Delegation of Nursing Care

2. Dr. Sheryl Cornelius, EdD, MSN, RN Delegation of Nursing Care

3. Upon completion of this module the student will be able to: • Define delegation and concepts surrounding the management of patient care • Utilize Five Rights of Delegation to determine appropriate delegation of patient care • Correlate barriers to delegation with methods for success • Outline the delegation process and key behaviors when delegating tasks. Objectives:

4. Definition: the act of empowering to act for another What is Delegation?

5. Position Statement • NC Board of Nursing Position Statement for RN and LPN practice on Delegation and Assignment of Nursing Activities • http://www.ncbon.org

6. Assign to other licensed or unlicensed assistive personnel (UAP) • Their own license • Assessment of the client’s status • Clinical competence of the person the duty is being assigned • Any variables that may impact (NCBON, 2010)

7. Before assigning/delegating nursing activities to staff, the licensed nurse needs access to information about the RN-validated competencies for each individual. (NCBON, 2010)

8. Authority – • Accountability – • Assigning- • Delegating – • Supervision - Definitions From NCBON

9. Right Task • Right Circumstances • Right Person • Right direction/communication • Right Supervision/Evaluation (National Council of State Boards of Nursing, Inc, 1997) The Five Rights of Delegation

10. Right Task • Appropriate delegation activities are identified for specific client(s). • Appropriate activities are identified for specific UAP. (National Council of State Boards of Nursing, Inc, 1997)

11. Right Circumstances • Assess health status of individual client(s), analyze the data and identify client specific goals and nursing care needs. • Match the complexity of the activity with the UAP competency and with the level of supervision available. • Provide for appropriate monitoring and guiding for the combination of client, activity and personnel. (National Council of State Boards of Nursing, Inc, 1997)

12. Right Person • Instruct and/or assess, verify and identify the UAP’s competency on an individual and client specific basis. • Implement own professional development activities based on assessed needs; assess UAP performance; perform evaluations of UAP based upon standards; and take steps to remedy failure to meet standards. (National Council of State Boards of Nursing, Inc, 1997)

13. Communicate delegation decision on a client specific and UAP-specific basis. The detail and method (oral and/or written) vary with the specific circumstances. • Situation specific communication includes: • specific data to be collected and method and timelines for reporting, • specific activities to be performed and any client specific instruction and limitation, and • the expected results or potential complications and time lines for communicating such information. Right Direction/Communication (National Council of State Boards of Nursing, Inc, 1997)

14. Right Supervision/Evaluation • Supervise or assign supervision to other licensed nurses • Provide directions and clear expectations • Evaluate the entire delegation process

15. Lack of trust/confidence in delegatee Preference for working alone Lack of experience in the job or delegating Fear of loss of control Fear of being disliked Lack of organization Perfectionism Barriers to Delegation

16. NC Board of Nursing Decision Tree for Delegation to UAP www.ncbon.org How to…delegate to a Uap

17. Assessment • Interpretation of data • Making a nursing diagnosis • Creation of a care plan • Evaluation of care effectiveness • Care of invasive lines • Administering medications • Client education • Performing triage • Giving telephone advice Tasks that may not be delegated to a uap

18. How to… delegate to an LPN • Follow up assessments • Reinforcement of teaching • Procedures • Medication administration • Continued implementation of the established care plan

19. Delegator ultimately responsible Communication is key Follow up is essential In conclusion…

20. The nurse has assigned the vital signs and daily weights of her patients to the unlicensed assistive personnel (UAP) on duty for that shift. It is still important for the nurse assigned to the patient to reassess each patient throughout the shift because: A) The nurse remains accountable for the patients' care. B) The UAP is not trustworthy. C) The UAP cannot report to the next shift. D) The nurse maintains the authority to care for the patients. Question 1 (NC Concept-Based Learning Editorial Board, 2011)

21. The nurse has assigned the vital signs and daily weights of her patients to the unlicensed assistive personnel (UAP) on duty for that shift. It is still important for the nurse assigned to the patient to reassess each patient throughout the shift because: A) The nurse remains accountable for the patients' care. B) The UAP is not trustworthy. C) The UAP cannot report to the next shift. D) The nurse maintains the authority to care for the patients. Answer 1

