Abstract

One of the most complex nursing skills is that of delegation. It requires sophisticated clinical
judgment and final accountability for patient care. Effective delegation is based on one's
state nurse practice act and an understanding of the concepts of responsibility, authority,
and accountability. Work Complexity Assessment, a program that defines and quantifies
various levels of care complexity based on the knowledge and skill required to perform the
work, has demonstrated that methods of patient assignment and staff scheduling that
support consistency increase what could be delegated to ancillary personnel by using the
more effective assignment patterns. The author begins this article by discussing delegation
and the related concepts of responsibility, accountability, and authority. Next factors to
consider in the delegation process, namely nursing judgment, interpersonal relationships,
and assignment patterns are presented. The author concludes by sharing how to develop
delegation skills.

Introduction

Registered Nurses (RNs) are brokers of patient care resources. RNs synthesize data
collected by nurses and other healthcare professionals so as to coordinate the patient's
safe, individualized care and to best address patient and family needs in a way that
maximizes available resources. RNs decide what patient care interventions are necessary
and how, when, and by whom these interventions need to be provided. These decisions are
made in a clinical environment in which shrinking resources and increased demands for
services heighten the need for nurses to delegate care based on professional guidelines
and their state nurse practice acts. The author begins this article by discussing delegation
and the related concepts of responsibility, accountability, and authority. Next factors to
consider in the delegation process, namely nursing judgment, interpersonal relationships,
and assignment patterns are presented. The author concludes by sharing how delegation
skills can be taught and strengthened.

Delegation and Related Concepts

Perhaps one of the most difficult responsibilities an RN has is that of effective delegation.
RNs are required to understand what patients and families need and then engage the
appropriate care givers in the plan of care in order to achieve desired patient outcomes
while maximizing the available resources on the patient's behalf. Delegation is an important
skill that influences clinical and financial outcomes; yet, an RN's delegation skills often are
not evaluated in the same manner as other clinical skills, even though a number of nurses
continue to need help in delegating appropriately.

The following scenario is a typical situation that RNs frequently describe when sharing their
need for more staff:
Near the end of her shift, the RN finds that the LPN and nursing assistant have all their work
completed and are sitting in the nursing station waiting for the next shift to arrive. The RN
has been running all evening trying to juggle competing patient needs, such as
administering blood and initiating IV antibiotics for patients assigned to the LPN and nursing
assistant, in addition to answering a pharmacist's questions about a patient's lab results and
performing requests made by team members from other services, all while trying to
complete the care needed for her patients. The RN is struck by how overwhelmed she feels
and questions the LPN and nursing assistant about why they did not help her. The LPN and
nursing assistant respond that had the RN asked them to help, they would have, adding,
"but we can't read your mind." The RN responded, "I didn't have time ask. Couldn't you see
I was busy?"

There is no doubt that this RN needed help. The RN's challenge, however, was not related
to a lack of available personnel. Rather the situation developed because the RN performed
work that others could have completed. Almost all RNs can benefit from strengthening their
delegation skills so as to maximize the available resources

Delegation and Related Concepts

Delegation is a complex process in professional practice requiring sophisticated clinical

judgment and final accountability for patients' care (National Council of State Boards of
Nursing [NCSBN], 2005). The variability and complexity of each patient situation requires
RN assessment to determine what is appropriate for the LPN, nursing assistant, and/or
other assistive personnel, or even another RN, to perform. In the delegation process, RNs
need to match the skills of the staff with the needs of the patient and family. Matching staff
skill to patient and family needs highlights the difference between delegation and
assignment. The NCSBN defines delegation as "giving someone a task from the delegator's
practice" (NCSBN, 1995, p.1). This task, however, needs to be one that the person
accepting the assignment is qualified to perform. Assignment is defined as "giving someone
else a task within his/her own practice and is based on job descriptions and policies"
(NCSBN, 1995, p.1). Clarifying the difference between delegation and assignment helps
staff members understand why one cannot develop a simple laundry list of what can be
delegated to others.

Delegation belongs to the practice of registered nurses, but often it is not well understood or
practiced. Ebright, Patterson, Chalko, & Render (2003) have stated that innovations, such
as work redesign, have contributed to increased complexity affecting how delegation
occurs. Work redesign has relied heavily on assistive personnel, sometimes called nurse
extenders; however, many tasks cannot be delegated to these assistants because they
exceed the scope of practice of these personnel (Ebright, et al.)
In the scenario provided above, the RN was the person directing the work of others.
However, the RN did not communicated with the LPN and nursing assistant about what
needed to be done. In addition, the RN accepted the responsibility to perform additional
activities requested by other departments rather than redirecting some of them. This
behavior is not uncommon. A study of 170,000 healthcare workers found that RNs often
performed inappropriate work or work that others could have done, thus contributing to a
loss of the professional components of nursing (Murphy, Ruch, Pepicello, & Murphy, 1997).

