2. Effective Delegation and Supervision
Delegation and Supervision in the
Health Care System

3. Issues Affecting Staffing Patterns
 Reduced reimbursement from Medicare, Medicaid, and
private insurance companies
 Prospective payment system
 Growing uninsured population
 Rapid advances in medical technology
 Nursing shortage

4. Changes in Staffing Patterns
 Decline in the number and utilization of registered nurses
(RNs) and an increase in the employment of nursing
assistive personnel (NAP)
 Increased utilization of NAP forces the RN to delegate more
nursing tasks.
 Roles and responsibilities of care providers (RNs, licensed
practical nurses/licensed vocational nurses [LPNs/LVNs],
NAP) are significantly overlapping

5. Economic Necessity
 Need competent, appropriately supervised NAP and
LPNs/LVNs in patient care
 RNs’ confidence with delegation and supervision skills is
essential
 RNs must understand legal responsibility related to
delegation and supervision

6. Effective Delegation and Supervision
What Is Delegation?

7. Definition
 Transfer of responsibility for the performance of an activity
from one individual to another while accountability for the
outcome is retained
 RN transfers responsibility and authority for the
performance of an activity but remains accountable for
overall nursing care
 Management strategy used to ensure the accomplishment of
cost-effective patient care

8. Two-Way Process
 RN delegator is responsible for the following:
 The act of delegation
 Supervising the performance of the delegated task
 Assessment and follow-up evaluation
 Any intervention or corrective action that may be
required to ensure safe and effective care

9. Two-Way Process
 The delegatee (LPN/LVN, NAP) is accountable for the
following:
 His or her own actions
 Accepting delegation within the parameters of his or
her training and education
 Communicating the appropriate information to the
delegator
 Completing the task

10. Effective Delegation and Supervision
What Should and Should Not Be Delegated?

11. No Definitive List
 No definitive list of what can and cannot be delegated
 Varies among states, organizations, and specific situations
 Assessment, evaluation, and nursing judgment cannot be
delegated.

12. No Definitive List
 RNs will have to seek guidance and integrate information
from
 State Nursing Practice Acts
 Patient needs
 Job descriptions
 Employee competency
 Policies and procedures
 Clinical situation
 Professional standards of nursing practice

13. State Nursing Practice Acts
 State Nursing Practice Acts
 Will provide guidance for legal delegation
 Delegation criteria may not be clearly spelled out or may
be presented in various parts of the Act
 State board of nursing also may offer guidance
 RN should understand the legal scope of practice for an
LPN/LVN
 Practice by NAP is generally governed by the health care
organization’s standards

14. Patient Needs
 RN is required to perform a patient assessment and to
know the level of care required
 Generally, the more stable the patient, the more likely
delegation is to be safe
 Many tasks that can be delegated may be intertwined with
a nursing responsibility

15. Job Descriptions
 Delineates the tasks, duties, and responsibilities required as
a condition of employment
 Generally comply with state laws and the health care
organization’s standards of care
 RN should be aware of the job training required to function
as described in the job description
 In all cases, legal requirements related to delegation
supersede any organizational policy or job description

16. Competencies
 Staff member must have the skills and knowledge necessary
to perform a task before it is delegated
 Competencies confirm that the individual has demonstrated
specific knowledge and skills
 Regulatory and accrediting agencies, such as The Joint
Commission, require written documentation of staff
competencies
 RNs should be knowledgeable about the documented
competencies of staff members whom they supervise

17. Competencies
 Examples of competencies for an ambulatory care clinic:
 Medication management
 Telephone triage
 Infection control
 Glucose testing
 Reporting abuse and neglect

18. Organizational Policies and Procedures
 The specific skill and supervision requirements for various
tasks are designated in written policies and procedures
 Ensure that the delegatee is trained in and understands
the organization’s general standards of care (e.g.,
infection control)

19. Clinical Situation
 Does the NAP/LPN/LVN realistically have time to perform
the task?
 Is the staff member familiar with characteristics of the
patient population?
 How complex is the task?
 Does the individual have the resources (supplies,
equipment) to perform the task?
 Is the RN able to provide an adequate level of supervision?

