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TRANSITION TO PRACTICE

Delegating as a New Nurse How to master this complex but common practice early in your career.

“Norma, it’s 4:30,” I call out to the nurs- ing assistant assigned to monitor the vital signs of my patients. “I’m going to take

Mr. Smith’s temperature.” Amidst the day’s whirl of activity, I’d forgotten to review the previous temper- ature readings but figured Norma would have told me if anything was wrong. As I looked at the current reading, my heart sped up. It was abnormal.

“He has a fever of 102°,” I said curtly. As I wrote the number in the patient’s chart, I saw that Norma had noted Mr. Smith had a low-grade temperature at 8 am. “Why didn’t you tell me?” I demanded.

Norma, who was sitting hunched over a computer, looked up and said loudly, “I just didn’t. Go tell the manager if you want.”

Shocked, I thought of all the dangers this high tem- perature potentially signaled for my patient—and what my knowledge of it earlier in the day could have ac- complished. Fuming as I prepared blood culture bottles and spoke to a physician about an antibiotic order, I realized I had delegated temperature taking to Norma, not the interpretation of this value. The latter was not her responsibility. As the patient’s nurse, it was mine.

THE STANDARDS OF DELEGATION According to the American Nurses Association (ANA), “Delegation generally involves assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel while retaining accountability for the outcome.”1 The standards of this complex but common task are based on nurses’ scope of practice within each state, as specified by state boards of nursing and nursing practice acts; these standards are also guided by theoretical documents, such as the ANA’s Principles for Delegation and its Code of Ethics for Nurses with Interpretive State- ments.1, 2

In 2016, the National Council of State Boards of Nursing (NCSBN) published an article, “National Guidelines for Nursing Delegation,” that details the responsibilities of employers and nurse leaders, li- censed nurses, and delegatees in the delegation pro- cess.3 These guidelines refer to the “Five Rights of Delegation,” a list for nurses to consider before they delegate, similar to the safety check nurses perform before administering medication (see Five Rights of Delegation).

Delegation requires much more than a checklist, however. It requires an appreciation of nuance and in- sight, both of which new graduates may lack. Delega- tion often requires skills that aren’t taught in nursing school and are difficult for preceptors to teach in the clinical setting. Marjorie M. Whitman has succinctly summarized the intricacies of delegation: “Nurses must delegate the exact tasks to be done, verify that the delegatee has been trained to do the tasks correctly, and explain how and when to report the results of the tasks.”4

PRACTICAL TIPS The process of delegation is a daunting one, so much so that the perceived potential for failure and confu- sion may lead new nurses to avoid delegating any tasks. The following are steps you can take to bypass barriers to delegation, establish effective delegatory relationships, and ease your transition to expert prac- tice.

Stay within scope of practice. According to the NCSBN, nurses may delegate tasks and aspects of care, but they cannot delegate the nursing process and judgment.3 Analyze your delegatory requests in the same way you would analyze any task that has been delegated to you. Just as you would not perform a duty that falls within a physician’s scope of practice,

By Amanda Anderson, MPA, MSN, RN, CCRN

This column is designed to help new nurses in their first year at the bedside—a time of insecurity, growth, and constant challenges—and to offer advice as they learn what it means to be a nurse. This article offers strategies new nurses can use and specific steps they can take to help them succeed in delegating tasks to LPNs/LVNs and unlicensed assistive personnel.

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an unlicensed staff member shouldn’t be asked to per- form a duty within a nurse’s scope of practice.

Take the time to understand your state’s nurse practice act and review the NCSBN’s Five Rights of

Delegation as well as your institution’s policies and procedures. Practice acts are located on the NCSBN website (www.ncsbn.org/npa.htm), as well as on the website of each state’s board of nursing. Knowing your scope of practice will help you to understand the scope of others’ work. Currently, American nurses can be licensed as RNs, advanced practice RNs, and LPNs/LVNs, with each state’s board of nursing regu- lating the scope of practice for each license. The edu- cational path to an RN license is varied, with nurses having completed a range of programs, from asso- ciate’s degree to accelerated bachelor’s degree pro- grams. Yet the basic elements of an RN’s scope of practice do not fluctuate based on the type of educa- tional program. By contrast, both educational levels and scope of practice vary among unlicensed assistive personnel (UAP) and LPNs/LVNs, whose practice must be supervised and is regulated by state legisla- tion and institutional policies and procedures.