Nurses are stewards of healthcare resources. They promote cost containment for
healthcare organizations (NCSBN & American Nurses Association [ANA], 2006). Delegation
is a skill that maximizes the available resources in the interest of patient care. Professional
nurses need to work effectively with assistive personnel because of the escalating shortage
of RNs, rising patient acuity, and increased therapy complexity (NCSBN & ANA). RNs are
responsible for the care they provide and for determining what care can be appropriately
delegated to others. LPNs and assistive personnel have technical expertise that can be
maximized when RNs become skilled delegators who understand the concepts of
responsibility, accountability, and authority, and grasp how these concepts influence what
activities RNs can delegate to others (Forte, Forstrum, & Lindquist, 1998).

Responsibility

Frequently when discussing delegation, RNs will comment: If I am responsible for someone
else's work, I would rather do it myself. This statement infers that one is liable or has to
answer for the actions of another. The ANA has stated that responsibility involves liability
with the performance of duties in a specific role (ANA Code of Ethics, 2001). Responsibility
is a two-way process that is both allocated and accepted (Creative Health Care
Management, 2008). Assistive personnel accept responsibility when they agree to perform
an activity delegated to them.

Accountability

Accountability involves a retrospective review which includes critical thinking to determine if

the action was appropriate and giving an answer for what has occurred. RNs demonstrate
accountability when they answer both for themselves and for others regarding their actions
(ANA Code of Ethics, 2001). RNs assure appropriate accountability by verifying that the
receiving person accepts the delegation and accompanying responsibility (NCSBN and
ANA, 2006).

Authority

RNs, by virtue of their professional licensure, have the authority to transfer a selected
nursing activity in a specific situation to a competent individual (NCSBN, 1995). Authority is
the right to act in areas where one is given and accepts responsibility (Creative Health Care
Management, 2008). RNs have authority, or legitimate power, to analyze assessments, plan
nursing care, evaluate nursing care, and exercise nursing judgment (NCSBN) which
includes delegation. In the scenario at the beginning of the article, the RN had the authority,
but did not exercise this authority, to delegate to the LPN and/or nursing assistant.

Summary

In the delegation process accountability rests within the decision to delegate, while
responsibility rests within the performance of the task. LPNs are accountable for the quality
of their performance and responsible for caring out the activities assigned to them. When a
RN delegates an activity, such as medication administration, to an LPN, the LPN is
accountable for safely performing this medication administration according to established
regulations and standards, and responsible for completing this activity. The RN is then
accountable to follow up with the LPN to review the outcome. This intentional reflection on
the delegated activity directs future efforts and promotes learning (Creative Health Care
Management, 2008). Understanding the difference between responsibility and
accountability helps to clarify how RNs can delegate work to another without being held
responsible for their actions.

Delegation and Nursing Judgment

The ANA Code of Ethics (2001) notes that delegation is based on the RN's judgment
concerning a patient's condition, the competence of all members of the nursing team, and
the degree of supervision required. This statement coincides with the Five Rights of
Delegation developed by the NCSBN (1995). These Rights of Delegation include: (a) the
right task, (b) the right circumstance, (c) the right person, (d) the right
direction/communication, and (e) the right supervision.

Additionally, four guidelines for effective delegation have been identified by Koloroutis
(2004, p. 136). They include the following:

1. Delegation requires RNs to make decisions based on patient needs, complexity of

the work, competency of the individual accepting the delegation, and the time that
the work is done.
2. Delegation requires that timely information regarding the individual patient be
shared, defines specific expectations, clarifies any adaptation of the work in the
context of the individual patient situation, and provides needed guidance and support
by the RN.
3. Ultimate accountability for process and outcomes of care – even those he or she has
delegated - is retained by the RN.
4. RNs make assignments and the care provider accepts responsibility, authority, and
accountability for the work assigned.
Delegation decisions are sometimes made based on a list of tasks found in a job
description, such as taking vital signs, bathing, or ambulating patients. In these cases the
RN is really assigning tasks rather than using professional judgment to match the staff
member's skills to patient needs. Assigning nursing assistants to perform all the baths or
take all the vital signs for a group of patients indicates that the delegation is task based
rather than judgment based. Making assignments based on a list of tasks in a job
description short-circuits the critical thinking skills of the RN because the RN's judgment is
not utilized. Matching the staff member's expertise to patient needs is essential for sound
delegation decisions.

