Does Delegation Help or Hurt Nursing?

The first nursing school was established in India in about 250 B.C., and only men were permitted to attend because men were viewed to be more pure than women. If you think of a woman dressed in scrubs with a stethoscope around her neck and a clipboard in her hands, you aren’t alone. An overwhelming majority of nurses in the United States today are women. However, nursing began as a practice reserved for men. It wasn’t until the 1800's that nursing became an organized practice.

During the Crimean War, Florence Nightingale and 38 volunteer nurses were sent to the main British camp in Turkey. Nightingale and her staff immediately began to clean the hospital and equipment and reorganized patient care. Nightingale pushed for reform of hospital sanitation methods and invented methods of graphing statistical data. When she returned to Britain, Nightingale aided in the establishment of the Royal Commission on the Health of the Army. As a woman, Nightingale could not be appointed to the Royal Commission, but she composed the Commission’s report. (Travel Nurses of America, 2010) Completed, the report was over 1,000 pages in length and included detailed statistical information.

Nightingale’s work led to drastic changes in army medical care, the establishment of an Army Medical School and medical records, and ignited the growth of nursing as an organized profession. For these contributions, Nightingale is widely accepted as the founder of nursing. Ironically, nursing has been taken on as a feminine profession, although as aforementioned, that was not its intention. Nursing are an extremely vital component of health care settings. According to the World Health Organization, nursing is defined as such: “Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. It includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people.”

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Keeping that definition in mind, nurses ensure that patients are being taken care of properly and efficiently. It is obvious that one nurse alone cannot do all the work that a health setting requires. This is where the idea of delegation comes into play. One of the vitals skill required by the Registered Nurse is the skill to assign tasks to subordinates (Saccomanos and Pinto-Zipp, 2011). When tasks are delegated to subordinates, the RN remains accountable (Nursing and Midwifery Council 2008). This concept of work delegation has positive and negative effects.

On one hand, it helps the RN (Registered Nurse) do more work in a shorter period of time, yet the downfall is that if the subordinate makes any mistakes, the results could be fatal and would still rest solely on the hands of the RN. Hence, delegation involves “responsibility, accountability and authority”. This research paper will analyze the role of a RN in relation to delegation.

This essay will examine the role of the registered nurse in relation to delegation. Areas that will be examined include definitions of delegation, benefits of distributing workloads, management in relation to delegation, nursing process and procedures when delegating, common mishaps of delegation, five rights of delegation, and barriers nurses must break through when to delegating. In conclusion, this paper will hopefully convey the importance of an RN, delegation, and how this effects the quality of care patients receive.

Delegation can be a useful tool that cuts costs, or a costly disaster waiting to happen From a management prospective, delegation is the idea of assigning tasks to other employees that a manager is currently undertaking. While delegation can be extremely helpful for speed, the question of efficiency and accuracy come into play. Delegation is seen as a daily routine in clinical settings which can be traced back even to the Bible. Moses delegated to his Father-in-Law Jethro, asking why would everyone sit around and have you work alone? But what does delegation mean to Nursing? Delegation, as defined by the American Nurses Association, is the ability to handover responsibility for the performance of a duty from one person to another while being held accountable for the outcome.

While effective, delegating another person in a health setting has its risks. Supervision is an essential tool in delegation because it involves direction, evaluation and follow up which must be provided by the RN to those she/he is delegating the task to (Finkelman 2006). However, the National Council of State Boards of Nursing (1995) also defines delegation as giving authorization to a capable individual to execute a particular nursing task in a particular situation. According to Lookinland, author of Team Nursing, the Registered Nurse was solely responsible for the care of the patients but due to staff shortage, budgetary constraints and high rate of sicker patients, the need to delegate duties to other Non-Registered personnel arose.

Delegation provides a lot of benefits for both the organization and the staff. Cost effectiveness and time savings have been identified as the benefits of delegation as these helps the organization to utilize resources and staff in an appropriate manner (Finkelman 2006). Consequently, Pearce (2006) suggested that delegating repetitive tasks could lead to RN’s time being used efficiently for other tasks. Moreover, when tasks are assigned to others, it leads to the tasks being done in an efficient manner and an increase in productivity (Finkelman 2006).

In the same light, Potter et al. (2010) stated with delegating duties to other staff, professional growth can occur as these staff have the opportunity of learning new skills, and having enough time in engaging in other activities. When delegation is used in an effective way, it builds up teams and improves quality care (Finkelman 2006). Chapter Three: Nursing and Delegation- Management Theory.

