CorrectCare

Delegate It Right! The Five Rights of Delegation

by Richmond James Rada, MSN, RN, CCHP

The role of registered nurses is continuously evolving and trends point to increased managerial and leadership responsibilities, with RNs expected to organize and supervise the work of other health care personnel. Crucial to success in this function is the ability to delegate routinely and effectively.

Today, many correctional facilities are relying on RNs to provide much-needed management and leadership in providing care to thousands of inmates in adult and juvenile institutions. Many of these RNs are veterans in correctional care but new to the management role, and some are even new to the correctional health care delivery system. These RNs could face some challenges in delegating certain tasks to both licensed and unlicensed health workers.

Delegating a task is sometimes intimidating to new lead RNs or RN supervisors. Many are unclear on the fundamental principles of delegation. Although it is an effective management tool, delegation also has a legal component and if not done correctly could result in liability. Delegation has been defined in many ways, but according to the American Nurses Association, it is transferring responsibility for the performance of an activity while retaining accountability for the outcome. This ANA definition is the basis for the legal dimension of delegating a task. It means that the person who delegates (delegator) an activity is ultimately responsible for the outcome of the actions by the person performing the delegated activity (delegatee).

To be an effective delegator, the RN must know the scope of practice of each licensed health worker in the clinic areas as well as the tasks permitted to be performed by licensed vocational/practical nurses, unlicensed workers such as certified nursing assistants and inmate-workers.

Some correctional institutions are starting to use unlicensed personnel as a cost-saving measure. Tasks that are often delegated to these personnel include the following:

1. Obtaining vital signs (CNAs)
2. Assisting in the performance of activities of daily living (CNAs and inmate-workers)
3. Recording intake and output (CNAs)
4. Transferring patients (CNAs and inmate-worker)
5. Collecting specimens (CNAs)
6. Administering medication except by intravenous route (LVNs/LPNs)

These are some of the RN tasks that cannot be delegated to an LVN, LPN or unlicensed worker:

1. Performing a comprehensive assessment
2. Validating assessment data
3. Formulating the nursing diagnosis for the patient
4. Identifying goals derived from the nursing diagnosis
5. Determining the nursing plan of care, including appropriate nursing interventions derived from the nursing diagnosis
6. Evaluating the effectiveness of the nursing care provided

The Five Rights of Delegation (Plus One)
Nurses are well aware of the five rights of medication administration. Similarly, in 1997 the National Council of State Boards of Nursing enumerated the Five Rights of Delegation to guide nurses in correctly and effectively delegating activities.

Right Task
This pertains to the appropriateness of the activities or tasks to be delegated. Appropriateness of activity must be individualize to meet the unique needs of each patient. Is the task within the scope of work of the delegatee? Does your institution have policies and procedures specifying the type of activities that can be perform by unlicensed staff such as CNAs and inmate-workers? The delegator must be aware of the tasks that are permitted and not permitted for each person working in the correctional setting. The institution should describe in writing what are the expectations and limitations of clinical activities and which staff can perform those activities. Many RNs in the correctional setting rely on CNAs to gather vital signs, record intake and output and aid with performance of ADLs regardless of the patient’s condition. This practice, although allowed, will increase the RN’s liability.

Right Circumstances
This is based on the RN’s assessment of the overall nursing needs of his or her assigned clinical area and developing a plan to meet those needs. The RN identifies the specific goals for the area and implements interventions to achieve the stated goals. For example, a one-day postoperative patient needs to ambulate. To whom would you delegate the task of assisting the patient to ambulate? What about a patient who had a recent stroke and is just beginning to eat orally? Should an inmate-worker be allowed to assist this inmate with feeding? The complexity of the tasks should match the skills and experience of the delegatee. Knowing the right circumstances can help the RN to delegate specific tasks for each staff member safely and effectively.