An example of this matching would be an RN's decision that an LPN with five years of long
term care experience prior to working in orthopedics is a more qualified care giver for a 91
year old post operative arthroplasty patient than an LPN who is also available but who has
less background in caring for geriatric patients. It is the understanding of the geriatric
patient's needs at this point in time that would lead the RN to intentionally select the LPN
with long term care experience. In this situation, the RN would still assume the responsibility
of first assessing the patient before delegating the care to the LPN, and the responsibility of
clarifying expectations of the care to be given in order to meet the desired outcomes. The
RN would periodically assess the patient's status and not hesitate to instruct the LPN about
what to monitor and direct specific interventions. In this example, the matching of patient
need to the nurse skills would be very intentional, relying on the RN's professional
judgment.

Although delegation is a skill that requires knowledge and practice, delegation is not
commonly identified as an RN competency. Understanding and applying the delegation
guidelines presented above provides a foundation for effective delegation.

Delegation and Interpersonal Relationships

Another important factor in delegation is the relationship between the RN and the LPN,
nursing assistant, and/or other team member(s). Each member of the healthcare team has
a valuable contribution to make to patient care (Creative Health Care Management, 2006).
This contribution is magnified when the RN has a healthy interpersonal relationship with the
team providing care. Delegation is the invitation for participation. The manner in which a
team member is asked to perform care by the delegating RN influences the team member's
willingness to respond. Communication style influences teamwork and relationships.
Engaging in direct, open, and honest communication is a characteristic of good teamwork.
Thus the ability to delegate and the quality of the delegation is influenced by healthy
interpersonal relationships, the manner in which the activity is delegated, and the openness
of the communication.
In contrast, in the scenario at the beginning of this article, comments made by various team
members set the stage for blaming. The LPN and nursing assistant stated that they would
have helped, had the RN asked them to do so, thus blaming the RN. One can wonder why
the LPN and nursing assistant did not offer help or take initiative on their own to do more.
Had the RN, LPN, and nursing assistant had a better relationship, the LPN and/or assistant
might have had a greater desire to see their team provide the best care possible and have
taken the initiative to perform the care that was within their scope of practice. Then the RN
could have better managed what needed to be done and better patient care could have
been provided.

In the ideal situation, the RN, LPN, and nursing assistant would have been active partners
in care and shared the work. The RN, anticipating what would need to be done while she
was busy with other activities, would have discussed openly, directly, and honestly with the
LPN and assistant the additional care she needed to ask them to manage. Healthy
interpersonal relationships among all personnel on the shift promote a synergy between
team members, enabling them to work together more effectively. Although there is a
connection between healthy relationships among team member and quality care, positive
interactions among all staff members on a given shift are not always demonstrated in
practice.

Trust is an important element in developing healthy team relationships. Kolorouits (2004)

has noted that effective delegation is based on both trust and an understanding of
professional practice. When RNs state that they are reluctant to delegate care when they do
not know their team member's skill level, they are likely saying that they avoid delegation
because they don't trust their other team members. Trust, a critical factor in relationships, is
based on knowledge of one another's capabilities and confidence in these abilities.
Caregiver consistency, which builds trust, is achieved by staffing schedules and methods of
patient assignment which directly impact how work is delegated. The staffing schedule and
patient assignment methods that promote consistency among caregivers and between
caregivers and their patients become the foundation for enhancing the quality of work
relationships (Koloroutis, 2004) as described below.

Delegation and Assignment Patterns

The correlation between consistency of care givers and delegation potential (the amount of
nursing care that can legally and safely be assigned to a non-professional staff member) is
explored in the Work Complexity Assessment (WCA) Program. WCA is a consultant-led
process, developed by Tom Ingalls and licensed through Creative Health Care
Management; it helps define and quantify various levels of care complexity based on the
knowledge and skill required to perform the work. The delegation potential is based on
what could be delegated rather than on traditional delegation practices that are often task
based. WCA uses the three scenarios (three different ways of assigning personnel) to
determine the delegation potential and examine the impact of staffing schedules and
methods of patient assignment on delegation. The three scenarios, namely unit based,
pairing, and partnering, vary in the amount of time in which nurses and other personnel
work the same shifts and care for the same patients (Koloroutis, 2004). Each scenario is
described below.

