Reading this article and undertaking the learning activity is equivalent to 60 minutes of professional development.

This learning activity is relevant to the Nursing Council competencies 1.1, 1.3, 3.3, 4.1 & 4.2

LEARNING OBJECTIVES

Questions this article will attempt to explore include:

  • Why are direction and delegation vital requirements of current nursing practice?
  • What is effective nurse direction and delegation?
  • What influences how nurses give and receive direction and delegation of tasks?
  • What are the impacts of poor direction and delegation on nurses, their practice, and team dynamics?

At the conclusion of this article, you will be able to:

  • Understand the importance of direction and delegation in nursing.
  • Identify the principles that underpin effective direction and delegation.
  • Identify some common barriers to effective direction and delegation and their impacts on nurses, practice outcomes and team dynamics.
  • Consider some strategies for nurses to improve the efficacy of their direction and delegation skills.

Introduction

The increased use of unregulated health workers in New Zealand has occurred in response to changing consumer needs, burgeoning health care demands, associated costs and fewer nurses on wards.

Simultaneously, nursing roles and responsibilities are continually being redefined1. Fiscally prudent employers aim to get the right skill mix of nursing and non-nursing staff to meet patient needs and provide optimal care.

There are three scopes of practice for nurses in New Zealand: nurse practitioners (NPs), registered nurses (RNs), and enrolled nurses (ENs)2. All must complete approved training and achieve required levels of competency, relevant to their respective scopes, before they are licensed to practice. The Nursing Council of New Zealand requires nurse training to include direction and delegation and for these skills to be formally assessed as one component of practice competence3.

Health care assistants (HCAs), also referred to as caregivers or support workers, are a well established and now much needed cohort of colleagues involved in care delivery. HCA training is now readily available, and in many workplaces, is compulsory. However, they remain an unregulated group of health workers.

Registered nurses retain overall responsibility for providing appropriate direction and delegation to those colleagues involved in care delivery, including HCAs, to ensure safe and optimal consumer health care. Following widespread consultation in 2010, the enrolled nurse scope of practice was reviewed and EN competencies amended to outline their role and responsibilities in directing and delegating.

Directing colleagues and delegating tasks is unproblematic for many nurses, but for others, it can be fraught with challenges. Poor direction and delegation can negatively impact on nursing practice, team dynamics, care delivery, and consumer confidence (see direction and delegation definition box at bottom of article).

What does direction and delegation involve?

There are five recognised principles that underpin effective direction and delegation.

The  right task involves ensuring that the delegated activity is appropriate for the consumer as well as safely achievable and within the skill level and scope of practice of the individual directed to do it. Assigning tasks requires robust professional nursing judgement.

The  right circumstances relates to the delegated activity being appropriate to the health setting and available resources.

The  right person involves the nurse responsible for delegation, selecting the right individual with the knowledge, experience, and skill level to complete the task.

The right communication refers to ensuring that direction and delegation instructions are clear and understandable. It is recommended that clear, concise descriptions of the delegated activity are given including objectives, limits, and expectations. Seeking feedback is crucial to ensure the person being directed has fully understood the assignment’s expectations and requirements.

The right supervision or evaluation involves recognising, monitoring and providing the necessary support for the delegated task to be successfully completed. And ensuring follow-up and evaluation on task completion. Provision of feedback is recommended5.

The delegation process involves:6

  • Defining the task
  • Deciding on the delegate
  • Determining the task
  • Reaching an agreement
  • Monitoring performance
  • Providing feedback.

Influences that impact on direction and delegation

Many factors impact on the efficacy and need for direction and delegation in health care provision. These can be broadly categorised as:

Clinical context: Includes but is not restricted to environmental considerations especially access to and availability of appropriate resources (including staff), to safely achieve quality health care relative to the consumer population and needs.

Personnel considerations: Relate to the scopes of practice and skill levels. Balancing staff levels and skill mix to meet varied patient needs influences delegation. Nursing communication styles, collegial respect, confidence in team member capabilities, and team dynamics will also significantly contribute to delegation outcomes.

