication-sending clear messages and listening carefully-is the foundation of successful delegation. In making an assignment, be sure to give clear directions-what you want done, why, and how soon. Instead of saying, “Please take Mr. Kowalski’s temperature,” say, “Please take Mr. Kowalski’s temperature right away so we can get packed red cells from the blood bank.” (Note the word “please,” which is always appreciated.)

If appropriate, also give the UAP specific instructions on when he should call or see you. Rather than saying, “Let me know if Ms. Chapman’s blood glucose is too high,” say, “Call me immediately if Ms. Chapman’s blood glucose is above 240.”

Ask the UAP to repeat what you’ve said, especially if you aren’t sure he understands the directions. Though you should let the UAP know that you’ll be available if he has any questions or encounters a problem, give him a chance to ask questions before you leave.

How much direction and supervision you’ll have to provide will depend on state regulations, practice standards or policies in your setting, and the training and job description of the worker. But you should also keep in mind the UAP’s skill level and experience and degree of trust you have developed with him. You would supervise a newly trained or float UAP more closely than one you work with regularly.

With any assistant, supervise in a supportive way; try not to be critical or confrontational. Listen to any concerns the UAP may have about performance of the task or about the patient. Again, make it clear that you’re available for answering questions or demonstrating the task.

Are you evaluating the worker’s performance?

The last step of the delegation process is evaluation. Evaluate both the assistant’s performance and the patient’s response to the intervention. If the UAP has done the job well, praise him. If he hasn’t, communicate specifically but in a supportive manner what mistakes he made. It’s always best to give criticism in private. And remember to say “thank you” for a job done well and in a timely manner.

Subpar performance by a UAP may be due to inadequate training or preparation. If the assistant doesn’t perform as well as can be expected from his training, speak with him privately to identify the reasons and to explore possible ways to improve his performance.

You might say, for example, “Lou, Ms. Chapman is upset that she was poked three times before you got a blood sample for glucose testing. Do you think you could use more practice in using the lancet? Would you like me to demonstrate it again”?

An assistant may have been assigned an unusual number of tasks and had trouble prioritizing them. Clearly communicating the importance of a task and whether it must be done immediately or can be done later can help prevent such situations. When they do occur, specific, constructive feedback can help keep them from happening again. Suppose, for example, that the UAP, after completing other tasks, has hurried through skin care of some patients who have spinal cord injuries. You might say, “Lou, I noticed that you didn’t follow the special skin care regimen we have for spinal cord injured patients. It’s vital that those patients get good skin care. Can you tell me what happened?” Many training programs include “what if” scenarios to help UAPs prioritize with the RN and handle a variety of potentially difficult care situations.

IMPORTANT SKILLS FOR UAPs

Basic Care

• • Understanding hospital standards, policies, and procedures
• • Taking vital signs
• • Measuring and recording intake and output
• • Transfers and body mechanics
• • Basic life support
• • Postmortem care
• • Documenting care measures listed above

Communication

• • Introducing oneself to a patient and his family
• • Listening to nurses and patients
• • Resolving conflicts between oneself and co-workers or patients
• • Giving and receiving feedback

Decision-making

• • Prioritizing tasks
• • Deciding what to report and when to the RN
• • Handling complaints from patients and families

Critical thinking

• • Identifying abnormal vital signs
• • Identifying risks to patients
• • Reporting a problem quickly to the RN

Never ignore poor performance. Document it (recording the facts of the matter, not your opinions), especially if it may threaten a patient’s safety, and report it to your unit manager. Your manager can advise you on how and where to document performance problems. Incident or variance reports are sometimes used for such purposes. Additional training of the UAP may solve the problem. If it becomes necessary to dismiss the UAP, documentation noting his chronic problems and remedial action you and others took will show that he was treated fairly and legally.

Does the patient know who’s caring for him?

Patients and their families need information about the care environment and the care team to prevent confusion and unnecessary worry. Many patients know that being hospitalized today isn’t quite what it used to be, but they may not expect to see staff members who are dressed like nurses but aren’t.

The JCAHO requires that health care organizations respect patients’ rights, and patients have a right to know who’s caring for them. So it’s important to name the types of caregivers on your unit, in simple terms, so that a patient doesn’t think that every uniformed person entering the room is a nurse.

Many nurses find it helps to briefly describe the health care team and even introduce staff members during the admitting process, so that the patient knows what to expect-and from whom. The patient should know who’s responsible for his nursing care, who else may be providing care, and whom he can call if he has special requests or problems.

