NSG451 University of Phoenix Daily Activities Leadership Paper

Chapter 26 Delegation: An Art of Professional Nursing Practice Maureen Murphy-Ruocco Delegation, a multifaceted decision-making process, is a learned leadership behavior acquired by understanding the art of delegation, developing critical judgment skills, and applying delegation decisions in clinical nursing practice. The overall purpose of delegation is to achieve nursing goals and improve patient care o

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utcomes. Registered nurses accountable for other staff members work must learn how to master the art of delegation. This chapter discusses different aspects of delegation, describes the implementation of effective delegation decisions, and explores the legal parameters of delegation in professional nursing practice. The chapter’s emphasis is on the role of registered nurses as delegators, regardless of the formal position they hold in the healthcare organization. Learning Outcomes • • • • • • • • • • Define delegation. • Understand the five rights of delegation. • Explain the different components of delegation. • Understand the role of unlicensed nursing personnel/unlicensed assistive personnel (UNP/UAP) in the delivery of health care. • Differentiate between assignments and tasks in the delegation process. • Evaluate how tasks and relationships influence the process of delegation. • Examine the role of the registered professional nurse in delivering high-quality health care. • Discuss the complexity of delegation decisions for registered nurses. • Comprehend the legal authority of the registered nurse in delegation. Key Terms Accountability Active delegation Authority Delegatee Delegation Delegator Individual Accountability Licensed practical nurse (LPN)/licensed vocational nurse (LVN) Organizational accountability Patient care associate (PCA) Passive delegation Responsibility Supervision Unlicensed nursing personnel (UNP)/unlicensed assistive personnel (UAP) The Challenge Kathryn King-Dyker, RN, MSN, CSN Former Emergency Trauma Nurse, Hackensack University Medical Center, Hackensack, New Jersey Not all emergency trauma care centers are created equally. Trauma centers are classified from Level 1 to 5, with Level 1 being the most equipped to meet the needs of critically ill patients. Emergency medical technicians (EMTs) often transport patients to hospital emergency trauma centers by ambulance, or patients are transported by a family member or friend. Hospital emergency trauma centers are staffed by physicians, registered professional nurses, radiology technicians, respiratory therapists, emergency technicians, transportation aides, clerks, and secretaries. When a patient arrives at a hospital emergency trauma center, critically injured patients should be immediately triaged by a registered nurse to determine the nature and acuity of their illness/injury. The challenge is to assess the patient‘s condition and provide emergency health care. If necessary, they must stabilize and transfer the patient to the most appropriate facility. Recently, the emergency trauma department has been expanded and needs to accommodate 15 more patients. To support patient care, the hospital administration hired additional staff, unlicensed nursing personnel (UNP), whose positions were being phased out in their free standing urgent care center, and employed them as emergency room technicians. The next emergency technician training program will not begin for 2 months. Therefore the new UNPs will be working as emergency room technicians in the emergency department before they are trained. The emergency department received a call that an explosion at a local chemical plant just occurred. The emergency medical services will be arriving with multiple patients injured in the accident. • o What do you think you would do if you were this nurse? Introduction Delegation, an art and skill of professional nursing, is a complex decision-making strategy implemented to improve the work-related performance of the staff employed in health care organizations. Learning how to distribute work appropriately builds the staff members’ confidence about caring for groups of patients safely and effectively. Conversely, inappropriate delegation of tasks creates apprehension in staff members’ about caring for the same group of patients. Therefore delegation used effectively improves patient care outcomes; used ineffectively it can produce negative effects on patient care delivery. The development of delegation skills and strategies often improve as the registered nurse gains more clinical experience and transitions from novice, advanced beginner, competent, proficient, to expert (Benner & Benner, 1984). Delegation is the most effective professional management strategy registered nurses (RNs) implement in clinical practice to improve the safety and quality of patient care. Historical Perspective Until the early 1970s, registered nurses were somewhat familiar with the concept of delegation. At that time, the majority of patient care delivery occurred in acute care hospitals, which were staffed by registered nurses (primarily diploma nursing graduates prepared in hospital-based nursing programs), licensed practical nurses/licensed vocational nurses (LPNs/LVNs) and nurses’ aides (commonly known today as unlicensed assistive personnel [UAP], unlicensed nursing personnel [UNP], or patient care associate [PCA]). UNPs provide direct patient care under the supervision of the registered nurse who retains accountability for patient care outcomes. Historically, concepts such as “team nursing” and “staffing ratios” permitted LPNs/LVNs and nurses’ aides to function as part of a staff on nursing units, limiting the number of registered nurses employed on the unit. This allowed a large portion of direct patient care to be provided by LPNs/LVNs, and nurses’ aides. During that time, direct patient care included providing physical comforts and basic treatments to patients. As health care advanced, patient care and treatments became more complex. As the complexities of patient care delivery increased, the work demands and expectations of registered nurses became more challenging and created the need to provide a higher staff ratio of registered nurses to UNPs to support patient care. During the 1970s and 1980s, many nurses entered the profession with relatively limited content knowledge and/or clinical experience about how, what, and when to delegate to others. In the mid-1990s, a dramatic shift from a model of primary nursing (an all professional nursing concept), to a multilevel nursing model (registered nurses mixed with LPNs/LVNs, and UNP) occurred. Fiscal constraints and the new complexities in health care created an urgent need for nurses to learn more about how to use effective delegation skills to deliver safe and effective nursing care. As the healthcare industry emphasized community-based care, delegation and supervision of staff became even more challenging. Today, a comprehensive knowledge base in delegation, and diagnostic reasoning and decision-making skills in clinical practice are required to provide expert nursing care. During the early part of the twenty-first century, the American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN) became increasingly concerned about the quality of the delegation decisions. The NCSBN stated that the “State Boards of Nursing should regulate nursing assistive personnel across multiple settings” (NCSBN, 2005, p. 160). It became evident that the approach in many states to regulate and certify nursing assistants in hospitals and/or health care facilities no longer met the needs of nursing. In addition, the NCSBN added an expectation that the basic education for nursing assistive personnel include an emphasis on how to receive delegation from nurses (NCSBN, 2005). The ANA (2005) outlined the principles of delegation for registered nurses. The ANA and the NCSBN (2006)collaboratively published a joint statement that serves as general guidelines for delegation decisions for registered nurse practice. The joint statement explains that the authority for delegation resides within the Nurse Practice Act of each state, examines the value of unlicensed personnel in patient care delivery, and declares that the importance of delegation decisions is safety and welfare of the public. The joint statement acknowledged that the decision to delegate should be based on multiple factors such as the patient’s condition, complexity of the task to be performed, and predictability of outcomes. Nurses need to understand that the “pervasive functions of assessment, planning, evaluation and nursing judgment cannot be delegated” (NCSBN, 2005 p. 1). Principles of Delegation (ANA, 2012) outline what nurses need to know and do in relation to this complex task. In the past, nursing content knowledge related to the principles of delegation, and successful strategies on how to delegate had not been a major focus in schools of nursing, especially as it related to nursing delegation in the community health setting. Nursing leaders also acknowledged that new nurses were not adequately prepared to master delegation decisions. Because of the changing healthcare delivery system, faculty in schools of nursing must teach, mentor, and develop students’ competencies in delegation. These competencies can be developed through different teaching learning strategies, such as didactic content, case studies, simulated experiences, online learning, and clinical nursing practica. Students’ proficiency in delegation is “greatly improved by pairing the active learning didactics from education and the clinical experience from the healthcare practice site” (Powell, 2011, p. 10). The nursing practicum experiences foster the application of theory to practice, the development of clinical judgment, and the ability to comprehend the legal authority of delegation decisions. Early in the nurse’s career, high-quality clinical delegation experiences and engagement with a nursing mentor foster professional self-confidence. These experiences advance the nurse’s ability to become a successful delegator and broker of patient care resources (Weydt, 2010). Delegation knowledge should also be reinforced in nursing continuing education programs. (Kaernested & Bragadóttir, 2012). These educational opportunities are essential to further develop “delegation and supervisory strategies to adapt to the RNs changing role” (Saccomano & Pinto-Zipp, 2011, p. 532). Delegation can be further complicated by other factors such as age, gender, and ethnicity. Younger generations, for instance, have a different view of the world and are often more open and flexible regarding change than older generations. Gender may play a role in learning delegation skills. The women’s movement and feminism have assisted female nurses in becoming “assertive and autonomous” (Harmer, 2010, p. 298). However, it appears that the “minority gender achieves a proportionally better and higher status than the traditional female nurse” (Harmer, 2010, p. 297). Ethnicity also plays a role in the process of delegation because individuals from diverse cultures perceive information and their ability to direct others to perform tasks differently. The need to increase the number of staff, especially UNPs, was usually directly related to the shortage of nurses. Today, with 50% of registered nurses near retirement age, an increase in medical and healthcare needs of individuals approaching 65 years of age, a greater emphasis on preventive health care, advances in medical technology, and recent healthcare reform that provides millions of individuals access to health care, another shortage of nurses and other healthcare professionals is predicted (ANA, 2013). Because of the potential challenges related to the supply of RNs and cost-effectiveness in health care, the role of RNs must change to meet the growing demands for patient care delivery. A nursing shortage is a “global challenge affecting every country in the world” (Littlejohn, Campbell, Collins-McNeil, & Khayile, 2012). The shortage will