Changing consumer needs and complexity: Can and does impact on delegation. Acutely unwell consumers with greater acuity levels are more complex to care for than those with stable chronic health conditions. Registered nurses might delegate hygiene, grooming, nutrition, and elimination cares to others while retaining responsibility for prescribed medical treatments and related consumer monitoring.

Legal and professional responsibilities: Accountability for all nursing practice and healthcare outcomes is mandated by the Nursing Council of New Zealand and closely governed by laws such as the Health Practitioners Competence Assurance Act (2003), The Code of Health and Disability Services Consumers’ Rights (1996) and the Health and Disability Services Standards (2008)7,8,9,10.

Common barriers to effective direction and delegation

The literature has revealed a variety of common nursing barriers that impact on the efficacy of direction and delegation11, 12.

  • Nurses believing that they are the only people who can do the job appropriately
  • Lack of trust and confidence in colleagues
  • Low self-confidence in ability to determine those tasks that can be delegated
  • Ineffective communication when delegating tasks to others
  • Professional insecurity
  • Vague job descriptions that lack specific roles and responsibilities
  • Inadequate training on or experience with delegating tasks to others
  • Inappropriate or inadequate staff recruitment
  • Time involved in explaining tasks needing to be delegated
  • Under-delegating, over-delegating or improperly delegating tasks
  • Reluctance to take the risks of delegating and thereby depend on others to fulfill requirements
  • Fear of loss of power
  • Subordinate resistance to delegation
  • Failure of the delegator to see the subordinate’s perspective
  • Highly challenging workloads with associated physical and mental demands
  • Belief of colleagues that they are incapable of completing delegated tasks
  • Inherent resistance to authority
  • Culturally diverse backgrounds of colleagues, which can impact on communication, expectations, values and beliefs.
  • Communication styles of those delegating and receiving instructions
  • Clinical context and prevailing workplace culture.

Impacts of ineffective direction and delegation on nurses, team dynamics and care provision

A consistently heavy workload or insufficient staff levels can result in over-delegation or improperly delegated tasks. Coping abilities of all staff can be strained when workloads are consistently heavy and demanding or when staffing levels are insufficient to meet care requirements. Poor decision-making and health care outcomes are exacerbated when nurses are busy and fail to plan care that is safely achievable 13,14,15.

Failing to take time to carefully plan care requirements, using available resources, can result in catastrophic outcomes. In worst case scenarios this can involve causing or exacerbating consumer ill health and even death. Suspension from nursing duties, practice sanctions. or loss of nursing qualifications can occur in those instances where inadequate direction and delegation of care has resulted in unfavourable client outcomes. Significant distress for nurses can result when formal complaints are made against them requiring legal practice investigations. 16, 17 (see case study box at bottom of article).

Nurses relying on HCA’s or others to implement delegated tasks, without using robust professional judgement, can jeopardise the safety of all involved18.

Workforce illness and unstable and/or frequently changing team members within a clinical environment can threaten team stability and effective delegation. Nurses can feel challenged when trying to identify the competency of new and or unfamiliar staff to undertake delegated tasks.

Poor documentation that fails to record the specifics of direction and delegation reflects poor practice and can also jeopardise safety19.

Staff can be quick to exploit nurses who lack confidence in directing and delegating and can sabotage professionally sanctioned activities by resisting or failing to carry out instructions as directed.

Sometimes colleagues are resistant to direction and delegation of tasks. Some ENs and HCAs who have worked in a clinical context for a long period of time believe they are knowledgeable enough to no longer require practice direction or task delegation. Previous bad experiences can also result in staff being less open and willing to receive and carry out directions.

Bad experiences might involve inadequate task explanations, expectations or follow-up by the delegating nurse. Being continually selected to complete tasks in preference to other colleagues can also result in an inequitable workload allocation, fatigue and collegial resentments20.

