Assigning, Delegating, and Supervising Client Care

Examples of Tasks that an RN Can Delegate to (U)APs (provided agency policy and state practice guidelines permit)

- ADLs - Bathing - Grooming - Dressing - Toileting - Ambulating - Feeding (without swallow precautions) - Positioning - Bed making - Specimen collection - I&Os - Vital signs

Assignment Factors: Client factors

- Complexity of care needed - Specific care needs (e.g., cardiac monitoring, mechanical ventilation) - Need for special precautions (e.g., private room with negative air pressure and anteroom, fall precautions, seizure precautions)

Care that cannot be delegated according to professional practice standards includes care related to:

Nursing process - Assessment - Diagnosis - Planning - Evaluation Nursing judgment

Supervision

Supervision is the process of directing, overseeing, and monitoring the performance of tasks by another member of the health care team. RNs have responsibility for supervising client care tasks delegated to assistive personnel (AP) and licensed practical nurses (LPNs) - also known as licensed vocational nurse (LVNs).

Assignment

Assignment is the process of transferring both the responsibility and accountability of client care to another member of the healthcare team.

Delegation

Delegation is transferring the authority and responsibility to another to complete a task, while maintaining the accountability. The registered nurse (RN) is responsible for providing clear directions when a task is initially delegated and for periodic reassessment and evaluation of the outcome of the task.

Five Rights of Delegation: - Right circumstance

Right Circumstance: - Assess the health status and complexity of care required by the client. - Match the complexity of care demands to the skill level of the healthcare team member. - Consider the workload of the team member. Right circumstance: - Delegate AP to assist in obtaining vital signs from a stable postoperative client. Wrong circumstance: - Delegate AP to assist in obtaining vital signs from a postoperative client who required naloxone (Narcan) for depressed respirations.

Delegatee factors: Considerations for selection of an appropriate delegatee include:

- Education, training, and experience. - Knowledge and skill to perform the task. - Level of critical thinking required to complete the task. - Ability to communicate with others as it pertains to the duty. - Demonstrated competence. - Agency policies and procedures. - Licensing legislation (state nurse practice acts).

Five Rights of Delegation

- Right Task - Right Circumstance - Right Person - Right Direction/Communication

Assignment Factors: Healthcare team factors

- skills - experience - nurse-to-client ratio

Five Rights of Delegation: - Right Task

Right Task: - Identify what tasks are appropriate to delegate for each specific client. -- A right task is repetitive, requires little supervision, and is relatively noninvasive for a certain client. - Delegate activities to appropriate levels of team members (e.g., LPN, AP) based on professional standards of practice, legal and facility guidelines, and available resources. Right task: Delegate AP to assist a client with pneumonia to use a bedpan. Wrong task: Delegate AP to administer a nebulizer treatment to a client with pneumonia.

Examples of Tasks that an RN Can Delegate to LPNs (provided agency policy and state practice guidelines permit)

- Monitoring client findings (as input to the RN's ongoing assessment of the client) - Reinforcement of client teaching from a standard care plan - Tracheostomy care - Suctioning - Checking NG tube patency - Administration of enteral feedings - Insertion of a urinary catheter - Medication administration (excluding intravenous medications in several states

Delegation factors: Task factors: Prior to delegating client care, the nurse should consider:

Predictability of outcome. - Will the completion of the task have a predictable outcome? - Is it a routine treatment? - Is it a new treatment? Potential for harm. - Is there a chance that something negative may happen to the client (e.g., risk for bleeding, risk for aspiration)? - Is the client unstable? Complexity of care. - More complex tasks should not be delegated. Need for problem solving and innovation. - Will a judgment need to be made while performing the task? - Does it require nursing assessment skills? Level of interaction with the client. - Is there a need to provide psychosocial support or education during the performance of the task?

Five Rights of Delegation: - Right Direction/Communication

Right Direction/Communication - Communicate either in writing or orally: - Data that need to be collected. - Method and timeline for reporting, including when to report concerns/assessment findings. - Specific task(s) to be performed; client-specific instructions. - Expected results, timelines, and expectations for follow-up communication. Right direction / communication: Delegate AP the task of assisting the client in room 312 with a shower, to be completed by 0900. Wrong direction / communication: Delegate AP the task of assisting the client in room 312 with morning hygiene.

Five Rights of Delegation: - Right Person

Right Person: - Assess and verify the competency of the healthcare team member. -- The task must be within the team member's scope of practice. -- The team member must have the necessary competence/training. - Continually review the performance of the team member and determine care competency. - Assess team member performance based on standards and, when necessary, take steps to remediate failure to meet standards. Right person: - Delegate an LPN to administer enteral feedings to a client with a head injury. Wrong person: - Delegate an AP to administer enteral feedings to a client with a head injury.

Five Rights of Delegation: - Right Supervision/Evaluation

Right supervision/evaluation - The delegating nurse must: - Provide supervision, either directly or indirectly (e.g., assigning supervision to another licen sed nurse). - Provide dear directions and understandable expectations of the task(s) to be performed (e.g., timeframes, what to report). - Monitor performance. - Provide feedback. - Intervene if necessary (e.g., unsafe clinical practice). - Evaluate the client and determine if client outcomes were met. - Evaluate client care tasks and identify needs for performance improvement activities and/or additional resources. Right supervision: - An RN delegates to an AP the task of ambulating a client after completing the admission assessment. Wrong Supervision: - An RN delegates an AP to ambulate a client prior to performing an admission assessment.