grow to one million nurses in the United States by 2020, and employment of RNs is expected to grow 26% from 2010 to 2020, faster than average for most occupations (U.S. Bureau of Labor Statistics, 2012). The registered nurses’ ability to delegate, assign, supervise and be ultimately accountable for providing safe, competent, and effective patient care are critical competencies for the twenty-first century nurse. Nursing’s ability to acclimate to new advances in health care will allow us to survive, often thrive, and be more effective as a profession. Definitions Delegation, a multifaceted decision-making process, has multiple definitions; however, all definitions have some consistent elements. The principles of effective delegation are derived from the corresponding states’ nurse practice act and through an understanding of the key concepts of responsibility, authority, and accountability (Weydt, 2010). Delegation is defined as the “transfer of responsibility for the performance of a task from one individual to another while retaining the accountability for the outcome” (ANA, 2012, p. 6). The NCSBN defines delegation as an “act of transferring to a competent individual the authority to perform a selected nursing task in a selected situation” (NCSBN, 2005, p. 1). ANA and NCSBN collaboratively define delegation as the “process for the nurse to direct another person to perform nursing tasks and activities” (ANA & NCSBN, 2006, p. 1). Delegation always involves at least two individuals (delegator and delegatee) who engage in open communication to achieve a goal. The terms delegator and delegatee represent the two key roles enacted in the process of delegation. Delegators are registered nurses who allocate a portion of work related to patient care to another individual. Delegateesare often comprised of UNPs, often called assistants, technicians, patient care associates, or aides. Although registered nurses do not supervise all unlicensed assistive personnel (e.g., physical therapy technicians), they have exchanges regarding patient care with UNPs and LPNs/LVNs. Some states have different delegation standards depending on the type of healthcare facility. For example, a long-term care facility may have an LPN/LVN responsible for a nursing unit with a registered nurse supervising the patient care. Nurses need to understand the nurse practice acts of their states, understand the delegation standard related to individual job descriptions, and function within their states’ regulatory guidelines. Responsibility refers to the reliability, dependability and obligation to accomplish work. It is a “two way process that is allocated and accepted” (Weydt, 2010, p. 3). Authority is the ability to perform duties in a specific role. Each individual is obligated to perform to the best of his or her ability and at a quality level. These individuals are also responsible for informing the delegator about any limitations that may prevent the accomplishment of the task or fulfillment of the expected outcome. In contrast, accountabilitydetermines if the actions were appropriate and provides a detailed explanation of what occurred (ANA, 2012; Weydt, 2010). The delegator discusses with the delegatee what tasks must be completed and transfers the responsibility and authority for those tasks to the delegatee. Even though the delegatee performs a task related to patient care, the registered nurse does not abandon the patient or the accountability for patient care. It is essential that the registered nurse complete a critical analysis, using the nursing process, to determine if the actions taken in a situation were appropriate, and if not, what occurred and why. In contrast, legal authority, by virtue of the professional nursing license, is the ability to transfer selected nursing activities in a given situation to a competent individual (Anthony & Vidal, 2010). When a nurse gives the delegatee the responsibility and authority for completing a task, the nurse retains accountability for ensuring that the task is completed by the right person and that person is supervised appropriately. Supervision is defined as the “provision of guidance and oversight of a delegated nursing task” (ANA & NCSBN, 2006, p. 1). Open lines of communication must occur between the delegator and delegatee to eliminate any misunderstanding about delegated tasks. The application of essential delegation skills is necessary for effective nursing management and high quality patient care outcomes. Figure 26-1 describes how delegated work is transferred along with the responsibility and authority to the delegatee; however, the nurses’ accountability remains constant. Communication must be clear, concise, timely, and reliable to produce safe and successful patient care outcomes. For example, when Hurricane Irene damaged much of the Caribbean and East Coast of the United States in 2011, and Hurricane Sandy damaged parts of the Caribbean, Mid-Atlantic and Northeastern United States in 2012, important lessons emerged about providing health care in a natural disaster. Communication, between and among healthcare professions and among state and national Figure 26-1 A delegation framework: delegation to achieve care outcomes. agencies, was the most critical factor in determining when and how to evacuate safely and effectively (U.S. Bureau of Labor Statistics, 2012). Delegation The ANA and NCSBN (2006) joint statement illustrates the process of delegation and describes how registered nurses must learn to delegate the right task, under the right circumstances, to the right person, with the right direction and communication, and under the right supervision and evaluation. Table 26-1describes the Five Rights of Delegation, specific questions to ascertain before delegating, and a “yes” response if the delegation is appropriate. Delegation is achieving performance of care outcomes by sharing activities with others who have the appropriate authority to accomplish the work. In this process, acceptance of the delegated work must occur either actively (i.e., communication indicates acceptance) or passively (i.e., no protest occurs). Delegation occurs only when two people are involved in a mutual work situation and one of the individuals has accountability and the other has some authority to perform the specific tasks. Delegation to UNPs can be challenging. Today, UNPs are educated in a formal program of study; however, the programs still vary in length from 1 week to several weeks. The position descriptions of UNPs define the authority for the specific position. The educational preparation and job description of UNPs are not consistent and remain a concern. NCSBN (2005) has expressed concern about the inconsistencies in the educational preparation of UNP and recommends that these educational programs have greater public accountability. A critical component of delegation is authority, and the delegated task must comply with the law, such as the state nurse practice act, and/or comply with the educational preparation and certification of the individual. Improper follow-through is another concern with delegation. An example of improper followthrough is when the delegator does not provide clear and concise directions to the delegatee. An example of improper follow-through on the part of a delegatee is failure to report results and findings. The nurse’s prior knowledge of the delegatee’s qualifications and experience related to the task is crucial for safe and successful delegation decisions. Table 26-1 The Five Rights of Delegation Delegation Rights Task The Right Questions (Answer the Following Questions) • • Circumstance • Yes Responses • Is the task appropriate to delegate based on institutional policies and procedures? • Is the task legally appropriate to delegate? The right task • Is the delegation process appropriate to the situation? The right circumstances Delegation Rights The Right Questions (Answer the Following Questions) • • • • Person • • • Direction/communication • • • • • Supervision • • Yes Responses • Is the environment conducive to completing the task safely? • Are the equipment and resources available to complete the task? • Do staffing ratios demand the use of high-level delegation strategies? • Does the delegatee have appropriate supervision to complete the task? • Is the prospective delegatee a willing and able The right person employee? • Does the delegatee have the knowledge and experience to perform the specific task safely? • Does the delegatee have the expertise to complete the task safely and effectively in relation to the acuity of the patient? • Do the delegator and delegatee understand a The right common work-related language? (Do terms such direction/communication as time frame, patient needs, and critical mean the same to each of them?) • Does the delegator provide clear and concise directions for the task? • Does the delegatee understand the assignment, directions, limitations, and expected results as they relate to the task? • Do the delegator and delegatee know how to maintain open lines of communication for the purpose of questions and feedback? • Does the delegatee understand how, what, and when to report to the delegator? • Is it clear that the delegatee will provide feedback The right supervision related to the task, when appropriate? • Is the delegator able to monitor and evaluate the patient appropriately? Adopted from American Nurses Association and National Council of State Boards of Nursing. (2006). Joint Statement on delegation. https://www.ncsbn.org/.Jointstatement.pdf and American Nurses Association. (2012). ANA’s principles for delegation by registered nurses to unlicensed assistive personnel. Silver Spring, Maryland. © 2013 M. Murphy-Ruocco. Achieving Optimum Outcomes Achieving optimum performance outcomes is the driving force of all health care. Thus all patient care is based on attaining expected outcomes, whether that care is provided directly by an individual or group of professionals, or shared between professionals and assistants. The communication style of the nurse influences how delegatees respond to assigned tasks and “influences teamwork and relationships” (Weydt, 2010, p. 3). Anthony and Vidal (2010) explore the effects of mindful communication as an approach to improving delegation and increasing patient safety. They explore “information quality, mindful communication (mindfulness) and mutual trust within the relational context of the delegation … improving the effectiveness of the delegation” (p. 1) Regarding the Five Rights of Delegation, the “right communication and direction” is the cornerstone of delegation and may arguably be the most instrumental in shaping quality and safety outcomes” (Anthony and Vidal, 2010, p. 3). The quality of the communication must be timely, meaningful, understood, and effective. Nurses who provide high quality information in a timely manner in the right context and consider cultural competencies of the delegatee enhance the safety and quality of patient care. Anthony and Vidal (2010) also describe characteristics of communication that interfere with the delegation process, such as “information decay,” that can occur when the patient’s health status changes rapidly and specific information loses its value or becomes irrelevant to the patient’s condition. An example is a rapid change in one or more of the patient’s vital signs: temperature, blood pressure, heart rate, respiratory rate, and pain. When the reported information is decayed or incomplete, it leads to poor clinical judgments that may have adverse effects on patient care. Another characteristic of communication is “information salience,” which assesses the quality, meaning, and clarity of the information. Diverse cultural, educational, and experiential backgrounds shape the meaning of information, and therefore, when delegating, the salience of the information that is shared between the delegator and the delegatee must be clearly understood (Anthony & Vidal, 2010). Healthy work relationships among all personnel, including registered nurses and unlicensed assistive personnel, promote a “synergy between team