Chapter 12 Murray Questions
1.
Which aspects are included in how nurses develop nursing judgment? Select all that apply.
1. Academic experience
2. Use of experience to help form an opinion
3. Analysis of information to help arrive at a decision
4. Leadership style
5. Level of administrative experience as opposed to being a staff nurse
Nursing judgment represents a clinical decision process based on analysis of information
supported by education and experience that are used to form an opinion. One's leadership style
and/or the level of administrative experience is not uniquely attached to the formation of nursing
judgment, as nursing judgment rests with the individual nurse rather than being ascribed to the
roles that are performed. Nurses exhibit nursing judgment independent of their leadership style
or the level of their administrative experience.
2.
Which examples represent improper use of delegation in the clinical setting by a registered nurse
(RN), licensed practical nurse (LPN), or unlicensed assistive personnel (UAP)? Select all that
apply.
1. UAP delegating a task to a LPN
2. RN delegating a task to a UAP or a LPN
3. LPN delegating a task to a RN
4. RN delegating a task to a RN
5. UAP delegating a task to a RN
In terms of delegation, a RN can delegate tasks to another RN, LPN, or UAP. LPNs may not
delegate to a RN but can delegate to a UAP. UAPs cannot delegate tasks.
3.
Which actions should not be delegated to a licensed vocational nurse (LPN) on a medical unit in
a hospital setting by a registered nurse (RN)? Select all that apply.
1. Initiating a blood transfusion
2. Inserting a urinary catheter
3. Administering chemotherapy infusion
4. Completing initial admission assessment
5. Performing post-operative dressing changes
Certain tasks cannot be delegated by an RN to a LVN, such as but not limited to initiation of a
blood transfusion, administration of chemotherapy infusions, and completion of an initial
admission assessment. The LVN can perform as a delegated task insertion of a urinary catheter
along with changing of a post-operative dressing.
4.
Introduction
Many definitions for delegation exist in professional literature. One of the most commonly cited definitions of the word was jointly established by the American Nurses Association and the National Council of State Boards of Nursing. These groups describe delegation as the process for a nurse to direct another person to perform nursing tasks and activities. Delegation involves at least two individuals: the delegator, and the delegatee. The delegator is a registered nurse who distributes a portion of patient care to the delegatee.
Essential Components of Delegation
Responsibility
Based on individual states’ nurse practice acts, registered nurses have a professional duty to perform patient care tasks dependably and reliably.
Authority
Authority refers to an individual’s ability to complete duties within a specific role. This authority derives from nurse practice acts and organizational policies and job descriptions.
Accountability
Accountability within the nursing context refers to nursing professionals’ legal liability for their actions related to patient care. During delegation, delegators transfer responsibility and authority for completing a task to the delegatee; however, the delegator always maintains accountability for the task's completion. The registered nurse is always accountable for the overall outcome of delegated tasks based on each state's nurse practice act provisions.
Possible legal and ethical constraints arise regarding delegation in nursing. Therefore, the American Nurses Association developed the five rights of delegation to assist nurses in making safe decisions.
Five Rights of Delegation
Right task
Right circumstance
Right person
Right supervision
Right direction and communication[1]
Issues of Concern
Five Rights of Delegation Case Study Approach
Mark is a new graduate registered nurse who has recently completed nursing orientation. He is now on his second week of non-precepted practice on a busy medical-surgical unit. During the middle of his busy night shift, Mark has several tasks that need to be completed quickly. These tasks include a linen change for a patient who just vomited, an assessment of a possibly infiltrated intravenous line, and the administration of intravenous pain medication for a patient who rates her pain 10 out of 10. Mark also needs to make hourly rounds within the next few minutes, and he is very behind on his charting. He knows he must delegate some of the tasks to his coworkers. However, Mark is unsure what he can delegate and to whom. He decides to use the five rights of delegation to help with his delegation decisions.
Right tasks
First, Mark needs to determine which tasks are right to delegate. Some questions he may ask at this time would include (1) which tasks are legally appropriate to delegate and (2) can I delegate these tasks based on this organization’s policies and procedures? Correctly answering these questions will require familiarity with institutional and nurse practice act guidance. Generally, registered nurses are responsible for assessment, planning, and evaluation within the nursing process. These actions should not be delegated to someone who is not a registered nurse.[2]
Right circumstances
After determining the right tasks for delegation, Mark considers the right circumstances of delegation. In so doing, Mark may ask the following questions: (1) are appropriate equipment and resources available to perform the task, (2) does the delegatee have the right supervision to accomplish the task, and (3) is the environment favorable for delegation in this situation? To appropriately answer these questions, it is imperative that Mark completes an assessment on each client. Patients who are or may become unstable and cases with unpredictable outcomes are not good candidates for delegation. For example, it may be appropriate for unlicensed assistive personnel to feed patients requiring assistance with the activities of daily living. However, if a patient has a high risk for aspiration and a complicated specialty diet, delegation of feeding to unlicensed assistive personnel may not be safe.