Delegation can be direct (such as verbal instructions e.g. assisting patients with activities of daily living) and indirect which involves activities carried out based on hospital policies (Masters 2009). Nursing management, when referring to Maslow’s Hierarchy of Needs, is a useful organizational framework that can be applied to the various nursing models for assessment of a patient’s strengths, limitations, and need for nursing interventions. (Smeltzer SC, Bare BG, 2004) It is noteworthy to state that in relation to delegation, the registered nurse who delegates task retains
accountability and responsibility for such task (ANA 2005).

Due to the risks and various factors in a health setting, it is important that a RN keeps in mind that when delegating task to any individual, the task should be well understood and that the individual carrying out the task should be knowledgeable, trained and competent enough to carry out the task being delegated (Masters 2009). Accordingly, and when good management is implemented among the nursing staff, when authority is passed from the RN to the delegate during delegation, it is appropriate to inform other members of the organization as they need to be aware of which task has been allocated and to who. It is also imperative for the employee to have access to resources as well as for the RN to allow the employee to take control of the task (Finkelman 2006).

Also, in the textbook, Fundamentals of Nursing, Patricia Potter stated that when delegating task, the RN must ensure adequate two way communication. Communication should be clear, brief and complete as effective communication is a key element of delegation (Potter et al. 2010). As a result, good communication allows the unlicensed personnel to ask question and seek clarifications where necessary. The RN should ensure that the unlicensed personnel understands what the delegated task entails and that he/she readily accepts the delegation as well as the responsibility that goes with (Finkelman 2006). Therefore, where the RN feels that when delegating task to unlicensed personnel may be unsafe, or that the person lacks competency or if she/he feels they may not be available to supervise such task, she/he has the right to inform the manager and refuse to delegate the task to any person they deem unfit. (NMC 2008)

Furthermore, as indicated by the NMC (2008), no one should be under any form of pressure to either delegate or agree to do a delegated task. Many times nurses have strengths and weaknesses in their profession. It is important to understand or recognize a nurse who is uncomfortable with a task or struggling. Management should also make it clear that staff should communicate to management if they need assistance.

Chapter Four: How is Nursing Organized? How is delegation run? In nursing, there are several categories that an RN can fall into. There are matron nurses, director of nursing, nurse managers and charge nurses. The matron nurse is the head senior nurse and in charge of delegation and subordinate tasks. If tasks and duties fail to be met, they are held accountable. The director of nursing is also a senior nurse, but tend to report to the CEO of the hospital. They oversee all tasks done by the matron, registered nurses and nurse managers. They are responsible for producing data and ensuring standards are being met.

Nurse Managers are responsible for a nursing unit and typically report to the matron. They are given a unit of nurses and delegate tasks and patients to them. And then there is a charge nurse who is the frontline of management for the nurses on a shift. The charge nurse oversees all the RNs. Registered nurses are extremely important in terms of delegation. Registered nurses are above certified nurse’s assistants and licensed nurse practitioners. It is crucial that an RN supervises and gives feedback on tasks that are performed because this creates an avenue for the subordinate to know where or what went wrong and how it could be improved upon to deliver quality health care.

In delegating tasks to an unlicensed personnel, the RN decisions should be based on the delegation process (that is assessment, planning, implementation and evaluation) which will help in reducing the risk associated with delegation (Newmann 2010). The assessment stage looks at if the delegated task is suitable for the delegate. The planning stage involves determining the competence of the individual to carry out the task and ensuring safety measures, implementation deals with the RN observations through supervision and evaluation gives a breakdown of the completion of the task (Neumann 2010). This process as indicated by Neumann (2010) is done to protect the nurse and employers against any legal issues that may arise as well as for the safety of the patients.

Delegated duties to unlicensed personnel must be within their scope of practice for which that person has the training and not tasks that may require having a certificate or license (Zimmerman 2001). Tasks which may be delegated to unlicensed personnel’s include tasks like activities of daily living, taking vital signs, errands and clerical duties (Zimmerman 2001). Other tasks which Zimmerman mentioned should not delegate by the RN to unlicensed personnel include duties such as nursing skills that involve invasive procedures, expert knowledge and professional decisions relating to patients care.

If the RN delegates tasks inappropriately, it could lead to the loss of her/his registration license and issues of liability may need to arise (Finkelman 2006). Before an RN delegates a task to individual or unlicensed personnel, care must be taken into consideration in relation to assessing proper training and level of competency of the individual regardless of how easy the delegated task may appear to be (NCSBN 2005). Unfortunately, the results of a failed task or malpractice do rest on the RN. It is important to delegate to knowledgeable individuals who understand their task fully.

