AACN Delegation Handbook, 2nd Edition Edited by: Deborah Ann Snyder, RN, MSN, CCRN Justine Medina, RN, MS Linda Bell, RN, MSN Teresa Ann Wavra, RN, MSN, CCRN, CCNS Copyright © 2004 TABLE OF CONTENTS Introduction...................................................................................................................3 Members of the Patient Care Team............................................................................4 Definitions of Delegation..............................................................................................5 Activities That May be Delegated................................................................................5 Direct Patient Care Activities......................................................................................6 Indirect Patient Care Activities...................................................................................7 Activities That May Not Be Delegated........................................................................8 Training of UAP........................................................................................................... 9 RN Scope of Practice and Encroachment.................................................................. 9 Deciding to Delegate.................................................................................................. 10 Effective Work Teams............................................................................................... 10 The 5 ‘Rights’ of Teamwork......................................................................................11 Recommendations to Ensure Successful Delegation................................................12 References....................................................................................................................16 Appendix A..................................................................................................................18 2 Introduction The Health Resources and Service Administration, (HRSA), National Center for Health Workforce Analysis is the primary federal agency responsible for providing information and analysis relating to the supply and demand of healthcare professionals. In 2000, the number of full-time employed registered nurses (RNs) nationwide was an estimated 1.89 million, while the demand was estimated at 2 million, resulting in a shortage of 110,000 or 6%. Based on historical trends, nursing shortages have been identified as a cyclical phenomenon. Unfortunately, with the current supply of RNs and their anticipated demand, the shortage is expected to continue to grow until 2010, by which time the HRSA forecasts the nursing shortage will reach 12%.1 Today advanced technology, higher acuity, and shorter lengths of stay leave an ever changing healthcare delivery environment. Cost-containment strategies leave RNs struggling in attempts to maintain high quality standards for delivering safe and competent nursing care with nurses spending more of their time on indirect patient care (non-nursing tasks), taking away from the provision of direct patient care. Ensuring the optimal use of an RN’s time is an important strategy in maintaining the delivery of high quality patient care. It involves allocating resources, maintaining adequate staffing determined by patient acuity, and establishing efficient support systems for patients and families. Concurrently, in the wake of the current nursing shortage and increased emphasis on cost-containment, it is vital for nursing administrators to identify strategies that allow their organizations to compete for viability in a lean and highly competitive healthcare market. One strategy may be redesigning the nurses’ workload by utilizing support personnel to assist in performing selected indirect patient care activities typically performed by nurses. The American Association of Critical-Care Nurses maintains the position that “the fundamental objective in reallocating these activities enables the nurse to concentrate and focus on the patient and their family members.”2 Unfortunately, in the 21st century, there has not been a great deal of research on the subject of delegation in general. More importantly, there has been precious little research on teaching nurses how to delegate effectively. 3 Members of the Patient Care Team Staffing decisions are made to guarantee that appropriate staffing patterns exist to ensure patient safety and quality patient care. Changes in clinical practice, patient needs, and financial resources have prompted the implementation of skill mixes in providing patient care. Today, RNs may have to delegate certain aspects of care to licensed vocational nurses (LVNs), licensed practical nurses (LPNs), unlicensed assistive personnel (UAP), and monitoring technicians. Patient care team members and their roles RNs (cid:131) Determine the scope of nursing practice. (cid:131) Are responsible and accountable for the provision of nursing services. (cid:131) Supervise and determine the appropriate use of any UAP involved in patient care. (cid:131) Define and supervise the education, training, and utilization for any UAP. LVN/LPN (cid:131) Complete a 1-year to 18-month educational program. (cid:131) Provide basic patient care that includes but is not limited to taking vital signs, dressing changes, performing phlebotomy, and assisting with activities of daily living, under the supervision of the RN. UAP3 (cid:131) Work under the