members, enabling them to work together more effectively” (Weydt, 2010, p. 3). Understanding another individual and developing a trusting relationship are critical components to successful delegation. Trust is developed through gaining “knowledge of one another’s capabilities and confidence in their abilities” (Weydt, 2010, p. 5). Delegating with confidence requires considerable trust between two or more individuals to create an effective team. Effective teams agree on specific times to meet to ensure that task achievement occurs within the agreed upon time frame. Specific time frames may include, but are not limited to, before and after breaks and meals as well as any time when the UNP has any questions or concerns. When working with UNPs, the “delegation potentials are significantly higher when caregivers are paired or partnered, with partnered scenario generally having the highest delegation potential” (Weydt, 2010, p. 6). Nurses with limited delegation experiences and UNPs with limited clinical experience can misuse valuable resources and diminish patient care outcomes. Nurses who do not trust other individuals and/or are unable to delegate appropriately because they choose to perform the tasks themselves, compromise efficient health care and limit their career opportunities. In the ever- changing healthcare setting, knowing and valuing how to be a successful delegator achieves optimum outcomes. Individual and Organizational Accountability Individual accountability is a component of delegation. The term refers to the individuals’ ability to explain their actions and results. The Code of Ethics for Nurses, Provision 4 (ANA, 2011), identifies the expectation of accountability and responsibility and specifically references delegation. Legally, the registered nurse has accountability for nursing care. For example, even when some portion of patient care is delegated to someone else, each individual nurse is accountable and responsible for his or her nursing practice, including the decision to delegate and the outcome of the delegated task. Organizational accountability is another component of delegation. The NCSBN concurs with ANA that the driving principle in decision making is patient (public) safety. Making appropriate decisions depends on how well the organization provides adequate resources, including an appropriate ratio of registered nurses to LPNs/LVNs and UNPs. Successful organizations that have achieved Magnet™ status, through an extensive evaluation process, usually have supportive work environments and assist teams to function effectively. Chief nursing officers (CNOs) are accountable for establishing systems to assess, monitor, verify, and communicate competency requirements related to delegation (NCSBN, 2005). Sharing Activities with Unlicensed Personnel (UAP/UNP) During the delegation process, the delegator allocates work to other unlicensed staff and gives them the responsibility to perform the work. When the registered nurse delegates work, he or she is merely sharing a set of functions to ensure quality patient care outcomes. In essence, sharing work does not negate the registered nurse’s accountability for the total patient care. The definition of delegation emphasizes that patient care itself is not delegated; only a group of tasks/functions/activities are delegated. Thus the final accountability remains with the delegator. Requesting UNPs to perform a specific task or activity within their scope of function or asking them to perform the same tasks as the previous day can be expected. For delegation to be effective, the nurse must understand that sharing activities is essential to benefit patient care. Professional aspects of care may never be delegated—only basic skills, such as activities of daily living and personal hygiene. In addition, some monitoring and technical skills may be delegated. Some organizations have UNPs with a two-level or three-level designation system, with the higher level designations indicating the ability to perform more skills. As advances in health care continue, more tasks and activities may need to be delegated to assist registered nurses in the delivery of quality patient care. Span of Control The registered nurse, the leader of the team, has responsibility for a group of individuals who work on the team. These individuals may include those with no formal preparation or legal recognition (e.g., unit secretary) and those with dependent status (e.g., UNP and LPNs/LVNs who function under the direction of a registered nurse or physician), or those who are designated as being answerable to the delegator (e.g., other RNs or healthcare providers who report to a designated delegator, such as a nurse manager). Span of control, the number of individuals you are ultimately responsible for, is an important concept to master as you interact with others to achieve optimum patient care. For example, if a nurse has responsibility for 5 staff members, each of whom cares for 10 patients, the registered nurse, in effect, has responsibility for 5 staff members and 50 patients. At first, this may seem overwhelming; however, if patients are in stable condition and the nursing care is somewhat predictable, it may be manageable. When nursing staff are well-prepared providers of routine care and the care environment is limited to a designated area, it makes patient care responsibilities less challenging. If these factors are not consistent, the responsibility for this number of patients may become overwhelming. When nursing staff render a portion of the care, these factors need to be assessed to determine the appropriateness of the patient care workload and whether it can be managed safely and effectively in each clinical situation. Appropriate Authority Appropriate authority to perform certain functions comes from various sources. Registered nurses have the appropriate authority to perform certain functions as healthcare providers. This authority is derived from state nurse practice acts and institutional policies. For example, the practice of LPNs/LVNs is defined by state titling or practice acts, as well as by institutional policies. UNPs are prepared to meet a specific set of tasks and the educational preparation of UNPs varies considerably. The education of the UNP, coupled with institutional policies, defines how the UNP may or may not function. Position descriptions should provide more specific details about the level of authority within each role. These elements—the titling or practice acts, position descriptions, and policies—form the expectations for what individuals in certain positions are expected to be able to accomplish safely. All organizations have descriptors of what tasks may be performed by an individual in a particular position. When a position description contains functions that are normally performed or are an essential part of the practice of a licensed individual (e.g., physician, nurse, pharmacist), the individual functioning in this role performs these functions through passive delegation. Therefore no active delegation decision is made by the registered nurse. In active delegation, the registered nurse assesses the situation, determines what is appropriate for patient care, directs a UNP to perform certain tasks and holds the individual accountable. Even when protocols/policies within organizations indicate that an individual may perform a task on behalf of a registered nurse, the delegatee must be competent to perform the task. This expectation suggests that the delegator makes an initial and ongoing assessment of the delegatee performance as well as an assessment of patient care needs. Furthermore, state laws governing professional nursing practice define what the registered nurse must do when another individual assumes certain tasks. A Framework for Delegation Hersey’s (2006) Situational Leadership® Model, even though not originally designed for the process of delegation, provides a solid foundation for delegation decisions. The “core competencies of a situational leader are the ability to diagnose the performance, competence and commitment of others, to be flexible and to partner for performance” (Lynch et al., 2011, p. 3). Multiple factors influence the effectiveness of the leader, including an assessment of personality characteristics, and readiness level of the individual as it relates to the type of task and goals to be attained, and specific environmental conditions. Hersey’s model (Figure 26-2) describes two factors that need to be assessed to determine the level of the followers’ readiness: ability and willingness. How these factors interact with each other also needs to be considered. Ability relates to knowledge and skills in a specific situation (job readiness). An individual’s ability does not change from one moment to the next (Hersey, Blanchard, & Johnson, 2013). Willingness relates to the individual’s attitude, confidence, and commitment toward the specific situation (psychological readiness). Willingness, however, can fluctuate from one moment to another (Hersey, Blanchard, & Johnson, 2013). If a delegatee indicates reluctance to perform some work, the delegator must evaluate the situation to determine if there is a knowledge deficit, if there is a psychomotor deficit that interferes with performing the work, or if the delegatee is bored, anxious, upset, or just unwilling to meet the expectations. Thus if the delegatee is less able or unwilling to perform in a specific situation, the delegator must be more actively engaged in the situation. In theory, the greater the ability and willingness of the delegatee, the more likely it is that the delegator can implement delegation strategies while interacting with individuals in a specific situation. The model also describes the style of the leadership required of an effective leader and its relationship between task behavior (the amount of guidance) and relationship behavior (the amount of support) needed in the given situation. In the Situational Leadership® Model (Figure 26-2), if Figure 26-2 Situational Leadership® Model. © 2006 Reprinted with permission of the Center for Leadership Studies. Escondido, CA 92025 www.situational.com All Rights Reserved. you insert a vertical line from the follower performance readiness box to intersect with the bellshaped curve for a given situation, you will determine the most effective leadership strategy. In Figure 26-2, situation one, if the delegatee has limited knowledge and ability to perform a task, the delegator needs to provide more guidance. However, if the relationship is limited (when two or individuals are unlikely to work together again), the delegator simply “tells” the individual what to do and how to perform. Hersey’s Model (2006) describes the leader’s behavior as guiding or directing, which is characterized as “telling.” In situation two, if a situation involves a new task and the relationship is ongoing (two individuals who will usually continue to work together), the delegator explains what to do and how to do it. Hersey’s Model (2006) describes the leader’s behavior as explaining or persuading, which is characterized as “selling.” Logically, if producing outcomes in a given situation is the driving force, the delegators are much less likely to spend the time and effort investing in limited relationships than in established relationships. In situation three, if the delegatee has the ability and willingness, but the relationship between the delegator and delegatee is relatively new, they need to establish mutual expectations and conditions of performance. Hersey’s model (2006) describes the leader’s behavior as encouraging or problem solving, which is characterized as “participating.” Finally, in the last situation, if the delegatee has the ability and willingness, the expertise to accomplish the work, and an established relationship, Hersey’s Model (2006) describes the leader’s behavior as observing or monitoring, which is characterized as “delegating.” Situational Leadership® styles can be observed in real work-related situations. For example, when a new team begins to work together to build a