Team Dynamics

By virtue of the common goal to provide quality and safe patient care, RN’s, EN’s, and HCA’s have a dynamic and reciprocal interdependence on each other.

Quality and cohesive team work that helps achieve acceptable outcomes is critical for staff satisfaction and a collaborative work environment22. Likewise, collegial resentments and workplace tensions or conflict can further compound direction and delegation processes.

Anecdotal evidence suggests that some nurses direct and delegate tasks simply because they can, by virtue of their qualification, and nurses can be perceived as being lazy by colleagues. Nurses may choose to delegate tasks they could do, rationalising nursing skills could be better used elsewhere. Both parties must realise that poor insight or understanding of collegial roles and responsibilities can result in wrongful assumptions, misunderstandings and reduced collaboration.

Direction and delegation of tasks without respectful communication or adequate negotiation can reflect an undervaluing of a team member’s roles and contributions. Assumptions that colleagues will know what they are expected to do without meaningful dialogue can cause offence 23,24.

Being unclear about objectives and expectations for a task can result in less than desirable patient outcomes. Tasks that are incorrectly, insufficiently implemented, or not completed at all directly impact on the consumer experience and outcomes. Missed care can be unsafe care, and in some instances, death can result. Staff resentment about implementing delegated care can detract from the quality of care provision25,26.

Strategies for improving direction and delegation efficacy

  • Take time to plan nursing care requirements. Ensure you have a full understanding of staff skill levels and scopes of practice at the start of each shift and evaluate as needed throughout the shift. This helps mitigate potential for errors.
  • Identify tasks that can and need to be delegated. Ensure these are assigned equitably using sound professional judgement and the five rights of delegation.
  • Ensure workloads are safely achievable for all team members, with sufficient support to enable quality outcomes for staff and consumers. Provide adequate resources to meet health care needs.
  • Seek feedback that instructions have been understood. Clarify any misunderstandings and expectations.
  • Document well: document directions, delegated tasks and outcomes appropriately ensuring they meet regulatory and legal reporting requirements.
  • Communicate delegated tasks respectfully: use appropriate language and outline task expectations. Acknowledge concerns and negotiate strategies to manage any actual or potential issues that could arise. When colleagues trust and feel supported, a greater willingness to accept direction usually results.
  • Provide training opportunities to assist staff of all scopes to safely gain new knowledge and skills using appropriate direction and task delegation26.
  • Role model delegated task(s) if necessary: This is useful for enhancing experiential learning or when tasks are to be repeatedly delegated.
  • Evaluate and monitor progress of delegated tasks regularly. This ensures tasks are being implemented appropriately and guides feedback. Evaluation confirms an assessed individual’s capabilities to safely implement delegated tasks. Monitoring progress reinforces support availability and demonstrates individual and collective accountability and responsibility for outcomes27.
  • Offer mentorship to new graduates or RNs lacking experience or confidence:
  • Mentorship and robust role modelling on how to direct and delegate tasks to colleagues, provides supported learning opportunities to put theory into practice.

Conclusion

Healthcare teams are made up of staff with mixed knowledge and skill levels but whose common objective is providing safe consumer care. Safe and quality healthcare requires a collaborative team approach and the appropriate use of staff direction and delegation. These skills form part of nursing training and are formally assessed as part of a nurse’s competence to practice. Direction and delegation also involve meeting specific regulatory and legal requirements.

Following the five “right” principles is recommended to ensure maximum efficiency when directing staff and delegating tasks. Failure to apply these principles can result in negative impacts for consumers and staff alike.

Ineffective communication, poor information sharing and documentation when directing and delegating nursing care can have adverse impacts.

For direction and delegation to be effective, fostering a culture of collaboration, mutual respect and team cohesion is useful. Understanding team member roles and responsibilities also helps. Starting the shift by planning and negotiating the staff required to meet patient care needs helps clarify the resources needed for everyone to be safely supported in care delivery.