22. Toward the end of the shift, an LPN reports to the RN that the recently hired UAP has not totaled client's I&O for the past 12 hours. Which action should the nurse take? A) Confront the UAP about not completing the intake and output measurements. B) Delegate this task to the LPN since the UAP may not have been educated on the task. C) Ask the UAP if assistance is needed to complete the I&Os. D) Notify the nurse manager to include this on the UAP's evaluation. Question 2 (NC Concept-Based Learning Editorial Board, 2011)

23. Toward the end of the shift, an LPN reports to the RN that the recently hired UAP has not totaled client's I&O for the past 12 hours. Which action should the nurse take? A) Confront the UAP about not completing the intake and output measurements. B) Delegate this task to the LPN since the UAP may not have been educated on the task. C) Ask the UAP if assistance is needed to complete the I&Os. D) Notify the nurse manager to include this on the UAP's evaluation. Answer 2

24. For client education about non pharmacological alternatives, which topic could you delegate to an experienced LPN, who will function with your continued support and supervision? A) Therapeutic touch B) Application of heat and cold C) Meditation D) Transcutaneous electrical nerve stimulation (TENS) Question 3 (LaCharity, Kumagai, & Bartz, 2011)

25. For client education about non pharmacological alternatives, which topic could you delegate to an experienced LPN, who will function with your continued support and supervision? A) Therapeutic touch B) Application of heat and cold C) Meditation D) Transcutaneous electrical nerve stimulation (TENS) Answer 3

26. Which pediatric pain client should be assigned to a newly graduated RN? A) An adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient-controlled analgesia (PCA) device to a long acting oral analgesic; he has been continually asking for an increased dose. B) A child who is receiving palliative end of life care; the child is receiving analgesics around the clock to relieve suffering , but there is a progressive decrease in alertness and responsiveness. C) A child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures. D) A child who has chronic pain and whose medication and nonpharmacological regimen has recently been changed; the mother is anxious to see if the new regimen is successful. Question 4 (LaCharity, Kumagai, & Bartz, 2011)

27. Which pediatric pain client should be assigned to a newly graduated RN? A) An adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient-controlled analgesia (PCA) device to a long acting oral analgesic; he has been continually asking for an increased dose. B) A child who is receiving palliative end of life care; the child is receiving analgesics around the clock to relieve suffering , but there is a progressive decrease in alertness and responsiveness. C) A child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures. D) A child who has chronic pain and whose medication and nonpharmacological regimen has recently been changed; the mother is anxious to see if the new regimen is successful Answer 4

28. In care of the client with pain and discomfort, which task is most appropriate to delegate to the UAP? A) Assisting the client with preparation for a sitz bath B) Monitoring the client for signs of discomfort while ambulating. C) Coaching the client to deep breathe during painful procedures D) Evaluating relief after applying a cold compress Question 5 (LaCharity, Kumagai, & Bartz, 2011)

29. In care of the client with pain and discomfort, which task is most appropriate to delegate to the UAP? A) Assisting the client with preparation for a sitz bath B) Monitoring the client for signs of discomfort while ambulating. C) Coaching the client to deep breathe during painful procedures D) Evaluating relief after applying a cold compress Answer 5

30. The nurse is caring for a client with esophageal cancer. Which task could be delegated to a UAP? A) Assist the client with oral hygiene. B) Observe the patient’s response to feedings. C) Facilitate expression of grief or anxiety. D) Initiate daily weights. Question 6 (LaCharity, Kumagai, & Bartz, 2011)

31. The nurse is caring for a client with esophageal cancer. Which task could be delegated to a UAP? A) Assist the client with oral hygiene. B) Observe the patient’s response to feedings. C) Facilitate expression of grief or anxiety. D) Initiate daily weights. Answer 6

32. When care assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be most appropriate to assign to an LPN under the supervision of a team leader RN? A) A patient with severe anemia secondary to GI bleeding B) A patient who needs enemas and antibiotics to control GI bacteria C) A patient who needs pre op teaching for bowel resection surgery D) A patient who needs central line insertion for chemotherapy Question 7 (LaCharity, Kumagai, & Bartz, 2011)