direct supervision of an RN to implement the delegated aspects of nursing care. (cid:131) Assist the RN in providing patient care. (cid:131) Enable the RN to provide nursing care for the patient. (cid:131) May include but are not limited to the following titles: o Patient care assistants o Nurses aides o Technicians o Multi-skilled workers o Practice partner o Nursing assistant o Nurse extenders o Orderlies o Support personnel o Practice partners The American Nurses Association (ANA) defines UAP as “an unlicensed individual who is trained to function in an assistive role to the licensed nurse in the provision of patient/client activities as delegated by the nurse.”4 Activities that may be delegated by RNs to UAPs are categorized as either direct or indirect patient care. Direct patient care activities assist the patient in meeting their basic needs. (cid:131) Indirect patient care activities focus on maintaining the environment in which nursing care is delivered and only incidentally involve direct patient contact. 4 Definitions of Delegation 1. ANA position statement “RN Utilization of UAP.” Defines delegation as “the transfer of responsibility for the performance of an activity from one person to another while retaining accountability for the outcomes.”4 The ANA further defines delegation categories. Direct delegation is defined as “a specific, usually verbal, direction from the delegator for another person to perform task/activity in specific nursing care situation.” Indirect delegation involves using a list of tasks and activities that have been approved by the healthcare facility.4 2. The Joint Commission on Accreditation of Hospitals Association (JCAHO) does not define who provides indirect or direct patient care. It does, however, mandate each organization to have evidence that an individual’s knowledge, experience, and competence are appropriate for his or her assigned responsibilities. JCAHO also requires that qualified individuals assess each patient’s need for care, recognizing that it is the RN who is responsible for assessing the patient’s need for nursing care.5 3. National Council of State Boards of Nursing defines delegation as “transferring to a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains accountability for the delegation.” 6 Activities That May be Delegated The nursing process can be utilized as a framework to support the RN in delegating patient care activities to support and assistive personnel. Prior to delegating, the RN assuming care of the patient is responsible for completing an assessment of the patient as well as reviewing the patient’s individualized plan of care. The RN should also verify proper training and competency evaluation of UAP before a task is delegated. Regardless of how simple the delegated task may seem, the RN is responsible for patient outcomes. Institutional policy and regulations from state boards of nursing and state departments of health may govern the activities of support personnel. (Appendix A) The following lists are examples of patient care activities that might be delegated:3 5 Direct Patient Care Activities Vital Signs (cid:131) Take and record blood pressure, respirations, temperature, and pulse rate (cid:131) Obtain daily weight (cid:131) Apply leads and connect to cardiac monitor (cid:131) Obtain 12-lead ECG (cid:131) Perform chest compressions in life support situations Intake and Output (cid:131) Measure and record intake and output (cid:131) Collect specimens Activities of Daily Living (cid:131) Perform total or partial bed bath (cid:131) Perform perineal care (cid:131) Shave (cid:131) Wash hair (cid:131) Perform mouth care (cid:131) Change linen and assist with making occupied bed Nutrition (cid:131) Feed patient (cid:131) Calculate and record calorie count Skin Care (cid:131) Perform back care (cid:131) Prepare skin for procedure (cid:131) Perform skin prep for operative procedure Activity and Mobility (cid:131) Assist in ambulating patient (cid:131) Perform passive and active range of motion (cid:131) Position (cid:131) Turn and reposition patient (cid:131) Assist with transfers 6 Respiratory Support (cid:131) Set up oxygen (cid:131) Assist patient with using an incentive spirometer (cid:131) Assist patient with coughing and deep breathing exercises (cid:131) Perform oral suctioning using an oral suction device Procedures (cid:131) Set up patient room (suction canisters, cables for continuous cardiac monitoring, tubing for chest tubes) (cid:131) Orient patient to room environment (cid:131) Set up and calibrate hemodynamic monitoring equipment (cid:131) Obtain necessary supplies for sterile procedure (cid:131) Discontinue peripheral intravenous catheter (cid:131) Perform postmortem care Indirect Patient Care Activities Cleaning (cid:131) Clean equipment in use and stored equipment (cid:131) Clean environment, including counter tops and desk tops (cid:131) Clean and defrost food refrigerators (cid:131) Clean patient care area after transfer or discharge (cid:131) Clean patient care area after procedures are completed (cid:131) Empty waste baskets in patient rooms and unit (cid:131) Empty linen hampers (cid:131) Remove meal trays (cid:131) Clean supply carts (cid:131) Clean and restock procedure rooms (cid:131) Make unoccupied beds Errands (cid:131) Deliver meal trays (cid:131) Obtain and deliver supplies (cid:131) Obtain and deliver equipment 7 (cid:131) Obtain and deliver blood products (cid:131) Check laboratory