Your employer will likely not ask you to review a state practice act during orientation but should pro- vide you with information about the institution’s pol- icies and procedures, which should align with state law. You may need to review this information when delegating, and your employer will expect you to know how to locate it in the hospital’s policy and procedure manual.

Know the level of competency. Successful delega- tion requires that you know the level of competency of your UAP and LPN/LVN colleagues. For example, if your hospital allows assistive personnel to perform certain advanced functions, like endotracheal suction- ing, make sure you know how to verify that a given colleague has gained this competency and that it’s cur- rent. You can do this by checking to see if departmen- tal records of competency exist and by observing the assistant performing the task, verifying that she or he is competent.

Communicate expectations and parameters. One of the most important aspects of delegation is commu- nication. In instances of miscommunication and un- clear communication, the delegation of duties can lead to errors or missed care. According to the Five Rights of Delegation, nurses should use two-way communi- cation when delegating. Ask clarifying questions and verify that the delegatee understands and accepts the delegated task. Additionally, you are responsible for making sure the delegatee knows that your nursing judgment is never being delegated and that the dele- gatee does not have the power to change or alter her or his responsibilities without notifying you.3

This may seem like a complex concept to grasp as a new nurse, so it may help to use an abbreviated SBAR (Situation, Background, Assessment, Recom- mendation) report to guide delegation to your UAP

Five Rights of Delegation

Right task • The activity falls within the delegatee’s job description or is in- cluded as part of the established written policies and procedures of the nursing practice setting. The facility needs to ensure the policies and procedures describe the expectations and limits of the activity and provide any necessary competency training.

Right circumstance • The health condition of the patient must be stable. if the patient’s condition changes, the delegatee must communicate this to the licensed nurse, and the licensed nurse must reassess the situa- tion and the appropriateness of the delegation.

Right person • The licensed nurse along with the employer and the delegatee is responsible for ensuring that the delegatee possesses the ap- propriate skills and knowledge to perform the activity.

Right directions and communication • Each delegation situation should be specific to the patient, the licensed nurse, and the delegatee.

• The licensed nurse is expected to communicate specific instruc- tions for the delegated activity to the delegatee; the delegatee, as part of two-way communication, should ask any clarifying questions. This communication includes any data that need to be collected, the method for collecting the data, the time frame for reporting the results to the licensed nurse, and additional information pertinent to the situation.

• The delegatee must understand the terms of the delegation and must agree to accept the delegated activity.

• The licensed nurse should ensure that the delegatee understands that she or he cannot make any decisions or modifications in car- rying out the activity without first consulting the licensed nurse.

Right supervision and evaluation • The licensed nurse is responsible for monitoring the delegated activity, following up with the delegatee at the completion of the activity, and evaluating patient outcomes. The delegatee is re- sponsible for communicating patient information to the licensed nurse during the delegation situation. The licensed nurse should be ready and available to intervene as necessary.

• The licensed nurse should ensure appropriate documentation of the activity is completed.

Reprinted with permission from the National Council of State Boards of Nursing. J Nurs Regul 2016;7(1):5-14.

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colleague.5 Communicating expectations using tools that you know, while also following national guidelines and those established by your institution, can provide a structure and format for delegatory conversations (see Table 1 for an example of how to do this based on the opening scenario in this article).