trusting relationship, the delegator must evaluate the ability and willingness of the delegatee. If the ability and willingness is low, the delegator should use the leadership style of telling or selling. If the nature of the relationship is limited, such as a when someone is only going to work for half a day on the unit, the leadership style should be telling because it provides a fair amount of guidance but limits the time spent on the interactions. Additionally, if the relationship is developing or ongoing, the delegator needs to understand the delegatee’s motivation related to the situation and the leader’s style should be selling, which takes more time, but leads to a supportive relationship. If the relationship is new or developing, more support is needed and the delegator and delegatee need to interact in a participatory manner. When a delegatee has a high degree of ability and willingness and is familiar with the expected task, little guidance is required. In theory, the greater the ability and willingness of the delegatee, the more likely the delegator can implement delegation strategies while interacting with that individual in a specific situation. In other words, both the amount of guidance (task behavior) and the amount of support (relationship behavior) would be relatively low, which works well for established work relationships. However, delegation can be viewed as a spectrum of behaviors based on the context and needs in a specific situation. To achieve effective outcomes, knowing how to interact with a given delegatee is one of the key challenges for the delegator. The Theory Box illustrates how Hersey’s Model applies to nursing. Table 262 presents the delegatee condition, relevance to the delegator, the original terminology, and a clinical exemplar on how to structure communication with the delegatee to achieve a goal. Exercise 26-1 Interview three RNs employed as direct care nurses, and ask them the following questions: 1.What factors need to be assessed before delegation? 2.What strategies are used by the delegator to interact with a delegatee? • • Figure 26-3 integrates the various considerations for delegation. Each registered nurse has assistants available during a designated shift. Mutual trust and shared responsibility must exist between the registered nurse and the assistants, and the focus is on the patients, the center of the model. The registered nurse retains accountability for the patient and considers Theory Box: Situational Leadership® Model Theory Key Ideas Application to Practice Hersey’s model contends that leaders/managers need to behave differently in specific situations. Registered nurses must analyze an individual’s knowledge and the work-related task before delegating. Registered nurses make decisions based on this analysis. Before delegating, the registered nurse must understand the kind of support an individual needs to successfully accomplish the work related task. Each staff member may need a different level of support for different tasks. Table 26-2 Communicating with a Delegatee Delegatee Condition Delegator Relevance Terminology Clinical Exemplar Has limited knowledge and ability to perform the task Requires more guidance Tell (if the relationship is not going to be ongoing) “It is important that you take his blood pressure every 15 minutes.” Has ongoing relationship, however a new task is delegated Requires explanation Sell “This is what you need to accomplish; in fact let me show you what is necessary.” Has willingness Requires that both and ability, but the individuals create relationship is new mutual expectations and conditions for performance Participate “Please tell me how you go about performing this procedure, and I will share with you my expectations about how frequently and under what conditions we need to communicate/report to each other.” Has established relationship and expertise Delegate “I know you know what you are doing and when to report. Just remember that I am available to you at any time if an issue or concern arises. Thank you for being part of th team.” Little guidance is needed Figure 26-3 Delegation framework. each nursing assistant’s abilities, authority, experiences, and willingness before delegating tasks to meet the needs of the patient. This decision-making process occurs in view of the organizational settings and policies, and in relation to laws and standards. Exercise 26-2 Select three experienced unlicensed nursing personnel (UNP) who work on a specific nursing unit and ask them what they expect from their interactions with the registered nurse delegator. Using the information you ascertained, consider the model in Table 26-1, Figure 26-2, and Figure 26-3 to determine what type of relationship the delegator has with each delegatee as it relates to specific tasks. Assignment Versus Delegation Assignment has two different meanings. It refers to the work every individual is responsible to accomplish in a designated work period. This assignment consists of patient care expectations and unit-related tasks, which may include, but are not limited to, learning activities, regulation activities, and unit management activities. The second meaning of assignment relates to the transference of both responsibility and accountability among RNs. Whereas registered nurses can be assigned patients, UNPs receive delegated tasks. Delegation is “task based rather then judgment based” (Weydt, 2010, p. 4). Thus, when a registered nurse assigns a patient to another registered nurse, both responsibility and accountability are transferred. When a registered nurse delegates care to a UNP, responsibility is transferred, however, accountability for patient care is not transferred and remains constant with the registered nurse. Thus, “accountability rests within the decision to delegate while responsibility rests within the performance of the task” (Anthony and Vidal, 2010, p. 3). Table 26-3 depicts the difference between assignment and delegation. Nursing managers face complex decisions with delegation involving patients and staff. Importance of Delegating Delegation, a critical leadership skill, must be learned and implemented to accomplish patient care in a timely and cost-effective manner. A common misconception about the nursing profession is that nursing care is a series of psychomotor tasks. Therefore professional nurses must convey the consistent message that performing a task is only one component of patient care. Although the performance of a psychomotor task is essential to providing patient care, it is the second component, the critical analysis, performed by the registered nurse that is clearly the determining factor for nursing action. To perform a critical analysis, the nurse uses the nursing process as a guide for delegation. The nurse assesses the situation to determine what is legally appropriate to delegate, plans an intervention and determines whether the delegatee is competent to perform the task safely, implements the plan including an observation of the delegatee (directly or by general supervision), and evaluates whether the delegation process was completed safely and effectively Table 26-3 Assignment Versus Delegation Concept Responsibility Accountability Assignment (RN) Yes Yes Delegation (UNP) Yes No (Neumann, 2010). Critical thinking, diagnostic reasoning, and the ability to synthesize information from various sources are what characterize the nurse as a licensed professional who plans effective nursing care. The role of the registered nurse in providing safe effective patient care is critical, whether patient care is performed by an individual registered nurse or by other members of the team through the process of delegation. Delegation has direct patient care and professional practice benefits. One benefit is that delegation allows more staff availability to assist with activities of daily living (ADLs). Another benefit is that an effective team utilizes members of the team to conserve time; however, decisions to delegate should never be solely based on time-saving considerations. Exercise 26-3 Interview a nurse manager, a direct care nurse, and a UNP about their perspective on the pros and cons of delegation. Compare and contrast the similarities and differences in the three perspectives and roles. Delegation is more challenging when the geographic area is greater, when other resources are limited, or when vulnerable populations are receiving care. The Literature Perspective illustrates delegation in a school setting. Literature Perspective Resource: Resha, C. (May 31, 2010). Delegation in the school setting: Is it a safe practice? OJIN: The Online Journal of Issues in Nursing, Vol. 15, No. 2, Manuscript 5. Delegation in the K-12 school setting has become a necessity because of the limited number of qualified school nurses, expanded responsibilities of school nursing practice, increased complexities of healthcare needs of children and adolescents, and limited resources. The appropriate school nurse-to-student ratio recommendation is 1 nurse to 750 students; however, in reality many school nurses provide coverage for more than one school building and the nurse-tostudent ratios are extremely high and not conducive to providing high quality health care. UAPs can be a valuable asset to the school nurse when they understand the legal parameters of their role. School nurses must develop effective delegation skills to properly train and safely supervise UAPs. A challenge regarding delegation for school nurses is when other non-nurse employees of the school do not realize the legal regulatory mechanisms that guide nursing delegation. They do not understand the necessity for medical orders for healthcare procedures performed in the school setting as opposed to those performed at home by the parent. Some administrators view nursing as a set of “tasks” rather than a “process” that assists in making nursing judgments that lead to high-quality nursing care. School administrators and others who delegate nursing tasks to nonnurse employees create litigious situations for themselves, the school nurse, and the school district. Implications for Practice The responsibility of a school nurse is to supervise UAPs and develop effective delegation skills to maintain a safe school health practice. School nurses also educate school employees (administrators, principals, teachers, psychologists, social workers, and other staff members) about the legal accountability of delivering nursing care. Therefore only nurses should delegate nursing care. The development of policies and procedures regarding delegation and open lines of communication with school employees prevent inappropriate delegation of nursing care and protect the employees, school nurse, administrators, and school district from any unnecessary liability. Legal Authority to Delegate Most state nurse practice acts address the concept of delegation; including some rules and regulations governing when and what tasks can be delegated. State boards of nursing are vested in protecting the public; therefore they regulate the educational preparation and practice of professional nursing. Legally, delegation is also a complex process. First, the delegator is personally responsible for prudent action. If the delegation task is not performed within acceptable standards, a potential for nursing malpractice emerges. Failure to delegate and supervise within acceptable standards may extend to direct corporate liability for the institution. Whenever care is provided by other staff rather than a registered nurse, the accountability for care remains with the delegator even though others provide various aspects of care. This view of professional liability is consistent with the concept that licensure conveys both privileges and expectations. Specific knowledge about nursing and delegation is necessary to make appropriate nursing judgments. The nurse is legally accountable and thus liable for his or her actions and those of the delegatee. Because the role of the nurse has evolved over time, maintaining current and accurate knowledge about the scope of liability of nurses is