Unit-based Scenarios

In the unit-based scenario, assistive personnel, such as the ward secretary and nursing
assistant, serve the unit. The nursing assistant works off a task list usually found in the job
description, and has minimal direction from, or interaction with the RNs. The nursing
assistant is often left to prioritize the multiple tasks given by differing RNs who are unaware
of one another's requests of the assistant. This lack of communication can cause conflicts.
The RNs do not know what their fellow RNs have also asked the assistant to do and the
assistant has no way of knowing to which RN they are ultimately accountable. Nursing
assistants express frustration with conflicts and work expectations that cannot be
negotiated. RNs express frustration about not knowing the nursing assistants whereabouts
or what they are doing.

An example of the unit based scenario is assigning a nursing assistant to take all the vitals
signs or bathe all the patients. The nursing assistant understands what is expected, but may
be interrupted in completing the vital signs and baths and asked to ambulate a patient by
one RN, who does not know that another RN has just requested the nursing assistant to
help with a dressing change. Meanwhile, the nursing assistant is trying to complete the
bathes and take all patients' vital signs, while the RNs are questioning why the nursing
assistant hasn't responded to their requests for help. In these scenarios the emphasis is on
completing tasks of care, rather than focusing on the care process. It is difficult to develop
healthy relationships and trust under these conditions.

Pairing

Pairing is the second scenario in which one RN works with an LPN and/or a nursing
assistant for the shift (Koloroutis, Felgen, Person, & Wessel, 2007). However, the RN and
LPN and/or assistant are not intentionally scheduled to work the same shift each day.
Although they may all work the same shift on the next day, they may not be paired on the
next day to care for the same patients. For a given shift, however, they work together, or are
paired, and care for the same group of patients. Delegation usually increases with pairing.
In this scenario, the RN and the LPN or nursing assistant discuss how care is to be
prioritized and how it is to be done, and identify expected individualized outcomes for the
shift. For instance, a patient's therapeutic goal for the shift might be for the patient to
ambulate the length of the hall 30 minutes after the pain medication has been administered,
with a pain rating no greater than 2 on a scale of 1 to 10 at the end of the walk. The nursing
assistant would report observations and the pain scale rating to the RN who would then
determine if the plan for pain control is adequate. Pairing increases the delegation potential
and promotes healthy relationships.

Partnering

The third scenario is partnering (Koloroutis, Felgen, Person, & Wessel, 2007). In partnering,
one RN and one LPN and/or nursing assistant are consistently scheduled to work together,
making a commitment to maintain healthy interpersonal relationships, trust each other, and
advance each other's knowledge. It is recognized that the RN has the authority to make the
delegation decisions. In this model, the LPN, nursing assistant, and RN know one another
well enough to anticipate what is going to be needed for patient care. The LPN or nursing
assistant who works in a partnership with the RN knows that the RN will want a specific
patient to ambulate and to achieve pain control by a certain time within a eight hour shift
and/or will need a particular piece of equipment or certain supplies at a certain time. This
knowledge enables the assistant to have the information or equipment available even
before the RN asks for it. Compared to the assistant in the paired assignment, the assistant
who is partnered could anticipate that the RN will want the patient walked within a given
timeframe after a pain medication has been administered, and could plan to be available to
walk the patient at the appropriate time. Together the RN and the LPN or nursing assistant
care for "our patients" rather than "your patients" and "my patients." This reflects a major
shift in thinking and in the method assignments are made. Had partnering been used in the
scenario at the beginning of the article, the staff involved would have known each other's
needs and expectations and would have been able to coordinate their efforts more
effectively.

Partnering is supported by a staffing schedule that is developed so as to consistently have

care givers working together and by the method of patient assignments that ensures the
same staff cares for the same group of patients for their length of stay. Partnering reflects a
philosophy of care that values continuity and relationships, with management and staff
honoring the partnership. The delegation potential is generally highest when staff partner
with each other because consistent relationships over time enhance knowledge about
capabilities and help to foster trust between members of the nursing staff.

Thus staffing schedules and patient assignments impact the delegation potential. When this
connection is understood and valued, staff members see how work can be done differently.
This becomes especially effective when staff at the point of care take ownership of a
staffing schedule that promotes continuity of care and when the patient assignment
matches the talents of the caregivers to the needs of the patient and family.

Because the depth of expertise varies within roles, including the RN role, delegation is more
difficult when the assistant is not known by the RN. Pairing and partnering increase
delegation because trust is developed, relationships are fostered, and growth is supported.
In partnering, there is increased commitment to one another and confidence that complex
situations can be managed. The partnership enables RNs to perfect their delegation skills
more fully.

Some staff members have shared with me that having limited nursing assistants or LPNs
available with whom they can partner poses a challenge to implementing this partnering
scenario. Creativity is needed to make this scenario work using existing resources. For
example, in situations with predominately RN staff, more experienced RNs could mentor
new RNs using pairing or partnering, thus enhancing care and helping the new RNs to grow
professionally.