Right person
If a task and circumstance are right for delegation, the next “right” of delegation is the right person. Mark needs to consider if the potential delegatees have the requisite knowledge and experience to complete delegated tasks safely, especially concerning the assessed patient acuity. Before delegating a task, the registered nurse must know the delegatee’s job description and previous training. Mark may be unsure about his potential delegatee’s qualifications. Therefore, he might ask the following questions before delegating a task: (1) have you received training to perform this task, (2) have you ever performed this task with a patient, (3) have you ever completed this task without supervision, and (4) what problems have you encountered in performing this task in the past?
Right supervision
The right supervision must be available in all delegation situations. Nurse practice acts require the registered nurse to provide appropriate supervision for all delegated tasks. In the case study, Mark must be sure that the delegatee will provide feedback after the task is complete. Following task completion, Mark is responsible for evaluating the outcome of the task with the patient. Registered nurses are accountable for evaluation and the overall patient outcomes.
Right direction and communication
Finally, the delegator must give the right direction and communication to the delegatee. All delegators must communicate performance expectations precisely and directly.[3] Mark should not assume that his delegatee knows what to do and how to do it, even for routine tasks. Mark must consider whether the delegatee understood the assigned task, directions, patient limitations, and expected outcomes before the delegatee assumes responsibility for it. The delegatee also must comprehend what, how, and when to report back after the delegated task is complete. Delegatees also need a deadline for task completion for time-sensitive tasks.[4]
Using the five rights of delegation, Mark appropriately took care of his patients’ needs. Mark delegated the linen change to trained unlicensed assistive personnel, and he entrusted his hourly rounds to his shift charge nurse. Mark opted to assess the patient with a possibly infiltrated intravenous site first. Upon finding the site infiltrated, he assessed his patient, removed the intravenous line, and placed a warm compress on the patient’s elevated extremity. He then administered another patient’s requested pain medications after delegating new intravenous catheter placement to an intravenous-certified coworker for the patient with the infiltration. Mark was able to complete all his documentation requirements by the end of his shift.
Clinical Significance
Reasons Delegation is Necessary for the Modern Health Care Environment
If delegation decisions are so challenging and legally charged, why should nurses delegate? Fiscal constraints, nursing shortages, and increases in patient care complexity have cultivated an environment in which delegation is necessary. If appropriately used, delegation can significantly improve patient care outcomes.
Improper Delegation
Improper delegation can negatively impact patient care while also potentially exposing the delegator to legal action.[5] All members of the health care team have valuable contributions to make toward safe, effective patient care.
Essentials of Communication
While employing the five rights of delegation in nursing practice, it is important to remember that the way the delegator asks the delegatee to perform a task can make a big difference. The delegator must use direct, honest, open, closed-loop communication to encourage teamwork and safe task performance.[6] Of the five rights of delegation, the right communication and direction are arguably the most important in ensuring good quality and safety outcomes.[7] Common delegation deficiencies for registered nurses occur when delegating tasks to unlicensed assistive personnel. These include unclear delegation directions from the registered nurse, a lack of retained accountability and follow-through, and the failure of the registered nurse to obtain the agreement of the unlicensed assistive personnel.[8]
References
1.Neumann TA. Delegation-better safe than sorry. AAOHN J. 2010 Aug;58(8):321-2. [PubMed: 20704120]
2.McMullen TL, Resnick B, Chin-Hansen J, Geiger-Brown JM, Miller N, Rubenstein R. Certified Nurse Aide scope of practice: state-by-state differences in allowable delegated activities. J Am Med Dir Assoc. 2015 Jan;16(1):20-4. [PubMed: 25239017]
3.Siegel EO, Young HM. Communication between nurses and unlicensed assistive personnel in nursing homes: explicit expectations. J Gerontol Nurs. 2010 Dec;36(12):32-7. [PubMed: 20669856]
4.Bittner NP, Gravlin G. Critical thinking, delegation, and missed care in nursing practice. J Nurs Adm. 2009 Mar;39(3):142-6. [PubMed: 19590471]
5.Gravlin G, Phoenix Bittner N. Nurses' and nursing assistants' reports of missed care and delegation. J Nurs Adm. 2010 Jul-Aug;40(7-8):329-35. [PubMed: 20661063]
6.Weydt AP. Defining, analyzing, and quantifying work complexity. Creat Nurs. 2009;15(1):7-13. [PubMed: 19343844]
7.Hopkins U, Itty AS, Nazario H, Pinon M, Slyer J, Singleton J. The effectiveness of delegation interventions by the registered nurse to the unlicensed assistive personnel and their impact on quality of care, patient satisfaction, and RN staff satisfaction: a systematic review. JBI Libr Syst Rev. 2012;10(15):895-934. [PubMed: 27820462]
8.Kalisch BJ. The impact of RN-UAP relationships on quality and safety. Nurs Manage. 2011 Sep;42(9):16-22. [PubMed: 21873843]