Know who to delegate to. Most of the time, nurses will delegate to UAP or LPNs. These staff play a vital role in caring for patients, and it’s our duty as nurses to be familiar with their legal scope of practice.1 New nurses should also consider the value of turning to other RNs for help, even if delegation to UAP is an option. A good rule of thumb is to first ask yourself, “If I don’t ask for help right now, will my patients be safe?” You can then determine what would best serve the situation: additional assistance or additional nurs- ing assessment? For example, if one of your patients is in intractable pain, another is having a reaction to a new antibiotic, and another needs water and a toilet break, don’t be afraid to ask a nursing colleague if she can determine the cause of your first patient’s pain. There is no substitute for a nursing assessment when

there is an increase in a patient’s pain. Asking your colleague for assistance allows you to focus on man- aging your other patient’s reaction to the antibiotic. You can then ask assistive personnel to attend to the patient who needs assistance with toileting. It’s impor- tant to consider that the right person for the job, in some circumstances, may be another nurse.1

Know when to delegate (not always, not never). Just because unlicensed personnel are available to per- form basic functions and care and to assist with activ- ities of daily living doesn’t mean you should delegate every one of these tasks. A nurse’s best assessment can be the one she or he performs while providing a bed bath, for instance. Similarly, wounds can be assessed when assisting with incontinence care. In another ex- ample, helping a patient to walk down the hall offers dual benefits: it allows you to build your relationship with the patient while also providing an opportunity to conduct a fall risk assessment.

Florence Nightingale likened a good nurse to one who could distinguish the call bell of her patient from that of others.6 Responding to call lights, providing

SBAR Step RN Statement 5 Rights of Delegation Step

Situation “Norma, I’m concerned about Mr. Smith’s temperature.”

Right task: This step confirms that the task you are about to delegate falls within the job description and scope of practice of the delegatee.

Background “He is being treated for pneumonia and has had low-grade fevers since his iv antibiotics were changed last night to oral antibiotics.”

Right circumstance: This step confirms that the situation is stable, and that the delegatee under- stands that if a change occurs, you need to know about it.

Assessment “He is stable now, but I am concerned about him becoming septic again.”

Right circumstance: This step confirms that the situation is stable, and that the delegatee un- derstands that if a change occurs, you need to know about it.

Assessment “I know that part of your responsibility on this unit is to take patients’ temperature.”

Right person: This step confirms that the delegatee is the right person for the task, based on her or his job description, scope of practice, competency, and the nature of the situation.

Recommendation “For the duration of our shift together, please take Mr. Smith’s temperature every 4 hours instead of every 8 hours and report to me any reading higher than 100°F.”

Right directions and communication: This step confirms that you’ve clearly communicated your directions, as well as the delegatory responsibility, to the delegatee.

Recommendation “Can you confirm the plan for Mr. Smith’s care today?”

Right supervision and evaluation: This step confirms the delegatee’s understanding of, and agreement with, your delegation and allows you to evaluate how it was carried out.

Table 1. Delegating with SBAR

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water pitchers and meals, and assisting with trips to the bathroom are duties too often automatically del- egated to nursing assistants. RNs risk becoming re- moved from the intimate physicality of our jobs and miss out on the way these responsibilities sharpen our assessment skills and help us to prevent emer- gencies if we are always on the sidelines.

This is not to say nurses should never delegate. There are instances in which nurses must bring their expert knowledge, skills, and labor to tasks that non- RN colleagues simply cannot perform. For example, if pulmonary edema is worsening in one of your pa- tients, it may be necessary to ask a nursing assistant to help clean another patient, who is incontinent. Hearing “Why don’t you change her?” from a nursing assistant may prove challenging. But if it’s your practice to work alongside your assistant, you will find that her or his pushback will lessen when you firmly delegate.

Make a practice of using simple responses drawn from established communication tools, such as the Agency for Healthcare Research and Quality’s CUS (Concerned, Uncomfortable, Safety) tool, which is part of its TeamSTEPPS program.5 By using these words intentionally, you highlight the facts and focus on the importance of the delegated task: “I am con- cerned about spending my time on this task right now. I am uncomfortable with the way my other pa- tient is breathing. I am concerned about her safety and need to assess her further. Thank you for com- pleting this work. As soon as I think the patient has stabilized, I will assist you.” In doing so, you commu- nicate that both your work and the work of your unli- censed colleague is important to your patients’ safety.

Be open to learning and teaching opportunities. The interaction described above promotes teaching opportunities, in which the nurse helps the assistant to gain valuable clinical knowledge. Nurses must also be open to learning from such interactions. Although some practices we see carried out by our unlicensed colleagues may be incorrect or unsafe, others might genuinely help our patient care. In care settings other than the hospital, such as in the home, RNs may see patients only weekly or during emergencies. Nursing

assistants often provide these patients with around- the-clock assistance. It’s thus important to learn how to interpret and appreciate their feedback, which can inform your assessment and the care to these patients you provide.