essential. Exercise 26-4 Review your state’s nurse practice act, rules, and regulations. Discuss with two or more colleagues what your state identifies as delegation. Create a written summary related to your conclusions. Selecting the Delegatee The selection of an assistant is extremely important as their work impacts patient care outcomes. In many settings, even though the registered nurse has the authority to delegate, he or she may not be able to select the nursing assistants with whom he or she works. However, at other times, the nurse will have the ability to select his or her own nursing assistants. For example, an LPN/LVN who has functioned in a physician’s office for a long time and is not familiar with working under the direction of a registered nurse may be concerned about being supervised by a registered nurse. Initiating a conversation about that person’s new role and function in the organization can open lines of communication to explain why supervision is necessary and can eliminate or diminish any negative feelings about being supervised. Thus the registered nurse’s ability to assess and communicate effectively is essential. Improving lines of communication can also occur by appreciating and valuing each other’s cultural perspectives. For example, a nursing assistant who does not concur with the philosophy of the organization, such as the goals of hospice care, might have a negative influence on patients. In addition, nursing assistants who have similar strengths as the delegator might want to perform the same tasks as the delegator, thus creating a gap in the delivery of patient care. However, experienced nursing assistants are more likely to adapt to changing situations. Therefore selecting an individual who has different strengths from the nurse enhances the work both can accomplish together. Building on the strengths and minimizing the challenges of the team prove to be an effective strategy. Realistically, balancing strengths through the deliberate selection of a delegatee may be almost impossible. However, it is even more important to consider all aspects of patient care to ensure that all of the patient care needs are addressed. Supervising the Delegatee Because registered nurses are always accountable for the assessment, diagnosis, planning, nursing judgment, and evaluation of patient care, UNPs must understand what elements of implementation they may complete and what elements must be completed by the registered nurse, such as the analyses of data. Both elements must be understood to ensure effectiveness in entrusting an element of care to another individual. Registered nurses are accountable for an initial assessment and the ongoing evaluation of patient care. When delegators decrease the amount of direct patient care they perform, they automatically increase their supervisory work. The importance of Literature Perspective: Nursing Delegation and Consumer-Directed Patient Care Resource: Reinhard, S. (2011). A case for nurse delegation explores a new frontier in consumerdirect patient care, Journal of American Society of Aging, Winter 2010-2011, 75-81. This article addresses older adults and younger individuals with disabilities and how delegating health maintenance tasks to unlicensed assistive personnel (UAP) can make a valuable contribution in assisting these individuals to manage their long-term health conditions at home. A major New Jersey pilot project, supported by the Robert Wood Johnson Foundation and the Office of the Assistant Secretary for Planning and Evaluation, was developed by the New Jersey Department of Human Services Division of Developmental Disabilities, and the Rutgers Center for State Health Policy to investigate how collaboration among nursing and consumer advocacy organizations can improve consumer choice and the quality of care. Because the health requirements of these individuals living in the community can be complex, some states have been discussing supporting safe delegation (or exemptions) for delegating health maintenance tasks to UAPs. Reinhard reports that barriers to delegation remain, even when states have broad regulatory guidelines that permit this type of delegation in these settings. Implications for Practice With a predicted shortage of nurses and a growing population of consumers living at home with chronic health needs, nurses must examine their norms and attitudes regarding delegation, eliminate any unnecessary barriers to health maintenance tasks being provided by UAPs, and educate themselves on how to delegate effectively. Training of UAPs in how to receive and implement delegated tasks is crucial for positive patient care outcomes. Consumers, nurses, and unlicensed assistant personnel must work collaboratively to improve the quality of community living for older adults and younger individuals with disabilities within a broad regulatory framework. giving clear directions, asking and receiving quality feedback regarding tasks, and having an agreed upon schedule for checkpoints are essential for a well-executed plan. This evaluation plan is influenced by factors such as knowledge of and experience with the delegatee, the number of delegatees and patients for whom the delegator is accountable, the geographic design of the unit, the stability of the patients, and the resources available to staff. Evaluating how the delegatee and patients are doing throughout the work period is also critical to work performance and patient care outcomes. The Literature Perspective on p. 498 presents a delegation situation related to home care. Delegation Decision Making Figure 26-4 illustrates the delegation process, which begins with assessing the health needs of the patient and the skills of the UNP. Key elements must be considered while assessing the UNP’s abilities to perform the work; they include, safety, critical thinking, stability, and time. Safety is a basic physiological need, and when a patient is unsafe for any reason, delegation may not be appropriate. Exceptions to this rule are usually related to monitoring behaviors of patients (e.g., when patients are placed on suicide precautions). Critical thinking, the intensity and complexity of nurses’ decision-making process, is vital to patient care decisions. For example, simple (straightforward) teaching, such as washing hands, can be performed by a UNP; however, complex (multifaceted) teaching, such as care required by diabetic patients, cannot be delegated. Stability, the patient’s level of strength or steadiness, is also a major factor in making patient care decisions. The greater the stability of a patient, the more likely a UNP can provide safe patient care. Time, the intensity and length of the interactions with the patient, is also a significant factor to consider in planning patient care. For example, emergency departments usually employ relatively few UNPs because patients are less stable; however, in extended-care and long-term care facilities where patients are more stable, a higher number of UNPs are employed. In these facilities, “delegation is the primary mechanism … for ensuring that professional nursing standards of care reach the bedside” (Corazzini et al., 2010, p. 1). Figure 26-4 The delegation process. Assuming that it is appropriate for a UNP to assist with patient care, the registered nurse must first assess the ability of the UNP. When the delegatee has the appropriate work and performance abilities, tasks can be delegated. When a delegatee has limited work and performance abilities, tasks can still be delegated, but the delegator must educate, monitor, and evaluate care very closely to ensure quality patient care. In this case, the UNP is performing tasks (their responsibility); the registered nurse is monitoring care and outcomes (accountability). The nurse should maintain open lines of communication and seek information, and the UNP should know how, when, and what to report. This two-way communication and follow-through allows patient care to be altered, if necessary, in a timely manner. At times, especially as new skills are acquired or new relationships are forged; the registered nurse should provide feedback to the UNP during the process of providing patient care. In all situations, the registered nurse needs to provide feedback about performance at the end of the activity. Furthermore, the UNP needs to understand that he or she is receiving support and direct feedback and is being monitored for professional growth and development to improve patient care outcomes. Failure to delegate to others is also an issue of concern. Some registered nurses believe delegation is too time-consuming or that it requires more energy to delegate to others. Others believe that they can do a better job themselves or want the recognition for providing total patient care. However, when we delegate we maximize our contributions to patient care. Exercise 26-5 Select three patient records from a clinical setting that involve delegation decisions. Based only on written documentation, evaluate any indications and assumptions about safety, critical thinking, stability, and time. Using Figure 26-3, identify how you would work with a prospective delegatee to accomplish patient care goals. State the rationale for your delegation decisions. Integrating Elements Applying the four elements of safety, critical thinking, stability, and time into decision making creates an integrative process that fosters effective delegation decisions. However, one of the elements may play a more important role than the other in different patient care situations. For example, when critical-thinking skills are of utmost importance in the patient care situation, other elements may be relatively less important in the delegation decision. Therefore making decisions about to whom to delegate, what to delegate, and when to delegate is a complex process. Creating a work environment where specific feedback about performance is ongoing is the best strategy for shaping the future behavior of individuals. A statement such as “You performed that procedure safely and professionally” is more effective than the statement “Nice job.” The first statement clearly identifies what the individual did well, whereas, the second statement is vague and not specific to the behavior. Equally important is the feedback from the individual performing the tasks. To elicit feedback a series of questions should be asked by the registered nurse, such as, “Has the work/task been completed?”, “What changes were observed with the patient?”, and “How did the patient respond?” Open-ended questions allow the registered nurse to gain pertinent information from the individuals delegated a portion of patient care. The experienced registered nurse also identifies verbal or nonverbal clues about the UNP’s perception of patient care interactions, and allows that information to continue to build a trusting relationship. The delegator should provide constructive feedback to the delegatee regarding his/her workrelated performance whenever possible. However, to convey satisfaction with an individual’s performance that is less than satisfactory diminishes the credibility of the registered nurse. A verbal attack on an individual does not produce effective change, and potentially undermines any long-term working relationship, such as “What is wrong with you today?” The best strategy is to provide open, honest, and constructive feedback, such as “Let me demonstrate a more effective way to perform the task.” Honest feedback about work-related performance and specific strategies for change provide the delegatee a quality improvement plan. Table 26-1 (p. 490) poses some appropriate questions for making delegation decisions. Another concern regarding delegation is that some individuals are not competent to hold their current position. One strategy for managing this issue is to temporarily lower expectations and provide additional support. This strategy allows individuals to build on their strengths, minimize their weaknesses, and gain confidence. However, it is essential to examine the effect the strategy of lowering expectations for an