Appropriate direction and delegation of tasks can assist with individual and collective team member growth and development. As someone put it (author unknown): “Teamwork divides the task and multiplies the success.28”

Download the learning activity here>>

BOX ONE

Direction and Delegation defined

The Nursing Council of New Zealand defines direction and delegation as:

DELEGATION is the transfer of responsibility for the performance of an activity from one person to another with the former retaining accountability for the process and the outcome4.

DIRECTION is the active process of guiding, monitoring, and evaluating the nursing activities performed by another4.

Direction is provided directly when the registered nurse is actually present and observes, works with and directs the person4;

Direction is provided indirectly when the registered nurse works in the same facility or organisation as the supervised person but does not constantly observe his/her activities. The registered nurse must be available for reasonable access, i.e. must be available at all times on the premises or contactable by telephone (in community settings)4.

NB definitions updated Oct 1 2017.

BOX TWO

A Health and Disability Commissioner’s Case Study21

Mr A, a 50 year-old man, is admitted to hospital with “classical signs of infection within the lungs.” He is treated for acute asthma. Then found dead at 6am, just over 40 hours from admission, as a result of pneumonia and obstructive airways disease. HDC investigation found multiple inadequacies in care, including code breaches by medical staff, nurses, and the district health board.

Case highlighted inappropriate delegation and lack of direction.

Situation for night staff

  • One RN off sick, message not given to supervisor, agency nurse started at midnight.
  • Senior RN responsible for supervising agency nurse and EN and overall responsibility for 25 patients as well as high acuity.
  • Medical team failed to state clearly in notes that Mr A required close supervision – what observations and when. ‘Pneumonia’ not mentioned.
  • RN did not inform night staff of deterioration in Mr A’s condition during handover and no mention of clinical observations required.
  • Night duty RN gained impression Mr A’s condition was stable.

Nursing Neglect

  • EN assigned to Mr A’s care.
  • RN available but unable to give direct supervision.
  • EN failed to monitor Mr A’s condition and to note observations.
  • EN working outside her scope of practice. EN said: “if I was aware at the beginning of the shift of the seriousness of [his] condition, I would not have accepted that patient.”

Health and Disability Commissioner’s Office findings

  • EN: Code breached for lack of observations and failure to document.
  • RN: Adverse comment – action tempered by workload.
  • DHB: Breach for staff shortages, EN outside scope of practice.

Recommended Reading:

NURSING COUNCIL OF NEW ZEALAND (2011) Guideline: delegation of care by a registered nurse to a health care assistant

www.nursingcouncil.org.nz/Publications/Standards-and-guidelines-for-nurses

NURSING COUNCIL OF NEW ZEALAND (2011) Guideline: responsibilities for direction and delegation of care to enrolled nurses

www.nursingcouncil.org.nz/Publications/Standards-and-guidelines-for-nurses

ANTHONY MK & VIDAL K. (2010) Mindful communication: A novel approach to improving delegation and increasing patient safety. Citation. The Online Journal of Issues in Nursing, 15 (2).

RUFF V. (2011) Delegation Skills: Essential to the contemporary nurse. Thesis, St Catherine University

About the author:

Noreen McLoughlin RN MA (Applied) Diploma Adult Education & Training, is an independent health auditor, self-employed professional development consultant for the last seven years and a registered nurse for 30 years.

This article was peer reviewed by:

  • Louise Slocombe RN, BN, clinical coordinator, Calvary Hospital, Southland
  • Lorraine Borthwick, EN, Gore Hospital