Troubleshoot pitfalls and barriers. As a new nurse, many of your delegatory relationships may be with

colleagues who are older than you. They may have different educational and cultural backgrounds, as well as varying levels of experience. At times, you may encounter communication barriers or resistance to your delegation efforts. Keep in mind that although a nursing assistant with 25 years of experience is an in- valuable resource, you have expert knowledge of clini- cal care and the ability to analyze clinical evidence.

Take advantage of cultural and in-service training programs, which can provide you with a better un- derstanding of the diverse health care workforce and effective delegation strategies. Pausing to consider a person’s background and cultural mores is never the wrong step. In my experience, relationships are of- ten born from the simple question, “So, where are you from?” asked with genuine interest.

Also, weigh the complexity of the delegated task. If it makes the delegatee uncomfortable, or if you don’t fully understand whether a task should be delegated, step back and ask for help from a colleague. More ex- perienced nursing colleagues can serve as leaders in these instances and should direct you to institutional policy and best practice resources.

If resistance persists, don’t hesitate to ask for sup- port from your nurse manager. Sometimes the most ef- fective tactic is to convene a meeting with the assistant and your supervisor as soon as possible. A third party can serve as an important sounding board in a dele- gatory relationship. In addition, your supervisor is responsible for maintaining an ongoing understand- ing of your relationship with your unlicensed colleague and for helping you find ways to improve this rela- tionship.

It is important to understand that working rela- tionships and delegatory instructions are not intended to achieve dominance or control. They are for the

It is important to understand that working relationships and

delegatory instructions are not intended to achieve dominance or

control. They are for the benefit of the patient.

benefit of the patient. If communication problems or cultural or behavioral issues get in the way of patient care, it’s important to immediately address this bar- rier with your colleague or supervisor.

Show your appreciation. To enter into any delega- tory relationship is to begin a conversation that should start with a respectful request, continue with encour- agement, and end with gratitude and praise. Leaving praise out of a delegatory relationship—or any work- ing relationship—will sour it quickly. Intentional and effective praise calls out specific behaviors, giving weight to the worth of your delegatee’s work. In the opening scenario, for instance, I didn’t offer praise to Norma for her assistance. Ideally, I would have checked the temperature readings she’d recorded ear- lier in the day and then said, “Norma, thank you so much for keeping a close eye on Mr. Smith’s tempera- ture today; because of you, we caught a change in his temperature trend as early as possible and got this in- formation to the physician right away.”

Expressing appreciation also establishes that you are a leader in this delegatory relationship. As such, you must engage in heathy practices to inspire engage- ment and team building. By rolling up your sleeves,

getting your hands dirty, and giving your UAP col- leagues credit for their contributions to the team, you’ll show that you value their work and rely on their unique assistance. ▼

Amanda Anderson works in nursing administration for the Mount Sinai Health System in New York City. She is also on the editorial board and a contributing editor of AJN. Contact author: [email protected] The author has disclosed no potential conflicts of interest, financial or otherwise.

REFERENCES 1. American Nurses Association. ANA’s principles for delegation:

by registered nurses to unlicensed assistive personnel (UAP). Sil- ver Spring, MD; 2012. https://www.nursingworld.org/~4af4f2/ globalassets/docs/ana/ethics/principlesofdelegation.pdf.

2. American Nurses Association. Code of ethics for nurses with interpretive statements. 2nd ed. Silver Spring, MD; 2015.

3. National Council of State Boards of Nursing. National guide- lines for nursing delegation. J Nurs Regul 2016;7(1):5-14.

4. Whitman MM. Return and report: establishing accountabil- ity in delegation. Am J Nurs 2005;105(3):97.

5. Agency for Healthcare Research and Quality. Module 2: Com- municating change in a resident’s condition. Appendix. Exam- ple of the SBAR and CUS tools. Rockville, MD; 2017. System design resources; https://www.ahrq.gov/professionals/systems/ long-term-care/resources/facilities/ptsafety/ltcmod2ap.html.