When meeting a new patient, you might say, “Hello, Mr. Wilson. My name is ___ and I’m your registered nurse. I’ll be admitting you and overseeing your care during my shift. My nursing assistant, Lou, will show you around your room and will check your vital signs. He’ll also help to keep you comfortable. If you or your family have any concerns, please let me know, or ask Lou to let me know, so that I can take care of them. We work as a team, but I have primary responsibility for your care.”

Rewards of mastering the art of delegation

Whatever your views on the use of unlicensed staff, take advantage of any opportunities your institution offers for learning more about how to delegate. One reason to develop good delegation skills is, of course, to protect yourself. If you know what you as a nurse can and can’t delegate and what staff members are trained and able to do, and you assign care tasks accordingly, you’re unlikely to put your license at risk.

Similarly, delegation skills are good malpractice insurance. Many nurses worry about being sued if a patient is harmed by an assistant’s actions. But the courts have generally ruled that supervisors aren’t vicariously liable for the actions of the employees under them, provided that the supervisor wasn’t negligent in supervision. This means that you’re relatively safe from liability claims resulting from an assistant’s actions if you have delegated and supervised properly. (That’s another good reason to document carefully when you run into problems.) The institution, not you, answers for its employees’ actions.

In a more positive vein, there’s a certain reward you get from mastering the art of delegation-rather like solving a puzzle. Let’s return to the delegation dilemma you faced at the beginning of this article.

You’d attend personally to Mr. Wong, who’s complained of pain. Assessment of any kind, including that of pain, can be performed only by an RN. Rather than tracking down Mr. Forbes’s laboratory test results for the physician yourself, you’d ask the unit clerk, who can easily retrieve this information. However, you would call the pharmacist yourself to let him know Mr. Pearson received his scheduled tobramycin. This allows you to discuss matters related to the drug, such as whether it’s necessary to perform plasma testing to monitor drug concentration. You’d instruct the nursing assistant to test Ms. Perez’s blood glucose right away (and to inform you immediately if it’s above 180), and then, after he’s taken routine vital signs for your patients, to assist Ms. Turner to walk no more than 10 feet from her chair and back.

In the real world of nursing practice, delegation is often a challenge. But as you master the art of supervising assistive staff, you’ll learn to deploy your organization’s resources more effectively on behalf of your patients. And you’ll gain a skill that will serve you well throughout your career.

SELECTED REFERENCES

1. American Nurses Association. Position statement on registered nurse utilization of assistive personnel. Am.Nurse25(2):7-8, Feb. 1995.
2. Anon. Working with UAPs. NSO Risk AdvisorSept. 1995, pp. 1,6.
3. Hansten, R. I., and Washburn, M. Delegation: How to deliver care through others. Am.J.Nurs.92(3):87-90, Mar. 1992.
4. Hansten, R. I., and Washburn, M. Knowing how to delegate. Am.J.Nurs.95(7):16H, 16J, 16L, July 1995.
5. Huber, D. G., et al. Use of nursing assistants: Staff nurse opinions. Nurs.Manage.25(5):64-68, May 1994.
6. Juleff, G. L. Assessing competencies of the nursing assistant. Nurs.Manage.26(8):77,80, Aug. 1995.
7. Rogers, C. R., and Roethlisberger, F. J. Barriers and gateways to communication. IN People: Managing Your Most Important Asset,ed. by Editors of the Harvard Business Review.Boston, Harvard Business Review, 1988.

Complete quiz post reading the above article.

 

• 22. The delegation “rights” a nurse must ensure include all of the following except
  • a. the right patient.
  • b. the right feedback.
  • c. the right communication.
  • d. the right person.
• 23. In most practice settings, it’s considered inappropriate for unlicensed assistive personnel to be assigned
  • a. to an RN.
  • b. to an LVN/LPN.
  • c. directly to patients.
  • d. to perform nurse-selected tasks.
• 25. The basis for successful delegation is effective
  • a. communication.
  • b. competency.
  • c. supervision.
  • d. evaluation.
• 29. Job descriptions for unlicensed assistive personnel should be
  • a. left purposefully vague to allow flexibility in using these workers.
  • b. detailed, explaining what tasks the workers can and can’t perform.
  • c. based mainly on Joint Commission for Accreditation of Healthcare Organizations criteria.
  • d. developed solely by human resources professionals, since they’re experienced in writing job descriptions.
• 30. The scope of practice of a licensed practical nurse is defined by
  • a. the nurse’s level of experience.
  • b. state law.
  • c. the employing institution’s policies and procedures.
  • d. schools of nursing.
• 31. The scope of practice of unlicensed assistive personnel is defined by
  • a. job descriptions.
  • b. state regulations.
  • c. institutional policies.
  • d. all of the above