20. Professional Standards of Nursing Practice
 Professional standards of nursing practice
 Agreed-upon levels of nursing practice as determined by the
American Nurses Association (ANA) and specialty nursing
organizations
 ANA’s standard states that in delegation, the RN will consider the
following:
 Assessment of the patient condition
 Capabilities of the nursing and assistive staff
 Complexity of the task to be delegated
 Amount of clinical oversight (supervision) the RN will be
able to provide
 Staff workload

21. Professional Standards of Nursing Practice
 ANA has delineated activities that can be delegated by
the nurse
 Functions that are technical and assistive in
nature and can be taught (e.g., feeding,
ambulating a stable patient)
 Activities that provide amenities to the patient
(e.g., making beds, cleaning the environment)

22. Professional Standards of Nursing Practice
 ANA has delineated activities that the RN cannot delegate:
 Initial nursing assessment and any subsequent assessment
that requires nursing knowledge, judgment, and skill
 Determination of nursing diagnoses
 Establishment of nursing care goals
 Development of nursing plan of care
 Evaluation of patient’s progress
 Health counseling or teaching
 Activities that require specialized nursing knowledge, skill,
or judgment

23. Effective Delegation and Supervision
Developing Safe Delegation Practices

24. Establish a Foundation of Knowledge
 Establish a foundation of knowledge
 Know delegation criteria delineated in the state’s Nursing
Practice Act
 http://www.state.tn.us/sos/rules/1000/1000-01.pdf
 Know specific skill requirements designated in written
policies, procedures, and standards of care
 Know delegatee’s scope of practice, competencies, and job
description
 Know professional standards for nursing practice and
specific recommendations on delegation

25. Know the Patient
 Assess the patient before delegation
 What is the potential for change in the patient’s condition
as a result of the delegated task?
 Can the patient’s safety be maintained with delegated care?

26. Know the Staff Member
 Does the staff member have the skills and knowledge
necessary to perform the task?
 Does the staff member perform the task on a routine
basis?
 Be involved in training programs and the development of
job descriptions for NAP and LPNs/LVNs

27. Know the Task to Be Delegated
 RN delegator must be competent and skilled in performing
the task
 Task must be in the RN’s scope of practice
 Routine, standardized tasks are the safest to delegate
 Complex tasks or activities that convey high risk for patient
complications or unpredictable outcomes must be carefully
considered

28. Explain Task and Outcomes
 Failure to effectively communicate may result in
unsatisfactory performance, errors, or patient harm
 Clearly explain the task, what must be done, and the
expected outcomes
 Demonstration and return demonstration may be
required

29. Expect Responsible Action
 Delegatee becomes responsible for his or her own actions
 RN should supervise appropriately
 RN should not intervene unless assistance is requested,
or an unsafe situation is recognized

30. Assess and Supervise Job Performance
 Assess and supervise job performance:
 Make frequent rounds, observe, and communicate
 Provide the appropriate level of supervision
 Be available for questions or unexpected problems
 Supervise in a positive and supportive manner
 Intervene immediately if the task is not being performed safely
and appropriately
 Never ignore poor performance—Document and report
 Use mistakes as learning opportunities

31. Provide for Positive Outcomes
 Ongoing communication and support are vital
 Necessary resources to perform the tasks should be available

32. Evaluate and Follow Up
 Evaluate and follow up:
 Always evaluate the delegated action by reassessing the
patient
 Evaluate the staff member’s performance
 Follow up with any interventions that may be required
 Review and document the skills that were learned

33. Characteristics of High-Risk Delegation
 Delegated task can be performed only by the RN
according to law, organizational policies, or professional
standards of nursing practice
 Delegated task could involve substantial risk or harm to a
patient
 RN knowingly delegates a task to an individual who does
not have appropriate training
 RN fails to provide adequate supervision
 RN does not evaluate the delegated action by reassessing
the patient

34. Delegation and the Nursing Process
 Components of the delegation process become familiar
when compared with the nursing process
 Assess the patient and plan the care, then identify tasks that
someone else can perform
 Implement the plan of care, and assign and supervise task
performance
 Evaluate the delegatee’s performance, planned outcomes,
and client response

35. “Five Rights of Delegation”
 Right task: Delegated tasks must conform to established
guidelines
 Right circumstances: Delegated tasks do not require independent
nursing judgment
 Right person: One who is qualified and competent
 Right direction and communication: Clear explanation about the
task and outcomes and when the delegatee should report back to
the RN
 Right supervision and evaluation: Feedback to assess and
improve the process; evaluate patient outcomes

36. Effective Delegation and Supervision
Supervision

37. Definition
 The active process of directing, guiding, and influencing
the outcome of a worker’s performance
 On-site supervision—The nurse is physically present or is
immediately available while the activity is being
performed
 Off-site supervision—The nurse has the ability to provide
direction through various means of written and verbal
communication

38. Definition
 Distinction between on-site and off-site supervision has
become unclear with the use of telecommunications
technologies
 ANA has established operational guidelines for
supervision related to telecommunication technologies
 Who is in control of the activity?
 How should controls be instituted?

