Nursing Delegation

&
Practice Boundaries

Will your license be stretched by delegation?

Know your boundaries!

The Basis for Decision Making Process

Decisions related to delegation of nursing

tasks are based on the principle of protection
of the health, safety and welfare of the public.
Boards of Nursing are responsible for the
regulation of nursing
A licensed nurse has the ultimate
responsibility and accountability for the
management and provision and delegation of
nursing care.

Decision Making Process cont.

Unlicensed assistive personnel (UAPs) are

equipped to assist--not replace--the nurse
The licensed nurse's specialized education,
professional judgment and discretion are
essential for quality nursing care.
A task delegated to an (UAP) cannot be redelegated by the unlicensed assistive person.

There is a greater need for increased

delegation of skills because of:
increased use of UAPs,
increased need for RNs/ decreased numbers
of RNs available,
increased acuity of care,
increased number of elderly,
increased number of very sick, young & old

(continued)
increased technology, number & type of
technologists,
corporate downsizing to decrease cost,
client-to-home faster to decrease costs,
increased availability of information on www,
accelerated pace of changing health care
technology, &
increased # of physician specialists.

Nurse Practice Acts for the RN usually include the :

Assessment process,
Diagnosis of nursing or collaborative problems,
Creating a plan of care,
Defining outcomes,
Selection of nursing interventions,
Choosing who will complete nursing interventions
(delegation), &
Evaluating the plan of care.
Retains responsibility/ accountability for plan
of care & its delivery.

The Delegation Process

Definitions

Accountability: Being responsible and answerable for actions or

inactions of self or others in the context of delegation.
Delegation: Transferring to a competent individual the authority
to perform a selected nursing task in a selected situation.
The nurse retains accountability for the delegation.
Delegator: The person making the delegation.
Delegatee: The person receiving the delegation. (a.k.a. Delegate)
Supervision: The provision of guidance or direction, evaluation
and follow-up by the licensed nurse for accomplishment of a
nursing task delegated to unlicensed assistive personnel.
Unlicensed Assistive Personnel (UAP): Any unlicensed
personnel, regardless of title, to whom nursing tasks are
delegated.

When any nurse delegates they are:

accountable to the patient,

accountable to the State Board of Nursing,
accountable to their peers;
accountable to the employer;
required by law to practice within the State Nurse
Practice Act,
required to practice within their job description,
ethically and possibly legally required to report
unsafe delegatory issues.

The licensed nurse determines and is

accountable for the appropriateness of
delegated nursing tasks.
Inappropriate delegation by the nurse and/or
unauthorized performance of nursing tasks by
UAPs may lead to legal action against
the licensed nurse and/or UAP.

Acceptable Use of the Authority to Delegate

The delegating nurse is responsible for an individualized assessment of the

patient/situational circumstances, & for knowing the competence of the
delegatee before delegating any task.
The decision to delegate must be based on careful analysis
of the patient's
needs and circumstances.
Supervision, monitoring, evaluation and follow-up by the nurse are crucial
components of delegation.
The delegatee is accountable for accepting the delegation and for his/her own
actions in carrying out the task.
The following must not be delegated
Assessment
Evaluation
Nursing judgment ( any task that doesnt have a certain or stable outcome)

The Five Rights of Delegation

Right Task
One that is delegable for a specific patient.
Right Circumstances
Appropriate patient setting, available resources, and other relevant
factors considered.
Right Person
Right person is delegating the right task to the right person to be
performed on the right person.
Right Direction/Communication
Clear, concise description of the task, including its objective, limits
and expectations.
Right Supervision
Appropriate monitoring, evaluation, intervention, as needed, and
feedback.

Considerations for Delegation

Delegation criteria
Nursing Practice Act
Permits delegation
Authorizes task(s) to be delegated or authorizes the nurse to
decide delegation
Delegator qualifications within scope of authority to delegate
Appropriate education, skills and experience
Documented/demonstrated evidence of current competency
Delegatee qualifications
Appropriate education, training, skills and experience
Documented/demonstrated evidence of current competency

The Steps to the Delegation Process

Assess the situation

Identify the needs of the patient, consulting the

plan of care
Consider the circumstances/setting
Assure the availability of adequate resources,
including supervision

The process cont.

Plan for the specific task(s) to be delegated

Specify the nature of each task and the

knowledge and skills required to perform it
Require documentation or demonstration of
current competence by the delegatee for each
task
Determine the implications for the patient, other
patients, and significant others

The process cont.

Assure appropriate accountability

As delegator, accept accountability for

performance of the task(s)
Verify that delegatee accepts the
delegation and the accountability for
carrying out the task correctly

The process cont.

Supervise performance of the task

Provide directions and clear expectations of

how the task(s) is to be performed
Monitor performance of the task(s) to assure
compliance to established standards of
practice, policies and procedures
Intervene if necessary
Ensure appropriate documentation of the
task(s)

The process cont.

Evaluate the entire delegation process

Evaluate the patient
Evaluate the performance of the task(s)
Obtain and provide feedback
Reassess and adjust the overall plan of
care as needed

AACN Key Factors

to Consider before Delegating?

Potential for harm? great or small

Complexity of task? simple or difficult
Problem solving needed? minimal or maximum
Unpredictability of outcome? stable or unstable
Level of interaction required with client?
simple or complex
(Refer to the NCSBN Delegation Decision Tree)

American Nurses Association says

RNs cant delegate:

Initial nursing assessment & subsequent assessment

if nursing judgement is needed;
Decisions/judgements about the nursing diagnoses;
Decisions/judgements about outcomes;
Determining & approving of plan of care;
Interventions that require professional nursing
knowledge, decisions, or skill; &
Decisions/judgements of the evaluation of care.

Activities That May Be Outside the

Scope of Practice for the LPN

Administering infusions of blood/blood products;

Administering infusions of total parenteral nutrition;
Administering infusions of chemotherapeutic or
antineoplastic agents;
Administration of IV therapy to neonates.
Administration of IV push medications.
Mixing IV medications.
Initiation of TPN in peripheral or arterial lines.
Ongoing administration of TPN in central lines.

(continued)

Programming or setting certain types infusion

pumps, i.e. PCA Pumps, Epidural Pumps
Discontinuing central or arterial lines.
Arterial puncture and management of arterial
lines.
Advanced Cardiac Life Support (ACLS).
Expanded roles that are performed outside of
facilities;
Leading group therapy.

RN
Assessment
Nursing
diagnosis
Planning &
implementing

LPN

UAP

Teaching from
standard care
plan

Activities of daily
living

Vital signs

Hygiene

Pass
medications
except those
specified

Specimen
collection, I&O,
vital signs

Maintain IV lines, Documentation

IV lines, blood
start IVs with
of I&O, V/S
and TPN admin. training

Barriers to Successful
Delegation
Underdelegation
Overdelegation
Choosing a person who lack skills,
education or ability to perform task
Delegation by default
Poor timing
Poor communication'" I can do this myself
attitude

Acts or Condition(s) That Would Be

Evidence of Inappropriate Delegation
Inadequate direct assessment of needs or
circumstances,
Incomplete estimation of competence of
delegatee,
Foreseeable harm- the possibility that tasks
assigned would not be performed safely
under the circumstances.

(www.ncsbn.org/files/delegati.html)

When the State Board of Nursing

may hold the nurse accountable ?

Foreseeable harm was present.

Patient may or may not suffer physical or psychological
harm.
A standard of care is breeched.
Actions do not follow those of a reasonable nurse.
Practice does not follow the states Nurse Practice
Act.
Advisory Opinions or guidelines from the state BON are
not followed. (Are not law, but are a guideline directly
from them).