individual has on other members of the team. Many questions need to be considered in the decision, such as, Why is one employee held to a standard and another is not? Who becomes responsible for the work that one individual cannot accomplish? Is it fair to compensate an individual for work that does not meet performance expectations? What are the potential liabilities of altering the standards of performance? Because delegation decisions are a complex process, registered nurses must understand that having individuals assigned to work that they are not capable of performing safely and effectively, and then not intervening creates a high risk for legal liability. “No one should delegate work unless they are certain the person expected to perform the task is competent to perform it” (Kline, 2013, p. 19). In addition to the legal ramifications of poor delegation decisions, ethical considerations should also influence the registered nurse’s decisions. Challenges Related to the Delegation Process Delegation, a complex decision making process, is successful when effective delegation strategies are utilized by the registered nurse. Understanding the specific skill set and capabilities of the delegatee are crucial elements to the delegation process. For example, selecting a delegatee who has the specific skill set for the particular task is a more productive strategy than just selecting a competent individual. In large organizations, registered nurses usually are afforded more opportunities to select their delegatee than in smaller facilities with fewer employees. In rural settings, the choice of the delegatee is usually more predictable because of the longevity of the employees; thus the delegation process may be easier because the delegator is more familiar with the skills and abilities of the various delegatees. When the registered nurse has limited clinical experience, whether in a career or a particular workplace, the nurse’s ability to make delegation decisions, especially during complex situations, can be difficult. In those situations, working together with the delegatee, as a team, to deliver patient care allows time to assess willingness and ability. Maintaining open lines of communication with the delegatee, without any derogatory or offensive comments, creates a collaborative and productive work environment. Providing constructive feedback allows the delegatee to be more receptive to and understand feedback. However, the ultimate goal of delegation remains the same: maximizing patient care outcomes. Another challenge related to delegation occurs when a registered nurse does not provide clear direction to the delegatee about the task and the delegatee implements the task based on their own decisions. It is important to have the delegatee understand how and when you want the task accomplished. Sometimes, when the delegator intervenes, the delegatee may lose confidence or become frustrated, and the delegator losses the benefit of effective delegation. However, assuming that no safety or ethical concern exists, the delegation process should continue to improve communication and build trust between the delegator and the delegatee. During delegation, the delegator must make sure two essential factors occur in the delegation process. First, the delegatee must be able to recall and understand what is expected, and second is that appropriate resources are available to accomplish the work. Deadlines for completing tasks keep the delegatees on target without having them feel they are being micromanaged. Clear expectations about task accomplishments provide a structure for ongoing evaluation of a delegatee. In settings outside hospitals, (long-term care facilities, clinics, school nurse offices) one of the greatest challenges of delegation relates to supervision. In these situations, it is especially important to be clear about what is expected of the delegatee. Box 26-1 presents a communication template used for the delegation of tasks. When there is a clear understanding between the delegator and the delegatee about a particular delegation situation, the greater the chance it will produce a positive outcome. Exercise 26-6 Develop a case study in which you must make a delegation decision. Use the delegation communication template found in Box 26-1 to practice with a classmate how to transfer the specific responsibilities for patient care. Box 26-1 Delegation Communication Template • • • • • • • • • • State exactly what is being delegated and the expected outcome. • Convey the authority to perform what is expected. • Identify priorities. • Acknowledge monitoring activities that may be performed. • Specify any performance limitations. • Specify deadlines, including the exact times if appropriate. • Specify report time frames and data expected. • Specify deviations, including when immediate action must be taken. • Identify appropriate resources, including individual consultants. • • • Emphasize what may not be delegated. • Ask the delegatee to provide examples of each. In other instances, a problem or issue related to delegation arises, and the nurse observes it but has no authority specific to the situation. If there are no safety issues, urgency to intervene, or potential negative patient outcome, the nurse can assist other registered nurses with delegation decisions by using three strategies: “asking,” “offering,” and “doing.” The first strategy, asking, begins with questions related to the problem or issue regarding patient care. Often, asking questions provides an opportunity to open lines of communication between delegator and the delegatee. It also allows the delegator to examine the situation differently and allows the nurse to reassess. The second strategy, offering, involves making a suggestion to facilitate the achievement of a desirable patient care outcome. The third strategy, doing, occurs by demonstrating the specific task or behavior to improve patient care. Briefly, the approach is described in Box 26-2. Exercise 26-7 Review a delegation decision made by a nurse manager or charge nurse related to a clinical experience. After reviewing the nurse practice act and professional standards, provide answers with an evidence-based rationale to the following questions: • 1.Did the nurse manager or charge nurse make clear what was delegated? Why or why not? • 2.Were the delegation decisions logical? Why or why not? • 3.Were the delegation decisions made within legal and ethical parameters? Box 26-2 Critical Communication • • • 1. Challenge (use his or her first name and a qualifier [e.g., “Susan, isn’t this a sterile procedure?”). 2. Perhaps you can use the gloves from the sterile kit you have. 3. Would you go check with the unit clerk to see if any of my lab results are back? I’ll take care of this procedure. Charge Nurses Charge nurses frequently emerge as the delegator because they have demonstrated their knowledge and expertise in the clinical setting. When registered nurses do not delegate (usually because of the limited numbers of LPNs/LVNs or UNPs), the charge nurse usually delegates. Thus a charge nurse usually has acquired a sophisticated level of competency skills in critical thinking, clinical practice, organization, leadership, communication, and time management. Conclusion Delegation is a multifaceted decision-making process necessary to achieve nursing goals and improve patient care outcomes. Regardless of the method of nursing care delivery, the registered nurse must master the art of delegation, develop critical judgment skills, and apply delegation decisions in nursing practice to provide safe, high-quality health care. The Solution Kathryn King-Dyker In a Level I emergency trauma department, the patient acuity is serious and is often changing. EMS is arriving with multiple patients injured in an accident at the chemical plant. The registered professional nurse managing the trauma center must understand the qualifications, experience, and abilities of the nurses assigned patients. The nurses also need to understand the qualifications, experience, and abilities of the emergency technicians to whom they delegate tasks. The emergency technicians who have been working in the center for a minimum of 1 year can be delegated tasks by the registered nurse. However, the qualifications and experience of the newly employed emergency technicians (UNP) were unknown. Since they would not begin the emergency technician training program for another 2 months, one experienced technician and a newly employed emergency technician worked with each registered nurse accountable for patient care. Each technician was directly supervised, observed, and evaluated by their registered nurse. Each staff member needed to understand what tasks can be delegated and what tasks cannot be delegated. • Would this be a suitable approach for you? Why? The Evidence Effective delegation skills are essential competencies necessary to practice as a registered professional nurse in the 21st century. Multiple factors play a role in the ability of the registered nurse to delegate effectively. These factors include, but are not limited to, the nurses’ educational preparation, demographic area, state practice acts, leadership style, employment area, clinical experience, and the individual’s self-confidence. When nurses are engaged in a work environment that utilizes an RN/UNP care model, they gain the clinical experience to effectively utilize delegation skills. Today, this type of care model supports nurses in providing high quality cost effective health care. Implications for Practice Nursing research, an instrument to support evidence based practice, should be utilized to manage patient care delivery. Nursing internships, offered in school, that provide delegation and supervisory experience of UNPs can enhance an individual’s clinical experience and confidence, allowing them to learn how to delegate safely and effectively. As registered nurses adapt to the rapidly changing healthcare environment, nurse managers must continue to support nurses with clinical experiences and continued professional education that enhances their leadership skills, allowing them to effectively delegate and supervise others. Chapter 27 Role Transition Diane M. Twedell This chapter provides information about role transition—the process of moving from a clinically focused position to a supervisory position with increased responsibility. The basic overview of management roles illustrates the complexity of managing work done by others and provides a foundation for understanding role transition. The exercises offer opportunities to recognize one’s own expectations, resources, and management potential. Learning Outcomes • • • • • • Construct the full scope of a manager role by outlining Responsibilities, Opportunities, Lines of communication, Expectations, and Support (ROLES). • Analyze specific examples of role transitions as a direct care nurse and a nurse manager. • Describe the phases of role transition by using a life experience. • Construct a response to an unexpected role transition. • Compare strategies to facilitate a successful role transition. Key Terms mentor role development role discrepancy role expectations role internalization role negotiation role strain role stress role transition roles The Challenge Melissa J. Bertelson, RN, BSN Nurse Manager, Mayo Clinic Health System – Albert Lea and Austin, Albert Lea, Minnesota Transitioning from house supervisor registered nurse (RN) position to that of a nurse manager was more complex of a change than I had anticipated! I had to transition from being a peer in the supervisor group to being their new manager. Suddenly I was privy to all issues and concerns within the supervisor group that were occurring and being addressed by the two hospital managers. The harder aspect of this for me was participating in bi-weekly meetings that are held one-on-one with just a small group of the supervisors. These meetings were held to address any immediate concerns or complaints that occurred as part of ongoing performance. The transition into participating and then conducting these