specimens for appropriate labeling (cid:131) Deliver specimens to clinical laboratory Clerical Tasks (cid:131) Place pages (cid:131) Place and answer phone calls (cid:131) Assemble, disassemble, and maintain patient chart (cid:131) Transcribe physician and nursing patient care orders (cid:131) Schedule diagnostic tests and procedures (cid:131) Order necessary office supplies and forms (cid:131) Sort and deliver mail (cid:131) Assist with unit orientation for float and registry ancillary personnel (cid:131) Prepare charges for unit-based billing (cid:131) Problem solve and locate lost charges (cid:131) Keep unit log books up to date with patient admissions, transfers, and discharges (cid:131) Maintain awareness of nursing bed assignments (cid:131) Update and retrieve information systems data Stocking and Maintenance (cid:131) Stock patient bedside supplies (cid:131) Stock unit supplies (cid:131) Stock utility rooms (cid:131) Stock treatment, examination, and procedure rooms (cid:131) Stock nourishments and kitchen supplies (cid:131) Check electrical equipment for inspections due dates (cid:131) Stock linen cart Activities That May Not Be Delegated Nursing activities that may not be delegated include: (cid:131) Performing an initial patient assessment and subsequent assessments or nursing interventions that require specialized nursing knowledge, judgment, and/or skill (cid:131) Formulating a nursing diagnosis 8 (cid:131) Identifying nursing care goals and developing the nursing plan of care in conjunction with the patient and/or family (cid:131) Updating the patient’s plan of care (cid:131) Providing patient education to patient and/or family (cid:131) Evaluating a patient’s progress, or lack thereof, toward achieving desired goals and outcomes (cid:131) Discussing patient issues with physician (cid:131) Communicating with physicians or implementing orders from physician (cid:131) Documenting the patient’s assessment, response to therapeutic interventions, in the patient’s plan of care (cid:131) Administering medications (cid:131) Providing direct nursing care Training of Unlicensed Assistive Personnel (UAP) Hospitals and other healthcare agencies are ultimately responsible for the orientation and training of an UAP. “The hiring of UAP’s increases the responsibility for orientation and training of these individuals because at this time, no community standards for content of training programs exist for these workers.”7 New employee orientation programs should include information about the training and competency expectations for UAP. The task that can be done by the UAP should be included in the written job description and assessed annually during performance evaluations. RN Scope of Practice and Encroachment When working with support personnel and delegating patient-care activities, RNs must be aware of encroachment. Encroachment is the act of trespassing or intruding. In nursing practice, encroachment is working outside the defined scope of practice. State nurse practice acts define activities that only a nurse can perform because there may be significant risk of harm to the public if they are performed by someone lacking the necessary skills, knowledge, and clinical abilities.8 RNs can only delegate nursing tasks; the practice of nursing cannot be delegated.9 9 Deciding to Delegate A consideration of the likely effects and consequences is critical when deciding to delegate. Assessment of the following factors must occur before deciding to delegate a nursing activity to anyone, for example, RNs, LVNs, UAPs, or other healthcare team members. 10 Potential for Harm: The nurse must determine how much risk the activity carries for an individual patient. Complexity of the Task: The more complex the activity, the less desirable it is to delegate. Only an RN should perform activities requiring complex psychomotor skills and expert nursing assessment and judgment. Amount of Problem Solving and Innovation Required: If an uncomplicated activity requires special attention, adaptation, or an innovative approach for a particular patient, it should not be delegated. Unpredictability of Outcome: When a patient’s response to the activity is unknown or unpredictable (depending on how stable the patient is), it is not advisable to delegate that activity. Level of Patient Interaction: Will delegation of a particular activity increase or decrease the amount of time the RN can spend with the patient and the patient’s family? Every time a nursing activity is delegated or one or more additional caregivers become involved, a patient’s stress level may increase, and the nurse’s opportunity to develop a trusting relationship is diminished. Effective Work Teams The delegation of direct and indirect patient care to other caregivers is reasonable, relevant, and practical. However, the concept of delegation is difficult for many nurses. Nurses who entered the workforce over the past 10 to 15 years have been socialized to a primary care delivery model in which the nurse is responsible for rendering all direct patient care. Team nursing was the predominate care delivery model before that time. Nurses in both groups may have a difficult time delegating because they highly value providing patient care. Each can benefit from appropriate training and mentoring to develop the skill of delegation. It is important to keep in mind that “effective teams focus on integrative work processes while working toward a common goal.” 11 10