Ovid: Appropriate Delegation.

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American Journal of Nursing

Issue: Volume 100(12), December 2000, p 24A, 24C-24D
Copyright: © 2000 Lippincott Williams & Wilkins, Inc.
Publication Type: [Hospital Extra]
ISSN: 0002-936X
Accession: 00000446-200012000-00023

[Hospital Extra]

Appropriate Delegation
Keeling, Bette PhD, RN, CNAA; Adair, Joyce MSN, RN,C; Seider, Debbie BSN, CNN; Kirksey, Gail BS, RN

Author Information
Bette Keeling is an executive consultant at Hillcrest Baptist Medical Center in Waco, TX. Joyce Adair is an adjunct
faculty member, Texas Woman's University, Dallas. Debbie Seider is a congregational nursing coordinator, Methodist
Hospitals of Dallas. Gail Kirksey is an education specialist at Methodist Medical Center, Dallas.

Outline
 Abstract
 CONTRIBUTING FACTORS
 ASSESSING THE SKILLS OF UNLICENSED PERSONNEL
 MATCH TASKS TO SKILLS
 COMMUNICATE CLEARLY
 LISTEN ATTENTIVELY
 PROVIDE FEEDBACK
 Tips for Successful Delegation
 SELECTED REFERENCES

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Abstract
Uncovering opportunities for improvement.  
 

At the beginning of her shift, nurse Susan Robeson  

believed she had a reasonable workload and was organized
and prepared. But as she walked down the hall to check on
Viola Black, whose blood pressure was dropping, she
remembered that another patient, Justin Hall, could be
discharged that afternoon only if he voided after his Foley
catheter was removed. Susan therefore asked Lynne Galland,
an unlicensed assistant, to discontinue Mr. Hall's catheter

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while Susan attended to Ms. Black. Lynne acknowledged

the request and, because the two had worked together
successfully in the past, Susan was satisfied that she had
delegated responsibility for the task appropriately.
After a prolonged and frustrating transfer process, Ms.  
Black was moved to the ICU and Susan had time to ask Lynne
about Mr. Hall's urinary output before catheter removal. Lynne
said she hadn't assessed the output and pointed out that she'd
only been asked to discontinue the Foley catheter. Susan-
frustrated with this response and strained from her work with
Ms. Black-berated Lynne for this oversight in front of both
staff and patients.FIGURE
With sicker patients, shorter lengths of stay, increased  
use of unlicensed assistive personnel (UAPs), and heightened
demand for cost-effective care, it's imperative that RNs
delegate some aspects of patient care to others. Research of
Blegen and colleagues identifies two basic requirements for
successful delegation: UAPs must be trained to carry out
certain tasks and nurses must know how to delegate
responsibility to them appropriately.
Some nurses are trained using a team model of patient  
care delivery and learn how to delegate responsibility; others,
however, are used to a primary care model of patient care
delivery, which doesn't involve delegacy. Regardless of
training, nurses can use encounters like this to help them
delegate tasks appropriately.
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CONTRIBUTING FACTORS
Several factors led to the undesirable outcome of the  
scenario. First, Susan assumed the task would be successfully
completed because of her experience working with Lynne. In
addition, Susan gave instructions based on her own knowledge
of Foley catheter discontinuation and assumed that Lynne
knew the procedure included measuring the patient's urine

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output; Susan didn't explain to Lynne exactly what was

involved. Another factor was the one-sided exchange between
Susan and Lynne, in which the former gave the latter
instructions but didn't allow Lynne time to ask questions or
seek clarification. Finally, Susan was tense after caring for a
deteriorating patient and failed to regain her composure
before responding to the news that Lynne hadn't obtained the
necessary information.
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ASSESSING THE SKILLS OF UNLICENSED
PERSONNEL
Determine what UAPs know and what they can do by  
asking a few carefully worded questions. Try to use open-
ended queries that are more likely to elicit conversational
responses than simple "yes" and "no" answers. For example, if
Susan had asked Lynne if she had previously discontinued a
Foley catheter, the assistant could have answered in the
affirmative or negative, which wouldn't have told Susan
whether Lynne understood that measuring output is a part of
discontinuing the catheter. A better approach would have
been to ask, "How do you usually measure the output from the
urine bag when you discontinue a Foley catheter?" Lynne's
response would have provided Susan with enough information
to determine whether she should be given the task.
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MATCH TASKS TO SKILLS
Susan may or may not have had knowledge of the  
performance expectations for UAPs in her facility. The
literature demonstrates that the training of these personnel
varies. As the use of multiskilled UAPs has increased, they
have been trained to perform tasks-such as phlebotomy,
electrocardiograms, and IV and Foley catheter discontinuation-
that traditionally have not been assigned to them.

