Many nurses are confused about direction and delegation roles.

Registered nurses worry they’ll get into trouble if the person to whom they delegate a nursing activity ‘mucks up’. Enrolled nurses (or healthcare assistants) worry what will happen if they turn down a task they think is outside their skill set.

Looking at the Nursing Council’s Guideline: responsibilities for direction and delegation of care to enrolled nurses is a useful starting point for discussing what is actually required for good direction and delegation. And who is responsible for what.

The 2011 guidelines are by necessity broad-brush as they cover both registered and enrolled nurses’ responsibilities across the diversity of nursing workplaces. (Similar guidelines were also released in 2011 for delegating to unregulated health care assistants (HCAs). The guidelines provide definitions (see box) of direction, delegation and accountability, and list a number of responsibilities required of both registered and enrolled nurses (RNs and ENs), and employers during delegation.

Accountability is clearly defined in the guidelines as “being answerable for your decisions and actions”. In the guidelines, and also in the enrolled nurse scope of practice, it states that the enrolled nurse is “accountable for their own nursing practice”. (Likewise the Nursing Council’s HCA delegations make clear the HCA is accountable for their own actions.) But despite no guideline or nursing document in New Zealand stating that an RN is responsible for a delegated EN’s nursing practice, many RNs continue to believe that they are.

At the same time, the enrolled nurses’ scope states that the RN maintains responsibility for the overall “plan of care”. But there is a lack of recognition that RNs are responsible for the way that direction and delegation is initiated and managed (as direction or delegation may be part of the overall “plan of care”).

This can create confusion for nurses who are told in their respective scopes of practice that they are required to direct or delegate, or be directed or delegated to, but are unsure how exactly to carry out this role.

This is especially true for new, inexperienced RNs who are required to delegate to highly experienced ENs, casual and agency RNs unfamiliar with the specialised ward they have been sent to, and new inexperienced ENs emerging on to the employment scene in greater numbers expecting to be directed, or delegated to.

Some of the direction and delegation assessments required of the RN include the need to “assess the health status of the health consumer, the complexity of the nursing intervention required, the context of care, and the level of knowledge, skill and experience of the enrolled nurse” (Nursing Council of New Zealand, 2011, p. 8). However, the EN’s role during these assessments is not covered in the guidelines.

The story in the following sidebar is a true account of an experienced EN who is sent to an unfamiliar ward due to overstaffing in her own workplace. The story illustrates what can happen when the art of delegation goes wrong because the skills and attributes required for ‘good’ delegation are not known (or used). So instead, delegation just becomes an allocation of tasks.  (See also related article: Direction and Delegation: when it goes wrong and the PD article and learning activity Providing nursing direction and delegation with confidence, wisdom, and respect.)

The art of assessment

The advanced communication and, more importantly, listening skills required by registered nurses to assess the knowledge and skills of an enrolled nurse (or HCA) they are delegating to are part of the art of ‘good’ delegation, along with the ability of the enrolled nurse (or HCA) to self-assess their own competence to take on a delegated activity or task.

Deanna’s story (see sidebar)  shows that an essential element for ‘good’ delegation practice is registered nurses understanding that enrolled nurses are responsible for self-assessing their own knowledge and skills and for saying ‘no’ if they are unsure of the delegated task or do not feel comfortable or safe to carry it out. A poor understanding of the rights and responsibilities of delegation can lead to confusion and poor outcomes for the nurses involved.

However, how an RN should carry out this professional competency – in particular the swift assessments required before delegating and directing a nursing task – are not included in any guidelines on direction or delegation in New Zealand. Nor are the advanced self-assessment skills required of the ENs. When registered nurses do not understand these roles and do not make the required assessments before delegating, there can be negative consequences for the patient, such as the EN carrying out unfamiliar and therefore unsafe tasks.

There is also an ambiguity related to lines of accountability in the guidelines, and there is no advice or discussion about the RN’s role in leading the direction or delegation interaction. The impact of a lack of leadership, and confusion about the direction and delegation role, are magnified when there is poor communication.

Poor communication and confusion about roles and responsibilities can lead to a reluctance to be directed or delegated to, or to direct or delegate. A lack of direction or delegation interactions means that both registered and enrolled nurses could be working outside their scopes of practice.

Summary

The art of direction and delegation is a delicate balancing act between ensuring a thorough set of assessments are carried out, leadership of the delegation interaction is provided, and that there is good communication. These skills and abilities are required in busy nursing workplaces where there are many decisions needed.

The consequences of getting it wrong can impact negatively on the patient on the receiving end of the direction or delegation decision – and on a nurse’s registration.

To master the art of direction and delegation, nurses need time to carry out assessments, to learn about direction and delegation, and time for their leaders to support their access to direction and delegation information and advice.

AUTHOR: Margaret Hughes explored registered and enrolled nurses’ direction and delegation communication practices in New Zealand for her PhD thesis (see p. 26). She is a senior lecturer at Ara Institute of Canterbury’s school of nursing.

Direction or delegation?

Direction is the active process of guiding, monitoring and evaluating the nursing activities performed by another. Direction can be provided directly or indirectly.

Delegation is the transfer of responsibility for the performance of an activity from oneperson to another, with the former retaining accountability for the outcome.

Recommendations

• Separate guidelines for registered and enrolled nurses that clearly explain who is accountable and for what  (including the registered nurses’ role in leading the delegation interaction).
• Guidelines make clear that an enrolled nurse has the right and the professional responsibility to self-assess and decline to do a delegated task.
• Guidelines include advice on inclusive and respectful communication strategies required by registered and enrolled nurses during the direction and delegation relationship.
• Workplace-specific information about direction and delegation roles and responsibilities would be a useful addition to the nursing tool box (see related story in Leadership & Management on p. 26).

Deanna’s story – a true account

Deanna* had been transferred to an unfamiliar ward because the ward was short of staff. Being shifted between wards had happened many times in her 40-year nursing career, but this shift turned about to be slightly different. The lack of welcoming to the ward and the lack of consultation about the tasks Deanna was ‘instructed’ to do were the start of an unpleasant and anxious time for her.

On arrival the RNs told her they had really wanted an “IVed” registered nurse, “not an enrolled nurse!” They then assigned her a set of tasks to carry out saying that “at least you can be another pair of hands”. Deanna explained that she did not feel confident doing the tasks they were asking of her as she had not worked in this specialty nursing workplace before. The delegating RN became angry and accused her of “being difficult”.

That evening the RNs got together to write a formal complaint about her poor performance. The charge nurse of the ward in question – new to her position and unfamiliar with delegation – had not supported Deanna’s right to self-assess and to decline to do the delegated tasks. The complaint from the RNs about her was upheld and there were further meetings and repercussions that “really knocked her confidence”.

The avoidable and unpleasant situation was hard for her to come back from and made her question if she wanted to continue in nursing. Deanna knew and understood that she had a responsibility to say ‘no’ if she felt that the task being asked of her was outside her skill level, training and confidence, but the charge nurse and the registered nurses who had written the complaint, did not.

It wasn’t until many weeks later that she realised how the lack of being welcomed on to the ward, and being referred to as “another pair of hands” had devalued and affected her. Deanna explained that she had worked with many RNs who had shared their knowledge with her and supported her to be a contributing member of the team. “We’re not just here for ourselves you know. We’re here to help others, so anything or anyone who helps me do this is respected by me.”

She believed that ENs needed to be assertive and know how to politely and diplomatically say ‘no’ to a delegated task when required so that they did not take on tasks that were unsafe for the EN, and therefore the patient. However, there needed to be a respectful and inclusive communication approach from RNs too.

*Not her real name