33. When care assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be most appropriate to assign to an LPN under the supervision of a team leader RN? A) A patient with severe anemia secondary to GI bleeding B) A patient who needs enemas and antibiotics to control GI bacteria C) A patient who needs pre op teaching for bowel resection surgery D) A patient who needs central line insertion for chemotherapy Answer 7

34. An 8 year old child has stomatitis secondary to chemotherapy. Which task would be best to delegate to a nursing assistant? A) Report evidence of severe mucosal ulceration B) Assist the child in swishing and spitting an anesthetic mouthwash C) Assess the child's ability and willingness to drink through a straw D) Help the client to eat a bland, moist, soft diet Question 8 (LaCharity, Kumagai, & Bartz, 2011)

35. An 8 year old child has stomatitis secondary to chemotherapy. Which task would be best to delegate to a nursing assistant? A) Report evidence of severe mucosal ulceration B) Assist the child in swishing and spitting an anesthetic mouthwash C) Assess the child's ability and willingness to drink through a straw D) Help the client to eat a bland, moist, soft diet Answer 8

36. Concept: Managing Care Exemplar: Delegation Course: NUR 213 Delegation: A registered nurse (RN) has a group of ten clients on a medical surgical unit in an acute care setting. There is also assigned a licensed practical nurse (LPN) and unlicensed assistive personnel (UAP) to the same group. Case Study

37. The clients are as follows: Room 101: A 48 year old female with breast cancer one day post bilateral mastectomy that has been crying all night and is asking that no visitors be allowed. She refuses to get out of bed and refuses to look at her bandages. Room 102: A 92 year old male with dementia and pneumonia. He has a bed alarm and has a history of falls. He has a large list of medications to be administered daily crushed and in applesauce. Room 103: An obese 72 year old female with a diabetic foot ulcer. Blood sugars have been 250-400 mg/dL since admission and her family continues to bring her food from fast food restaurants. She is on a calorie and carbohydrate restricted diet which she eats in addition to the food her family brings. Room 104: A 36 year old male three days status post open spleenectomy following a motor vehicle accident. He is anxious to get home and back to work for fear he will lose his job. He is being discharged today. He is employed as a stone worker where he lifts heavy stones every day. Room 105: A 54 year old female three days status post abdominal hysterectomy with subsequent dehiscence of wound 12 hours post op. The wound is being packed with normal saline soaked Nugauze three times a day. Room 106: A 67 year old male with Clostridium Difficile and Vancomycin Resistant Enterococcus (VRE). He has been complaining of abdominal cramps and diarrhea all night. The stools have subsided and he has just gone to sleep. Room 107: A newly admitted 55 year old female with anemia and possible gastrointestinal (GI) bleed that has not been assessed. She does not have an IV access. She will be receiving 2 units packed red blood cells (PRBC) ASAP. Room 108: An 89 year old male with resolving pneumonia that is being discharged back to the nursing home later this afternoon. He requires turning, feeding, and bathing. Room 109: A 49 year old male with hypertension and resolved stroke for possible discharge today. Room 110: A 43 year old female with new onset Type II diabetes mellitus. She has met with the diabetic educator and has been checking her own blood sugars and ordering her own meals.

38. Which duties cannot be delegated therefore the RN must complete? Provide rationale. • What clients or tasks should be delegated to the LPN? Provide rationale. • What tasks should be delegated to the UAP? Provide rationale. • What is the RN’s responsibility before the end of the shift in reference to the delegated activities? Provide rationale. • Should the charge RN need to help with any of the days tasks? Why or why not? Questions to answer

39. AACN Delegation Handbook 2nd edition American Association of Critical Care Nurses www.aacn.org Guidelines to Effective Nursing Delegation www.nursetogether.com Position Statement on Delegation and Assignment of Nursing Activities North Carolina Board of Nursing www.ncbon.org LaCharity, L., Kumagai, C. & Bartz, B., (2011) . Prioritization, Delegation, and Assignment. Port Ludlow, Washington: Mosby, Elsevier. National Council of State Boards of Nursing www.ncsbn.org North Carolina Concept-Based Editorial Board, (2011). Nursing: A Concept Based Approach. Upper Saddle River, New Jersey: Pearson Education, Inc. References and further readings