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Familiarize yourself with the UAP training program at your  

facility to avoid delegating tasks for which UAPs have not been
trained. Nurses can be reasonably sure that UAPs who have
completed basic orientation and training should be able to
safely perform a set of fundamental skills. You need to know
what those skills are and what steps constitute the
performance of each one. In some institutions, for example,
discontinuing a Foley catheter could consist of simply deflating
the balloon before removal.
In your review of the orientation materials, determine if  
critical thinking, conflict resolution, or listening skills are
included in UAP training. Regardless of their abilities to
perform tasks, UAPs must be able to recognize when there is a
potential for harm to a patient. They need to know what
should be reported, including changes in vital signs, the lack
of urine output, and saturated dressings.
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COMMUNICATE CLEARLY
Was Lynne given the information needed to complete the  
task to Susan's satisfaction? Obviously not. Jung and colleagues
reported that UAPs were better satisfied with their jobs when
they received unambiguous, complete directions and worked
in structured environments. Clearly describing a task, the
desired outcome, and the time period within which the task
should be completed provides explicit direction and increased
structure.
The interview between the RN and the unlicensed  
assistant should be bilateral. When Susan requested that
Lynne discontinue Mr. Hall's catheter, she asked a closed-
ended question and followed it with a statement indicating
that her focus was elsewhere, offering Lynne little opportunity
to seek clarification.
Ideally, Susan would have said: "Lynne, I need you to  
discontinue Mr. Hall's Foley catheter. Please do it before 9:30

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AM so he can be discharged this afternoon after he voids.

Write the urine bag output volume on his input and output
sheet. OK?" Not only would this have provided more
information, it would have also communicated to the assistant
that she's part of the team. By phrasing her request this way,
Susan also would have shown that she was just as focused on
the task she was delegating to Lynne as she was on caring for
Ms. Black. For these reasons, Lynne would have been more
likely to seek clarification or ask questions.
The communication would have been even better if Susan  
had asked Lynne to respond. For example, she could have
either asked Lynne to repeat the instructions or inquired
whether she had any questions or concerns regarding the task.
Keep in mind that more than 80% of communication is  
nonverbal. Tone of voice, rate of speech, and body language
can have a greater influence on the clarity of communication
than words do. If you want communication to improve, focus
on these aspects. Stand in front of a mirror and, looking
directly into your eyes, enact a conversation. Remember that
failure to establish eye contact may be construed as dislike. If
Susan had briefly stopped, looked directly into Lynne's eyes,
and then made her request, the outcome might have been
different. Direct eye contact would have been more personal,
and it would have demonstrated respect.
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LISTEN ATTENTIVELY
In addition to posing open-ended questions and requesting  
assistance in ways that invite response, nurses should also
listen attentively to such a response. According to Stephen
Covey, you should "listen with your eyes," with the intention of
understanding rather than responding.
If these techniques don't encourage UAPs to ask questions  
or request clarification of orders, then ask them to repeat the
instructions. While listening to the answer, observe the

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assistant's body language. Does she look away, cross her

arms over her chest, or assume a wide-legged stance? Any of
these responses can indicate discomfort. If you notice this
type of body language, point it out and ask if the assistant is
uncomfortable with the request.
After encouraging a response, be sure to listen to it. Don't  
interrupt, even in the face of an explosive response, unless to
suggest that you seek privacy. Focus your attention fully on
the complete message-words, tone of voice, rate of speech,
and body language. When permitted to express their feelings,
workers are usually more effective.
UAPs are often assigned to work with more than one RN.  
In this instance, the assistant may have several imminent
deadlines. Therefore, RNs and UAPs should spend a few
minutes organizing and prioritizing the tasks at hand;
workloads will be more bearable and teamwork will be honed.
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PROVIDE FEEDBACK
Delegation is incomplete unless you offer UAPs feedback  
regarding performance, regardless of outcome. If there had
been a desirable outcome, Susan could have openly thanked
Lynne for a job well done. In this instance, as Susan wasn't
satisfied with the assistant's performance, she should have
taken Lynne aside and discussed the miscommunication and
desired outcome. Rather than blaming Lynne for her
inadequacy, Susan could have accepted responsibility for an
incomplete set of instructions and then committed herself to
giving clearer directions.
Regardless of education and experience, delegation is a  
challenge, the successful meeting of which depends on the
consistent application within practice of the principles
summarized in Tips for Successful Delegation, on page 24C.
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Tips for Successful Delegation
• Assess the knowledge and skills of the delegate.  
• Match tasks to the delegate's skills.  
• Communicate clearly with the delegate.  
• Listen carefully.  
• Be specific.  
• Provide feedback.  
• Communicate directly-avoid giving instruction through  
others.
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SELECTED REFERENCES
Blegen MA, et al. Survey results. Who helps you with your  
work? Am J Nurs 1992;92(1):26-31.
Covey SR. The seven habits of highly effective people:  
restoring the character ethic. New York: Simon & Schuster;
1989.
Hendrickson G, et al. How do nurses use their time? J Nurs  
Adm 1990;20(3):31-7.
Jung FD, et al. Evaluation of a program to improve nursing  
assistant use. J Nurs Adm 1994;24(3):42-7. Request
Permissions Bibliographic Links
Kreplick J. Unlicensed hospital assistive personnel: efficiency  
or liability? J Health Hosp Law 1995;28(5):292-309.
Bibliographic Links
McCloskey JC, et al. Nurses' use and delegation of indirect  
care interventions. Nurs Econ 1996;14(1):22-33. Bibliographic
Links
Parkman CA. Delegation: are you doing it right? Am J Nurs  
1996;96(9):42-7; quiz 8.
 

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