An RN delegates to a Licensed Practical Nurse (LPN) to initiate oxygen therapy that has been ordered by a physician on a patient with Chronic Obstructive Pulmonary Disease. The LPN accidentally sets the oxygen at a rate higher than what was ordered and the patient dies.
An RN prepares daily hypertensive medication for a resident in a nursing home, places it at the bedside and delegates to the Unlicensed Assistive Personnel (UAP) to assure the resident takes the medication with breakfast. The medication is forgotten and the resident suffers a stroke.
An RN directs a non-licensed Nurse Intern in his or her last year of nursing school to administer medications to a group of assigned patients in an acute care unit while he/she finishes documentation on each patient record. The nurse intern administers the wrong dose of a medication to one patient and the patient experiences a fatal reaction.
Delegation for an RN is a necessary skill to develop and to utilize in the care of patients. Without it an RN is not able to manage his or her workload and patient care suffers. If this skill is not performed prudently however, the above hypothetical scenario presentations, can become very real.
Delegation, according to the American Nurses Association (ANA), is “one of the most difficult responsibilities of the RN” (http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No2May2010/Delegation-Skills.html). Delegation requires that nurses are able to properly apply critical thinking skills and utilize high levels of clinical judgement to determine the appropriateness of the task or skill being delegated. This includes knowledge of the nurse practice act, scopes and standards for delegation in the state in which the nurse practices as well as knowledge of the scopes and standards of practice for the person being delegated to and the ability of that person to carry out the delegated task. The ANA also states that “RNs have authority, or legitimate power, to analyze assessments, plan nursing care, evaluate nursing care, and exercise nursing judgment (NCSBN) which includes delegation.” The RN maintains accountability and responsibility in the management of patient care, this includes the ability to delegate (http://health.mo.gov/living/lpha/phnursing/delegation.pdf).
Delegation can be a scary experience for the new nurse who believes that if they delegate, the tasks will not be done correctly, and they have no control. Without it however, the new nurse will soon realize that the amount of care and responsibility they must manage due to staffing and financial difficulties in an organization is to overwhelming, and they must learn to delegate to assure each and every patient receives high quality care. For the experienced nurse, the risk may not be in the failure to delegate as it is with the new nurse, but rather the failure to assess, monitor, and evaluate the assigned delegated task. This occurs as a result of the demands of workload, as well as in my opinion, nursing fatigue and perceived lack of control over the environment in which the nurse is employed, while making every attempt to just get the volume of work done. Of course, either the experienced nurse or the new nurse can make the mistake of not delegating when appropriate or failing to assess, monitor, and evaluate the assigned delegated task.
The key is for the RN to learn how to delegate properly and to gain confidence in their ability to delegate according to the standards for delegation. It is also important for them to follow the rights of delegation consistently, without missing a single step in the process, regardless of who they are delegating to.
The National Council of State Boards of Nursing (NCSBN) in a joint statement with the ANA https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf list several principles for delegation that the RN must adhere to. If these principles, along with standards in the state the nurse is employed, are not followed the nurse places his or her professional practice at legal risk. These principles as stated in this joint statement include the five rights of delegation. These are:
- The right task
- Under the right circumstances
- To the right person
- With the right directions and communication; and
- Under the right supervision and evaluation.
All RNs are educated in their schools of nursing on the nursing process. The nursing process is an excellent tool to help guide the RN through the five rights above. Posted by the Missouri government http://health.mo.gov/living/lpha/phnursing/delegation.pdf this nursing process is used as a decision making tool for nurses to utilize and may be helpful for all nurses to review. A brief outline from this PDF is cited here:
- Assess your delegation criteria (these are stated in your states nurse practice act and scopes and standards of practice)
- Assess the situation
- Plan for the specific task to be delegated
- Assure appropriate accountability
- Supervise the performance of the task
- Evaluate the entire delegation process
- Re-evaluate and adjust the overall plan of care as needed
When performed correctly delegation is a very useful and responsible tool for the RN to utilize in his or her practice. This is not a skill that should be feared. The RN must be fully accountable and responsible in his or her nursing practice and this includes knowing when and how to delegate appropriately. When the rights of delegation are followed properly, risk in patient care is reduced, and optimal outcomes can be achieved.
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As a legal nurse consultant I not only provide medical record review and legal support for attorneys and medical clients but I also speak publicly on a variety of topics to improve the workplace and reduce risk.
The Legal Nurse