On busy wards every day, rapid decisions are being made to delegate patient care into another’s hands

When PhD researcher Margaret Hughes interviewed registered nurses and enrolled nurses about direction and delegation roles, she found “utter confusion”. But that confusion only becomes visible, she says, if a delegation of patient care goes “horribly wrong”.

Hughes’ qualitative research involved indepth interviews with 36 nurses – 17 registered nurses and 19 enrolled nurses – across a range of settings and from the inexperienced to the very experienced. She concluded that gaps in the Nursing Council’s direction and delegation guidelines need to be filled and aspects of the delegation process should be made more overt.

“The strength of the guidelines is that they are broad, but that is also their downside,” says Hughes. “And very few nurses actually read them as they don’t provide the practical help nurses are seeking.” She says all the nurses she spoke to wanted more training and support from their leaders on how to direct and delegate.

Hughes says the current workforce includes a generation of registered nurses (RNs) who rarely worked with enrolled nurses (ENs). So the arrival on wards and other healthcare settings of a new cohort of ENs – plus health care assistants (HCAs) with variable skillsets and qualifications – exposes skill gaps in direction and delegation. As one RN she interviewed put it: “We are just supposed to know this stuff by osmosis.”

Hughes says her findings highlight not only the confusion around the different roles in the direction and delegation relationship, but also the need to overtly state that ENs (and likewise HCAs) have the right and responsibility to self-assess and decline a delegated nursing task if they believe they can’t do it safely.

The confusion could be reduced, believes Hughes, by leaders and managers providing workplace-relevant information and training on how to carry out ‘good’ direction and delegation. Some of her suggestions for useful additions to the nursing tool box in this area include looking at communication strategies, how to quickly assess or self-assess an EN’s or HCA’s skills, and providing clear, workplace-relevant guidelines on who is responsible for what.  (See also related article ‘Utter confusion’ and the PD article and learning activity Providing nursing direction and delegation with confidence, wisdom, and respect.)

Not just an allocation of tasks: good communication needed

Respectful communication is essential for developing a good direction and delegation relationship, says Hughes.

A harried nurse standing hands on hips in the corridor telling an EN or HCA to “go do this” or “go do that” is neither good communication nor a respectful relationship.

Hughes’ research shows that for delegation to be successful it needs to be a relationship rather than just one person issuing a set of instructions to another. And communicating professionally and well is crucial, otherwise the relationship can break down and patient safety suffers as a result.

Providing staff with training in respectful and inclusive communication styles and strategies is therefore important, says Hughes – including the basics such as what tone to use, and avoiding body language like hands on hips.

“I know nurses are busy; you are tired and you are running, but if you don’t get the communication right you have a communication breakdown and that puts the patient at risk.”

Speedy assessments required

In a busy ward the delegation of patient care can by necessity happen very quickly.

A lot needs to happen in that short time including, according to the Nursing Council guidelines, the RN assessing “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”. At the same time, though not stated, the EN (or HCA) needs to self-assess whether they currently have the skill and experience to do the task or tasks asked of them.

Hughes says during her interviews it became clear that nurses want guidance from their leaders and inservice education on performing this quick but very important assessment role.

If the RN and EN (or HCA) has a longstanding working relationship, this assessment may be relatively simple. But when staff are new, inexperienced or – as increasingly happens under the Care Capacity Demand Management system – have been sent to help out in an unfamiliar ward or service, they may have to start that relationship from scratch.

Hughes says the first rule is to ask and not assume anything, which sounds obvious, but her research showed it wasn’t happening. “Just because the enrolled nurse looks older – don’t assume they are experienced, as they may have just graduated.”

Likewise, because an EN or HCA is able to perform a task in a surgical setting, don’t assume they are skilled enough to do it in a spinal unit or mental health service.

RNs also need to make sure they are asking in an environment where the EN or HCA doesn’t feel too intimidated to say, “I’m really sorry but I can’t do that”.

“But I’ve come across examples of RNs putting their hands on their hips and asking (in a scathing tone) ‘so what can you do?’” says Hughes. “And if an EN or HCA doesn’t feel safe to say they aren’t skilled enough for a certain task then that impacts on patient safety.”

Of course, says Hughes, an EN or HCA can’t just continue to say “I can’t do this” as it will eventually become an employment issue. But there is also an onus on the clinical nurse management team to provide training opportunities so an EN or HCA can upskill, as well as provide clear role descriptions for staff, based on their scopes. In addition, employers are responsible for ensuring the right skill mix to provide safe patient care and for ensuring that RNs are supported and sufficiently competent to safely delegate care and that ENs and HCAs understand their delegated roles and responsibilities.

Dedicated training and planning tools could be useful

Developing an e-learning tool dedicated to training nurses in the knowledge and skills needed for direction and delegation would be very useful, believes Hughes.

Similar training programmes have already been developed in district health boards around the country to teach the handover or communication tool ISBAR (introduction/identify, situation, background, assessment, request/recommendation – also known as SBARR or SBAR).

She says such a tool needs to go beyond the current delegation guidelines and should cover areas like handy hints on collaborative communication, guidance on how to assess and self-assess skills, and making clear the responsibilities of each party to a delegation relationship.

These include making clear that an RN is not responsible for the nursing practice of the enrolled nurse (or an HCA’s actions) but is responsible for the way that direction and delegation is initiated and the patient’s overall plan of care. Similarly, the EN or HCA is responsible for self-assessing and declining a task that they don’t have the skill or experience to undertake safely.

Depending on the model of care, the development of suitable planning tools could also be useful. Hughes says she spoke with one RN who had experienced a planning tool used in an Australian hospital where the RN and EN worked through a patient’s care plan together to decide who was best suited to perform each listed task, and then ticked them off as they were completed.

Hughes acknowledges that having good direction and delegation all takes time and, while the Nursing Council recommends employers factor time into a nurse’s workload to safely delegate care, this doesn’t always happen.

“The RN has got to slow down and take the time to quickly – in seconds – assess the EN (and find a replacement if the EN is not able to do it). And also take the time to make sure that the tone, and what, and how she is saying things is collaborative. Also time for the EN to self-assess, do the job, and report back to the RN. All of this takes time.”

Hughes says you could argue that expecting nurses to find the time to do delegation properly is just “pie in the sky”.

“But actually there were two patient deaths just in the course of this research and many, many examples of lack of patient dignity, like patients wetting beds as their bells weren’t answered,” says Hughes. “That is not acceptable and it goes totally against the Bill of Rights.”

All nurses she spoke to want to do it better to ensure they keep their patients safe.

“It’s the how to do it that they are asking for.”

Recommendations for nurse leaders to improve direction and delegation skills

• Enrolled nurses (and healthcare assistants) must be given time to quickly self-assess and decline a task they are not confident to do.
• Workplace leaders supply information and training to support ‘good’ direction and delegation interactions including on assessment roles, communication styles and who is responsible for what in the interaction.

Recommendations for updating Nursing Council guidelines

• The guidelines should make clear that an EN has both the right and the professional responsibility to self-assess and decline a delegated task.
• That there should be separate guidelines for registered nurses and enrolled nurses that make clear who is accountable for what in the delegation relationship and include guidance on good communication strategies.