Work Complexity Assessment consultants have demonstrated that the amount of work
delegated can be expanded when direct care givers work together consistently. Delegation
potentials are significantly higher when caregivers are paired or partnered, with the
partnered scenario generally having the highest delegation potential. In analyzing the
findings from delegation potential studies, RNs frequently cite trust with their co-workers as
a key factor when delegating. They state that delegation requires an understanding of one
another's knowledge and skills. Direct care givers who work together consistently have
been found to experience the following gains in the work setting: (a) more knowledge about
each other's competence and continued growth in competence; (b) increased commitment
to each other and ability to deal with more complex situations; and (c) increased efficiency
in getting the work done through natural synergy (Weydt, 2009, p. 11). The Table compares
the description, outcomes, and challenges of the unit-based, pairing, and partnering
assignment patterns

Developing Delegation Skills

Delegation is a multifaceted skill set that begins with understanding one's state nurse
practice act which outlines nursing's legal responsibility, authority, and accountability for
patient care. RNs are encouraged to conduct ongoing reviews of their state practice act with
special attention given to delegation. The review often prompts discussion about
organizational policies and procedures as well as clarifying roles, such as that of the LPN or
technical support staff. The role clarification becomes increasingly important as new
positions develop to address the variety of complex patient care needs. Understanding the
role expectations as well as knowing the expertise of the staff to whom care is delegated
influences what the RN delegates.

Delegation skills can be strengthened when:

• RNs understand the nurse state practice act

 • Nursing education and nursing service support students and RNs as they continually
expand their knowledge about delegation
• Simulation exercises using scenarios found in daily practice are used to teach and
demonstrate delegation competency
• Pairing and/or partnering is utilized and supported by the staff schedule and method
of patient assignment
• Delegation is viewed as competency that is based on a skill set and that requires
ongoing development

Developing delegation skills is indeed a multifaceted activity. Developing delegation skills

begins during pre-licensure nursing education. It is important that educators and
organizations provide clinical experiences for students to see delegation as a skill set that
has to be practiced in order for it to be perfected. Developing practice environments that
foster students' learning of delegation skills reinforces the authority of all RNs to delegate to
LPNs and nursing assistants who may see the student as inexperienced. As new RNs enter
professional practice, they need ongoing support and education to perfect this skill.

Delegation skills can also be developed using simulation to create practice scenarios
reflecting daily practice. Both clinical aspects of care and delegation skills can be evaluated
during the simulation. Simulation creates the opportunity for feedback and analysis of how
pre-licensure students and/or RNs directed the work of others during the simulation, with an
emphasis on the effect that the simulated delegation would have had on clinical and
financial outcomes. RNs can evaluate their interpersonal skills used during the simulation,
as well as review the work performed, asking how the work could have been done
differently and considering who else might have been in a position to do this work.

Simulation might be used, for example to improve both the skill of delegation and that of
administering blood for a post-operative patient. In the simulation scenario, the required
technical skills of blood administration could be evaluated as well as the RN's ability to
appropriately delegate, during the procedure, some responsibilities for patient care to either
the LPN or nursing assistant. The post-simulation discussion (debriefing) could include an
evaluation of both the blood-administration procedure and also the quality of the delegation
with a focus on the RN's communication skills. The LPN and nursing assistant could provide
feedback as to their perception of the RN's delegating skills.

Conclusion

Delegation is a complex professional skill requiring sophisticated clinical judgment and final
accountability for patients' care. Effective delegation is based on one's state nurse practice
act; it serves to maximize patient care resources. Concepts of responsibility, accountability,
and authority are integral to each RN's understanding of professional nursing practice,
which includes properly assuming authority for the decisions and outcomes associated with
patient care, sharing the process of patient care with other responsible members of the
nursing team, and holding all members of the nursing team accountable for their
responsibilities. Delegation requires RNs to use critical thinking skills in order to match staff
expertise with patient and family needs. Staff relationships also influence the delegation
potential and the delegation process. Three assignment scenarios are used in Work
Complexity Assessment, namely unit based, pairing, and partnering, to determine the
delegation potential for a specific patient care unit/service. Staffing schedules and
consistent patient assignments that support pairing and partnering enable staff members to
increase knowledge about each other and help to foster a strong sense of trust, thus
increasing the delegation potential.

When RNs do not effectively delegate to others, quality of care can be lessened and
valuable resources can be mismanaged. Resources will surely continue to shrink and care
demands will surely continue to rise, thus increasing the risks of inappropriate delegation.
Having clarity about what can be delegated helps to define quality professional practice not
only for nurses but also for other team members, patients, and families.