meetings, sometimes on my own, was not comfortable. I also was now in charge of two departments, bringing with them employee concerns, operating budgets, audits, and equipment. I had to make sense of the issues that people brought to me rather than depending on a nurse manager to address it. I was now the nurse manager! • o What do you think you would do if you were this nurse? Introduction Role transition involves transforming one’s professional identity. A new graduate makes a transition from the student role to the nurse role. Expectations of students are clearly specified in course and clinical objectives. Expectations for a new nurse as an employee may not be so clear. The new graduate nurse faces the first of several professional transitions. These transitions will continue with career growth and development. Consider the direct care nurse who becomes a nurse manager. The direct care nurse performs tasks related to the care of patients. As a follower, the direct care nurse has accountability and responsibility for the work that is accomplished. A direct care nurse who becomes a nurse manager must transition into the new role as a generalist, orchestrating diverse tasks and getting work done through others. A direct care nurse who moves from an acute care setting to a home health agency must also undergo a role transition. Instead of balancing the needs of multiple patients, the home health nurse can focus on one patient at a time. Yet when a collegial opinion is needed during a visit, there are no peers there to consult with. Registered nurses who transition to nurse practitioner roles and other advanced practice roles experience this same type of role transition. Organizations play a key role in assisting employees through role transitions. Changes in roles can be either painful or exciting and depend largely on the work culture and support provided. According to Chari (2008), “Transitions are critical times and are extremely challenging as modern organizations are of bewildering complexity and do business at a rapid pace” (p. 111). Knowing what to expect during this transformation can reduce the stress of accepting and transitioning into a new role and result in quality outcomes. After an overview of the roles of leader, manager, and follower, this chapter describes the process of role transition, with an emphasis on strategies that can be used to ease the transition. Types of Roles Accepting a management or formal leadership position dictates accepting three roles that involve complex processes. The roles of leader, manager, and follower are complex because they involve working through and with unique individuals in a rapidly changing environment. Examples of the people with whom you interact and the processes involved in each role are shown in Table 27-1. In nursing, each of these roles relates to patients and clients. The transition from a direct care nurse role to a nurse manager/leader role can occur overnight. The nurse moves from the clinical work of patient care to lead a group of employees. Leadership The role of follower involves respecting the authority of others and working within the system to contribute to the organizational outcomes. Managers as followers recognize their accountability to the persons above them on the organizational chart. Within a team, the manager recognizes the leadership being provided by others and supports decisions made by the group. Weinstock (2011) notes, “Every new role creates a Table 27-1 Leader, Manager, and Follower Roles: People with whom You Interact and Processes Involved in Each Role Role People with whom Interactions Occur Processes Involved in the Role Leader Persons being led Listening Peers Encouraging Motivating Organizing Problem solving (high level) Developing Supporting Manager Persons being supervised Organizing Administrators Budgeting Supervisors Hiring Regulating agencies Evaluating Reporting Disseminating Listening Problem solving (unit level) Follower Supervisor Conforming Peers Implementing Contributing Completing assignments Alerting Listening Problem solving (patient and team level) change in work tasks, leadership hierarchy, productivity demands, and shifts in all relationships, including one’s relationship with oneself” (p. 211). In the evolving healthcare environment, the nurse leader providing direct patient care also must function as a leader, manager, and follower. As leader, the nurse leader recognizes the uniqueness of each patient and provides feedback on clinical progress. As manager, the nurse leader links the patient to the resources to achieve clinical outcomes. Medical information is translated into a format that the patient can use to make informed decisions about treatment and self-care. Through referrals, the nurse leader facilitates continuity of care within the larger system. As follower, the nurse leader is accountable to the team and the supervisor for completing the work that is assigned. The nurse leader as a follower practices within the policies and procedures of the organization and the standards of the profession. Learning the leader, manager, and follower aspects of any new role can be overwhelming. Another approach to the complexity of role transition is the acronym ROLES, in which each letter represents a component common to all roles. Roles: The ABCs of Understanding Roles Acronyms help us retain and organize information. ROLES (Box 27-1) is an acronym that is useful in role transition. R stands for responsibilities. What are the specified duties in the position description for the new position? What tasks are to be completed? What decisions must the person in this position make? For example, the job for a nurse manager might include 24-hour accountability, whereas a job description for a nurse practitioner may involve direct care in a primary care setting. Every position has specific tasks for which the position holder is responsible. O stands for opportunities, which are untapped aspects of the position. In the employment interview, the nurse executive may have said that the previous manager did not encourage the direct care nurses to participate in continuing education. Or, while touring the unit, a manager observes that the report room lacks amenities. Maybe there is a new method of delivering patient care that is appropriate for the unit. These possibilities represent opportunities for a manager to influence organizational and unit goals. L represents lines of communication, which are at the heart of every leadership role. No matter what role an individual is in, multiple relationships Box 27-1 Roles Acronym • • • • • Responsibilities Opportunities Lines of communication Expectations Support exist with individuals including supervisors and peers. Roles incorporate patterns of structured interactions between the manager and people in these groups. The nurse manager receives and sends messages. Being a skillful listener can be more important than being skillful in sending messages. Skill is required to communicate both the content and the intent of the message effectively. Only through practice can one develop skill. In Chapter 18, techniques of effective communication are described that are extremely important to a new manager in building the team. E stands for expectations. Expectations vary depending on your goals. Colleagues may expect a new nurse anesthetist to be on call every weekend. Direct care nurses have specific expectations of their managers and particularly want the manager to be a facilitator and a leader. The nursing executive or administrator will likely have expectations about how managers spend their time on the job—even about how much time they spend at work. Nurse executives’ expectations evolve from their perspectives of the manager’s accountability and duties. Finding out in advance what the explicit and implicit expectations are of the people involved can facilitate a smoother role transition by decreasing role ambiguity (Hardy, 1978). Hardy’s work with role theory suggests a strong relationship between role ambiguity (one type of role stress) and role strain. The major concepts of role theory are presented in the Theory Box. Theory Box: Hardy’s Role Theory Theory/Contributor Key Ideas Hardy (1978) is credited with applying role theory to healthcare professionals. Role is the expected and actual behaviors associated with a position. Role expectationsare the attitudes and behaviors others anticipate that a person in the role will possess or demonstrate. Role stress is a social condition in which role demands are conflicting, irritating, difficult, or impossible to fulfill. Role strainis the subjective feeling of discomfort experienced as the result of role stress. Role stress is a precursor to role strain. Role stress is associated with low productivity and performance. Role stress and role strain can lead a person to withdraw psychologically from the role. Clear, realistic role expectations can decrease the role stress for a new nurse manager. Application to Practice Clear, realistic role expectation can increase productivity. Data from Hardy, M.E. (1978). Role stress and role strain. In M.E. Hardy & M.E. Conway (Eds.), Role theory: Perspectives for health professionals. New York: Appleton-Century-Crofts. Personal expectations related to performance as a manager is another factor to consider. You have a mental image of the role of a manager or person in this position. The process of role transition unfolds as a new manager identifies expectations, recognizes the similarities and differences, and develops the roles of leader, manager, and follower. S stands for support, which is closely tied to expectations about performance. All roles are shaped to some degree by the support and services others provide. The acute care nurse has peers readily available when a second opinion is needed. The same nurse may feel lost when confronted with questionable findings during a home visit. The nurse manager who must develop the unit’s budget in a skilled care facility may have no accounting department to provide services, such as a detailed analysis of the facility’s expenditures. Each role has some support available. When a new position is being considered, it is important to evaluate whether support is available in areas in which a manager may lack knowledge or skill. When implementing changes in roles, the organization needs to develop support services to facilitate role transition. Role Transition Process One way to think about the way in which someone transitions to a new role is illustrated in Box 27-2 and Table 27-2. Thinking about transitions in terms of a common social perspective may be helpful for some. Box 27-2 Role Transition Process Unlearning old roles while learning new roles requires an identity adjustment over time. The persons involved must invest themselves in the process. In this way, role transition can be compared to developing a relationship. The process of developing an intimate relationship with another person provides a familiar framework for considering role transition. Relationships typically move through the phases of dating, commitment, honeymoon, disillusionment, resolution, and maturity. Role Preview During the dating phase, the interested persons spend structured time together. Both parties present their best characteristics and dedicate much energy to developing the relationship. Although both parties present their best characteristics, both also are alert to clues that the other party cannot meet their expectations. For example, one may consider the financial and emotional resources that the other person would bring to the relationship. The individuals might spend time with each other’s families to get a feel for the emotional climate in which the other person grew up. Interviewing for a management position is similar to dating. An interview involves touring the unit, visiting with people, and attempting to make a good impression. The potential employer is also attempting to make a favorable impression. The interviewee wants to find out whether this is an organization that will support his or her growth as he or she supports