6. Nightingale F. Notes on nursing for the labouring classes. London: Harrison; 1861.

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TRANSITIONS PAPER ASSIGNMENT GUIDELINES ADDENDUM

Purpose

The purpose of this assignment is to explore a critical concept in nursing through summarizing an approved article on the concept and reflecting on the information. The student will be able to demonstrate application of information literacy and ability to utilize resources (library, writing center, Smart Thinking, located within the Tutor Source tab under Course Home, APA resources, Turnitin, Essay Review Service, and others) through literature search and writing the paper.

Course Outcomes

This assignment enables the student to meet the following course outcomes:

CO 2: Identify characteristics of professional behavior including emotional intelligence, communication, and conflict resolution.

CO 3: Demonstrate information literacy and the ability to utilize resources.

Requirements and Guidelines

You must choose one of the articles from the “Approved Articles for the RUA” document located in the files. Your article choice must be submitted by the end of week 1 into the appropriate assignment drop box. The articles are based on the following nursing topics:

• Safety

• Delegation

• Prioritization

• Caring

After you select your article from the approved list, you will complete a one – two-page summary of the article and reflection. The paper should be completed in APA 7th edition format and include the following:

• Page 1: A cover page (not included in the page number requirement)

• Pages 2-3:

o A one paragraph introduction.

o The summary of the article based on the rubric must include:

▪ A level one heading labeled “Summary of Article”.

▪ One direct quote from your reference, appropriately cited as per APA within the text of the paper.

▪ One indirect quote (or paraphrased quote) appropriately cited as per APA within the text of the paper.

o A one paragraph conclusion. This should include a level one heading labeled “Conclusion”.

o The reflection should be in a separate paragraph with a level one heading labeled “Reflection”. This is the ONLY portion of the paper that can be written in first person. This should also be the last paragraph of the RUA.

• Page 3 or 4: A reference page appropriately formatted using the APA 7th edition.

• Citations and references should be in APA format, using the 7th edition and the College APA format guidelines.

TOTAL POINTS: 150 POINTS Best Practices in Preparing the Paper

Utilize resources available to you to assist with preparing for and writing the paper (e.g., Smart Thinking which is located within the Tutor Source tab under Course Home; the writing center; Turnitin; APA manual; online resources; the Essay Review Service, and/or the librarian).

Helpful Hints (tips to gain all the points available):

1. Start early. The deadline is closer than you realize. Time moves fast in nursing school.

2. The purpose of this assignment is to explore a critical concept in nursing through summarizing an approved article on the concept and reflecting on the information. This assignment will also assess how well you can read, understand, and paraphrase one article.

3. There should be ONLY ONE reference on your Reference page. Since you are only summarizing one article and providing your personal reflections, you do not need supporting documentation.

4. The article must be chosen from the approved article list in the course files. No exceptions!

5. Use the APA template located in the files (in the RUA folder) to write your paper. It will keep you on track not only with APA format, but also with organizing your paper according to the rubric requirements.

6. Use the video in the Media Gallery to help you understand the rubric.

7. Visit faculty open office hours for help understanding the rubric.

8. Use Grammarly to be sure your grammar and sentence structure are professional.

9. Use the Essay Review Service to review your document for grammar and format.

10.Use of the Turnitin Draft Submission drop box is required PRIOR to submitting your paper for grading.

a. First submit your paper into the draft submission drop box; your similarity score must be 24% or less.

b. If it is above 24% you should revise your paper and resubmit it into the same box for a new score.

c. You can do this as many times as necessary to meet the requirement.

d. After you have achieved a Turnitin similarity score of 24% or less, you also need to submit the paper into the Week 5: RUA: Transitions Paper drop box.

11. The late policy will apply to this assignment.

The grading rubric will help you understand how your paper will be evaluated. Use it as a checklist to make sure that you have included all the important elements.

Grading Criteria for Transitions Paper Assignment

Category Points % Description: See Rubric for Specific Details of Grading

Introduction Use of an article that is NOT on the appr