Right Person
Again, the RN as a delegator must know the scope of licensure and the allowed tasks for each health care staff member (licensed and unlicensed). The RN must also consider the experience and skills of the delegatee before assigning the task. How often has the delegatee performed the tasks in the past? Is the delegatee comfortable with doing the task? Is the task within the delegatee’s scope of licensure or duties? Usually, simple and basic tasks with a predictable outcome are delegated to less experienced staff whereas more complex activities should be reserved for those with more experience. As a delegator, you should know the level of skills and aptitude of each staff member under you. Will you delegate an LVN to do a cell-front assessment of an inmate who complains of chest pain because you are doing something else at that time? Remember, licensed vocational nurses have very limited scope in performing patient assessment. What if the LVN reported back to you that the inmate is fine and later the inmate had a massive cardiac arrest and died? Ultimately, the RN is responsible for the outcome.

Right Directions and Communication
This is a very important aspect of the delegation process. For the delegatee to perform the assigned task, the delegator must provide clear, straightforward and easy-to-understand direction. This direction should match the educational level, experience and skills of the delegatee. With giving direction comes ongoing communication. A delegator should maintain open communication before, during and after the performance of the delegated activities. Here are two examples of giving direction on monitoring urine output of a patient with catheter delegated to a CNA during the health services team’s morning meeting. Vague direction: “CNA Smith, please record the output of Mr. Doe.” Clear direction: “CNA Smith, please monitor and record Mr. Doe’s urine output every two hours and let me know immediately if his urine output every two hours is less than 100 ml and if the urine color changes. I am available if you have questions.”

Right Supervision and Evaluation
The RN as a delegator should provide ongoing supervision before, during and after the performance of the delegated activity. Remember, when you delegate a task, you transfer only the performance of the task; the accountability remains with you as the delegator. Therefore, constant supervision is essential to ensure that the delegated activity is performed safe and effectively. As a delegator, you also need to evaluate the effectiveness of the delegation. Is the result of the delegated task the outcome you expected? This is also your opportunity to provide feedback to the delegatee on how he or she did. Giving constructive feedback will help the delegatee gain confidence in performing delegated activities in the future. With the example above, you could say to CNA Smith, “Good job of telling me that you noticed decreased volume on Mr. Doe’s catheter bag for the past two hours. His catheter got clogged and I flushed the catheter and was able to remove the clot. Urine is flowing again.”

See this table for an example of a matrix that the RN may use in making decisions in delegating certain elements of nursing care.

Right Documentation
Although the National Council of State Boards of Nursing listed only five rights of delegation, as a correctional RN, you must also remember the sixth “right,” which is the right documentation. The nursing care plan should reflect the tasks of each staff member and who will be supervising for the delegated tasks. It is also important to put in your institution’s operating procedures the clinical activities that are in the scope of licensure of your licensed staff and the permissible activities of your unlicensed staff.

Safe Delegation
Inherent in each of the rights is the concept that merely because one can delegate a task does not mean that the task should be delegated. The more unpredictable the outcome, the less likely it is that a particular task can be safely delegated. The delegator must consider all aspects of the delegation, including whether delegating the task will ensure the provision of competent and quality nursing care.

The nursing process provides an easy-to-remember framework for delegation. Under assessment, the delegating RN determines if delegation is appropriate (right circumstances) and what tasks may be legally delegated (right task). Planning includes determining whether the delegatee is competent to perform the act (right person) as well as ensuring that it will be safely carried out. This may include formal training, certification or return demonstrations. Implementation includes the RN observing, by either direct or general supervision, that the delegatee safely and competently performs the task (right direction and communication, right supervision). Evaluation provides an analysis of whether the delegation was safely and successfully completed.

Delegation is not a mysterious art but a management function that can be learned and improved with practice. Delegating activities, if done correctly, will help correctional RNs to function efficiently while providing timely, appropriate and quality nursing care to the inmate population they serve.

— About the author: Richmond James Rada, MSN, RN, CCHP, does nurse consultant program review for California Prison Health Care Services, Nursing Services–Northern California Region. Reach him at richmond.rada@cdcr.ca.gov.

[This article first appeared in the Spring 2011 issue of CorrectCare.]