Delegation in Nursing

The National Council of State Boards of Nursing (NCSBN) and the American Nurses Association (ANA) have issued a joint statement on delegation which defines delegation as "transferring to a competent individual the authority to perform a selected nursing task in a selected situation". The nurse retains the accountability for the delegation. The nurse who delegates a task or assignment must know the chosen person is competent to do that task. The Registered Nurse (RN) selects the particular task, given the knowledge of the individual client's condition and that particular circumstance. Legally the RN is obligated to delegate based on the unique situation, clients, and personnel involved and for ongoing follow-up. Supervision is an integral part of delegation, whenever a nurse delegate, he or she must also supervise. Supervision is defined by NCSBN as "the provision of guidance and direction, oversight, evaluation and follow up by the licensed nurse for accomplishment of a nursing task delegated to nursing assistive personnel." The act of delegating is just the beginning of RN's responsibility. As for the accountability the delegates, they are accountable to "accept the delegation and for their own actions in carrying out the act." According to joint statement from ANA and NCSBN, The RN uses critical thinking and professional judgment when following the five rights of delegation which are: right task, right circumstances, right person, right directions and communication, and right supervision and evaluation. RNs should utilize a decision making process to delegate in a manner that protects public health, welfare, and safety.

The case scenario is on a medical surgical unit with 24 patients. The shift consists of one charge nurse two RN's, two LVN's, two CNA's and one unit secretary. One of the RN left for lunch break. A patient's family member is at the nursing station requesting to speak with the Charge Nurse. RN in the Emergency Department is on the phone requesting to give report to the nurse on the new admission being transferred to the unit. A 4-hour post-operative hysterectomy patient is requesting medication for pain. One of the patient requires assistance with feeding and another patient who is two days post hip replacement is asking for assistance to get up to the bathroom. The CNA notifies the charge nurse that a first day post-op cholecystectomy patient is complaining of difficulty breathing and shortness of breath. A physician is requesting assistance to perform several complex dressings on a client who has extensive packed wounds. The Radiology department has called and asked that a patient be prepared for an angiogram. They will send transportation in 30 minutes to pick up the patient.

The delegation process includes assessing client/patients and resources. The charge nurse assesses the health status of groups of client/patients, analyze the data and identify collective nursing care needs, priorities, and necessary resources. Staff RNs shall assess client/patients individual health status, analyze the data, and identify the client/patient's specific goals, nursing care needs and necessary interventions. First the RN charge nurse should develop a delegation plan. The delegation plan should include selecting and identifying nursing interventions which may be delegated. Staff RNs shall communicate decisions regarding selected interventions and the conditions of supervision to licensed nurses responsible to provide supervision and to unlicensed persons responsible to provide nursing interventions as appropriate. Then implement the delegation plan by providing direction and supervision. Directions/communications includes: initial instruction related to the delegated interventions, monitoring to assure that the delegated nursing interventions have been provided, and evaluating client/patient responses and delegated nursing interventions.

According to the joint statement on delegation by the ANA and NCSBN, the steps necessary for the delegation process is first assess and plan the delegation based on the patient needs and available resources. Then communicate directions to the delegate including any unique patient requirements and characteristics as well as clear expectations regarding what to do, what to report, and when to ask for assistance. The RN will be delegated to assess the first day post-op cholecystectomy patient who is complaining of difficulty breathing and shortness of breath. According to CPR guidelines priority will be given on airway, breathing and circulation. The RN will be given clear instructions on assessment of the client and instructed to ask immediate assistance if he/she needs. Surveillance and supervision of the delegation, including the level of supervision needed for the particular situation and the implementation of that supervision, including follow-up to problems or a changing situation.

The Nurse practice act in the state of California defines the practice of registered nursing as those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill, including all of the following: Direct and indirect patient care services that ensure the safety, comfort, personal hygiene, and protection of patients; and the performance of disease prevention and restorative measures. Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist, or clinical psychologist, as defined by Section 1316.5 of the Health and Safety Code. The performance of skin tests, immunization techniques, and the withdrawal of human blood from veins and arteries. Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics, and implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures.

The charge nurse needs to assess the 4-hour post-operative hysterectomy patient and administer necessary pain medication. The Board of Registered Nursing from the state of California, Licensed nurses make judgments regarding administration of ordered medications, timing of patient care activities, and phoning physicians regarding changes in patient conditions; these licensed nursing functions

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