39. Components of Supervision
 Initial direction: instructions provided when the task is
first delegated
 Periodic inspection: the decision the RN makes regarding
frequency of monitoring the delegatee’s performance

40. Levels of Supervision
 Unsupervised
 One RN works with another RN in a collegial
relationship
 Neither RN is in the position of supervising the
other

41. Levels of Supervision
 Initial direction/periodic inspection
 RN is supervising a licensed or unlicensed caregiver
 Knows the individual’s training and competencies
 Has developed a working relationship with the
individual

42. Levels of Supervision
 Continuous supervision
 RN has determined that the delegatee will need
very frequent to continual support and assistance
 Continuous supervision is required when
 The working relationship is new
 The task is very complex
 The delegatee is inexperienced or has not
demonstrated an acceptable level of competence

43. Effective Delegation and Supervision
Assigning versus Delegating

44. Definition of Assignment
 Distribution of work that each staff member is responsible
for during a given work period
 Designates activities consistent with job position and
description, legal scope of practice, and educational
background
 The staff member assumes responsibility and is
accountable for completing the assignment.

45. Assignment Considerations
 Assigning groups of clients to various care providers,
including NAP and LPNs/LVNs is not appropriate
 NAP assignments would include functions and tasks
 LPNs/LVNs may be assigned specific clients for which to
perform care, but RNs remain responsible for all nursing
practice activities

46. Assignment Considerations
 The RN is responsible for assignments made to nursing
personnel and should consider the following:
 Patient’s physiologic status and complexity of care
 Infection control or cross-contamination issues
 Level of supervision required
 Staff development opportunities such as assigning a
less experienced nurse to a more complex patient
with an increased level of supervision

47. Utilizing the Interdisciplinary Health Care
Team
 Interdisciplinary team members will be valuable in
meeting patient care needs
 RNs should know scope of practice and training
background of team members

48. Utilizing the Interdisciplinary Health Care
Team
 RN should know how the work is delegated or assigned to
interdisciplinary team members
 Interdisciplinary team members may report to the RN,
who is responsible for assigning and delegating patient
care tasks
 Interdisciplinary team members may report to
supervisors in their individual disciplines and may
work in a collaborative manner with the RN to provide
patient care

49. Effective Delegation and Supervision
Building Delegation and Supervision Skills

50. Novice Nurses’ Barriers to Effective Delegation
 Fear of being disliked, losing control, taking risks,
making mistakes
 Lack of confidence
 Lack of knowledge

51. Communicate Effectively
 Know exactly what needs to be done and what outcomes
are expected
 Maintain self-control and confidence
 Listen carefully to the delegatee’s response
 Ask for feedback by using open-ended, nonthreatening
statements if the delegation action elicits a negative
response

52. Create an Environment of Trust and Cooperation
Maintain a nonthreatening and nonjudgmental
attitude—Problems will be reported more
quickly
Avoid blaming and criticizing when mistakes
occur—Look for root causes such as inadequate
training or too heavy workload
Encourage staff members to report and discuss
problems

53. Create an Environment of Teaching and Learning
 Remember that inadequate training is a common cause
for poor performance in the work setting
 Identify staff learning needs and provide educational
programs aimed at building skills and competencies
 Be willing to teach and demonstrate how to perform a
task rather than merely telling how it should be done

54. Promote Patient Satisfaction
 Clients need and want to know their caregivers’
qualifications
 The RN is responsible for describing the health care team to
the client

55. Provide Feedback and Follow Up
 Delegation process is not complete until the RN
reassesses the patient and adjusts the plan of care as
indicated
 Provide honest feedback to the delegatee about his or her
performance
 Praise good performance
 Address poor job performance
 Stop inappropriate, unsafe, or incompetent performance
immediately; document and report to the nurse manager
or supervisor
 Request additional training or other appropriate action to
ensure that patient safety is protected