There are certain errors and mistakes that occur during delegation. The most reported errors include over delegation, under delegation and improper delegation (Feldman et al. 2008). Over delegation arises when time management skills are not properly developed in an individual or where one is not too sure about their own capability to carry out a task (Feldman et al. 2008). Under delegation as stated by Feldman (2008) happens when the RN has no confidence in the subordinate to perform the task which is to be delegated while improper delegation means delegating task outside an individual’s expertise.

In order to avoid such common mistakes and being a professional, when delegating task, the RN must be familiar with the five rights of delegation which the NCBSN (1995) identified as right task, right circumstance, right person, right direction and communication, right supervision and evaluation. The right task has to do with deciding if a task should be delegated for a specific patient. The right circumstances looks at the client’s environment, client’s conditions and available resources. The right person takes into account the right individual delegating the right task to the right person to carry out the task on the right patient.

The right direction or communication focuses on communication being clear and having a concise description of the task explained including all expectation for having the tasks accomplished. The right supervision deals with monitoring the task, implementation, evaluating task and also providing feedback in relation to the task (ANA 2005). These rights as noted by the NCBSN (2005) assists the RN to determine a suitable and appropriate method to use during delegation. Delegation is seen as a process which the RN has to be properly equipped and well educated in (Finkelman 2006). However, delegation can become problematic in relation to shortage of staff, having to do obnoxious task and the inexperience of the subordinates (Curtis and Nicholl 2004).

Administration will then face a barrier such as lack of trust in the subordinates which leads to the attitude of “doing it all by myself” (Feldman 2008). This can affect effective delegation because when leaders lack trust in their subordinate’s capabilities, they are likely to make mistakes (Feldman, 2008). Similarly, some RNs may feel they are perfectionist and as a result are unlikely to delegate because of the fear of having to deal with any negative outcomes by the subordinates (Curtis and Nicholl 2004). This causes hostility within administration. It is very expensive to have head nurses on the floor, yet if they won’t delegate workload, they must be there.

This causes cost to go up, speed to go down, and employee trust to diminish. In relating this to clinical practice, some nurses may not be willing to delegate tasks to student nurses for fear of being held accountable for any mistakes. As stated by the NMC, the RN who decides to delegate is held accountable for such delegation. It causes a lack of trust on the floor from one employee to another. Another barrier as identified by Curtis and Nicholl (2004) occurs when there is shortage of staff or having inexperienced staff members. This leads to staff being overburdened with work load. As suggested by Curtis and Nicholl (2004), when there is shortage of staff, it is imperative for the work load to be lessened until there is an improvement in the availability of staff.

Many nurses may feel that tasks that are beneath them can be constituted as a barrier in delegation. As indicated by Feldman (2006) when managers discriminate by delegating tasks which may be unpleasant or boring to certain subordinates and keep the better or interesting tasks for certain people, it leads to subordinates refusal to perform such tasks. For this reason, it is essential to assign task which are interesting and task should be assigned equally and fairly to all individuals concerned taking into
account their skills and ability (Kourdi 1999).

This impacts management negatively. It causes the head nurses to get away with picking and choosing their tasks while the employees beneath them become frustrated and annoyed. Tasks must be divided up fairly, not just because the head nurse does not want to do them.

Conclusion:

In conclusion, delegation as discussed in the essay is considered to be an essential aspect of nursing and play an important role for the RN. As Marquis and Hustin (2008) stated, “delegation is a necessity and not an option”. So it is important that nurses as well as students preparing to become nurses are well trained and equipped in this field. As someone who is going to school in September for Nursing, I am fully aware that delegation is vital. If there is a team effort, then tasks will get done much faster and much more accurate.

Delegation is an important nursing skill which requires a systematic plan to ensure optimal patient care (Finkelman 2006). Referring back to Maslow, nursing needs to be organized and delegated appropriately. Delegation is a skill that can be calculated to minimize costs, maximize quality, and ensure effectiveness. More management courses in health care should be given to depict how to delegate properly, not just with nursing, but perhaps with all health care personnel. Since delegation improves with practice, it is important for nurses understand when to delegate and how.

Learning these skills will also prepare the nurses in future to delegate task when they qualify and become RN’s. In relation to nursing practice, registered nurses should help other nurses by delegating tasks to them that are within their level of competence as well as making sure that all tasks assigned to them are duly supervised and follow up on the delegated task.

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