REFERENCES

  1. NURSING COUNCIL OF NEW ZEALAND (2013) The future Nursing Workforce: Supply Projections 2010-2035. www.nursingcouncil.org.nz/News/The-Future-Nursing-Workforce
  2. MINISTRY OF HEALTH (2013) Enrolled Nurses http://www.health.govt.nz/our-work/nursing/nurses-new-zealand/enrolled-nurses-new-zealand
  3. NURSING COUNCIL OF NEW ZEALAND. Scopes of practice. www.nursingcouncil.org.nz/nurses/Scopes-of-Practice
  4. NURSING COUNCIL OF NEW ZEALAND (2011) Guidelines: responsibilities for direction and delegation of care to enrolled nurses
    http://www.nursingcouncil.org.nz/Publications/Standards-and-guidelines-for-nurses
  5. Delegation as a function of nursing management. (2011) http://currentnursing.com/nursing_management/delegation.html
  6. ibid.
  7. NURSING COUNCIL OF NEW ZEALAND Health Practitioners Competence Assurance Act (2003).
  8. HEALTH & DISABILITY COMMISSIONER (1996). The HDC Code of Health and Disability Services Consumers’ Rights (1996)
    www.legislation.govt.nz
  9. MINISTRY OF HEALTH (2008) The Health and Disability Services Standards.
  10. VERNON R, CHIARELLA M, & PAPPS E. (2011) Confidence in Competence: legislation and nursing in New Zealand. International Nursing Review, March 58(1):103-8
  11. RUFF V. (2011) Delegation Skills: Essential to the contemporary nurse. Thesis, St Catherine University.
  12. CIPRIANO P (2010) Overview and Summary: Delegation Dilemmas: Standards and Skills for Practice The Online Journal of Issues in Nursing, 15(2) http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No2May2010/Overview-and-Summary-Delegation-.html
  13. CURTIS E & NICHOLL H. (2004) Delegation: A key function of nursing. Nursing Management, 11(4):26-31
  14. HUGHES R (ed) (2008) Nurses at the sharp end of patient care (chapter two) Patient safety and Quality: An evidenced-based handbook for nurses, Agency for healthcare research and quality, United States.
  15. WESTON K. (2008). Public safety must be paramount. Kai Tiaki Nursing New Zealand, 16(6):30
  16. 1 KALISH BJ (2006). Missed nursing care: A qualitative study. Journal of Nursing Care Quarterly, 21(4): 306-313
  17. KLEINMAN CS, & SACCOMANO S J. (2006) Registered Nurses and unlicensed assistive personnel: an uneasy alliance. The Journal of Continuing Education in Nursing, 37(4):162-170.
  18. WEYDT A (2010) Developing delegation skills. Citation http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No2May2010/Delegation-Skills.html
  19. FINN E. (2010) Case Study, The importance of documentation. Presentation to 2010 Enrolled Nurse Conference. Health and Disability Commissioner’s Office.
  20. WARD J. (2013) The importance of teamwork in nursing. www.nursetogether.com/the-importance-of-teamwork-in-nursing (NOT AVAILABLE ONLINE in 2017)
  21. FINN E. (2010) ibid
  22. POTTER P, DESHIELDS T, & KUHRIK M. (2010) Delegation practices between registered nurses and nursing assistive personnel. Journal of Nursing Management, 18: 157-165
  23. McNEISH J & MANN JS (2010) Knowledge sharing and trust in organisations The IUP Journal of Knowledge Management January, April 8(1,2):18-38
  24. ANTHONY MK & VIDAL K. (2010) Mindful communication: A novel approach to improving delegation and increasing patient safety. Citation. The Online Journal of Issues in Nursing, 15 (2).
  25. KALISH,BJ, LANDSTROM GL & HINSHAW AS (2009). Missed nursing care: A concept analysis. Journal of Advanced Nursing, 65(7): 1509-1517
  26. CORRAZZINNI K, ANDERSON RA, RAPP C, MEULLER C, McCONNELL E, & LEKAN D. (2010) Delegation in long-term care: scope of practice or job description The online journal of issues in nursing 15(2) Manuscript 4 http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No2May2010/Delegation-in-Long-Term-Care.html
  27. CURRIE P (2008). Delegation considerations for nursing practice. Critical care Nurse, Oct 28(5): 86-87 http://ccn.aacnjournals.org/content/28/5/86.full
  28. http://www.quotegarden.com/teamwork.html

NB all website links checked and active on October 1 2017

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