the growth of the organization. Questions are asked about the role of the manager, and the potential manager mentally evaluates whether the described role matches personal expectations about management. Both of these examples represent the phase “role preview.” Role Acceptance Through the dating process, two people may decide that they want to spend the rest of their lives together and commit to the relationship. Sometimes, one or both of the people decide that they do not want to establish a long-term relationship. In a similar way, following the role preview of the interview process, both parties may agree to establish a relationship as employee and employer. Or one or both of the parties may decide not to establish the relationship. In dating, the public decision to leave other similar relationships and establish this new relationship represents a formal commitment. In role transition, the formal commitment of the employment contract implies acceptance of the management role, or “role acceptance.” Role Exploration In new relationships, a time of dating and commitment is usually followed by a honeymoon. More than a trip to a vacation spot, the honeymoon has become synonymous with excitement, happiness, and confidence. In a new work role, people also experience a honeymoon phase. The new graduate may be relieved that the educational program was successfully completed and now a salary can be earned. When a new manager is hired, the employer is excited that the search is over. The staff is happy to have a leader, especially if staff members had input into the hiring decision. The new manager is happy, excited, and, most of all, confident in exploring the new roles involved in the management position. Role Discrepancy Whether by a gradual process or as the result of a particular event that serves as the turning point, eventually the honeymoon is over and disillusionment about the relationship occurs. For example, one person may make an expensive purchase without consulting the partner. An argument is followed by a period of painful silence. Similarly, the honeymoon phase in a new employment position can be followed by a period of disillusionment. Role discrepancy, a gap between role expectations and role performance, causes discomfort and frustration. Role discrepancy can be resolved by either dissolving the relationship or by changing expectations and performance. The importance of the relationship and the perceived differences between performance and expectations, the basis of role discrepancy, must be considered in light of personal values. When the relationship is valued and the differences are seen as correctable, the decision is made to stay in the relationship. This decision requires the couple or the manager to develop the role. Role Development Choosing to change either role expectations or role performance or to change both is the process of role development. In an intimate relationship, open communication can clarify expectations. Negotiation may result in reasonable expectations. Certain behaviors may be changed to improve role performance. For example, one person in the relationship learns to call home to let the other know about the possibility of being late. To reduce role discrepancy in a new management position, the same open communication and negotiation must occur. Expectations need to be clarified and stipulated by both parties. New managers evaluate management styles and techniques to determine which ones best fit them and the situation. The personal management style evolves as the individuals develop the management roles in their own unique ways. If role discrepancy can be reduced and the role developed to be satisfactory to both parties, the new manager can focus on developing the roles of the position and proceed to the phase of role internalization. Role Internalization Role internalization occurs in relationships as they mature. No longer do the persons in the relationship consciously consider their roles. They have learned the behaviors that maintain and nurture the relationship. The behaviors become second nature. The energy spent on establishing and developing the relationship can be redirected toward achieving mutual goals. In the same way, managers who have been in management positions for several years have internalized their roles. Usually they do not consciously consider their roles. Managers know they have reached the stage of role internalization when they focus on accomplishing mutual goals instead of contemplating whether their role performance matches their role expectations. Managers who have internalized their roles have developed their own unique personal style of management. Table 27-2 summarizes the comparison between the phases of developing an intimate relationship and the phases of role transition to a nurse manager. Unexpected Role Transition Not every relationship is successful. Some relationships end in an argument, divorce, or death. When a relationship ends unexpectedly, a person goes through a grieving process. In a similar way, when a person is fired, a position is eliminated, or a job description changes dramatically, the person may have to grieve before being able to engage in role transition. Health care is in a tumultuous state. Mergers, acquisitions, and reductions in force are commonplace. To be successful, workplace restructuring must be undertaken with the same sensitivity afforded a person who has lost a relationship through death or divorce. Role transition takes time, even in reverse. The initial response to a change in role can be shock and disbelief. The person may feel numb and unable to function. As the numbness wears off, the person may become angry. The anger fuels resistance to the change and may be directed toward those who initiated the role change. The anger may be directed internally, leading to depression. If the person is unable to acknowledge and talk about the loss, the period of grief may be extended or emotional baggage may be created that is carried into the next role. Grieving can eventually resolve in acceptance. Lessons learned from the experience are identified and internalized. A new role is sought, and the “dating” begins again. When a relationship is dissolved in the case of death or divorce, a legal document is prepared to formally dissolve the financial and social obligations between the persons involved. The loss of a position as a result of restructuring or a buyout should involve a similar process. The employer may offer the nurse a severance package that includes financial compensation and outplacement services. If the employer does not offer a written agreement, the nurse should formally request and negotiate reasonable compensation and assistance. Similar to signing a prenuptial agreement, a nurse may have signed a contract with the employer when hired. The terms of that agreement may require the employer to buy out (pay the salary and benefits) for the time remaining on the contract. Written by Jennifer Jackson Gray. Table 27-2 Comparison of Phases in Developing an Intimate Relationship and in Undergoing Role Transition as a Nurse Manager Phase in Role Phase in Developing an Transition as a Nurse Intimate Relationship Manager Characteristics of Phase Dating Role preview Presentation of best characteristics to make favorable impression; both parties evaluate each other to determine likelihood of the other being able to fulfill one’s expectation Commitment to relationship Role acceptance Public announcement of mutual decision to initiate contract Honeymoon Role exploration Experience of excitement, confidence, and mutual appreciation Disillusionment Role discrepancy Awareness of difference between role expectations and role performance; reconsideration of whether to continue with contract Resolution Role development Negotiation of role expectations; adjustment of role performance to approximate expectations and to find own unique style Maturation of relationship Role internalization Performance of role congruent with own beliefs and individual style; achievement of mutual goals Strategies to Promote Role Transition Becoming a manager or assuming a new role requires a transformation—a profound change in identity. Such a transformation invokes stress as the person unlearns old roles and learns the management role. Several strategies can be helpful in easing the strain and speeding the process of role transition (Box 27-3). Box 27-3 Strategies to Promote Role Transition • • • • • Strengthen internal resources • Assess the organization’s resources, culture, and group dynamics • Negotiate the role • Grow with a mentor • • Develop management knowledge and skills Internal Resources A key strategy in promoting role transition is to recognize, use, and strengthen one’s values and beliefs. Behavior is influenced by values and beliefs. It is important that new leaders do not lose sight of their own values and beliefs. The role of manager is not for everyone. One must consider whether personal goals and professional fulfillment can best be achieved through management. One’s commitment to the challenges of managing can provide the desire to persevere during the process of role transition. If an individual in transition understands his or her own personal values, these will help the person respond to situations and relationships. A person’s value does not depend on the quality or quickness of the adjustment to the management role. An exercise such as writing down short statements of belief or self-affirmations and posting this information may be helpful as a visual reminder. Changing circumstances in health care raise the need for flexibility. The effective leader must be able to learn and master new skills, translate information for staff, and adapt behavior to the situation. It is also important for the new leader to not expect too much of oneself all at once; understanding that this transition takes time will help with flexibility. Weinstock (2011) states that new leaders often take a year to understand their role, system, and boundaries. Organizational Assessment A new manager is much like an immigrant in a new country. An immigrant learns how to access the available resources to acclimate to the new environment. Cultural practices of the new country may seem strange or odd. Such differences can be analyzed and decisions made about which aspects to incorporate into one’s own culture. More subtle differences in communication patterns or group dynamics can also be identified. Understanding the nuances of social interactions is often the most difficult aspect of acclimating to a new country. The transition is smoother for the immigrant who understands himself or herself, assesses the new environment, and learns how to communicate within groups. The new manager must also learn how to access resources in the organization. Approaching the organization as a foreign culture, the new manager can keenly observe the rituals, accepted practices, and patterns of communication within the organization. This ongoing assessment promotes a speedier transition into the role of manager. The immigrant who spends energy bemoaning the difficulties of the new country may fail to enjoy the advantages that drew him or her to the country in the first place. In the same way, the manager who focuses on the weaknesses of the organization may lack the energy to internalize the new role, a step that is critical to being an effective leader. Role Negotiation A strategy that is helpful during conflicting role expectations is role negotiation. The ROLES assessment (see Exercise 27-1) may have identified areas of significant conflict. Writing down the expectations is the first step in resolving areas of conflict. It is important to review the expectations listed to determine whether they are realistic. Unrealistic expectations strongly held by others may require diplomatic reeducation so that their expectations can become more realistic. The priority of different role expectations may also require role negotiation with the person above you in the line of command. Ask for input as to which expectations have the highest priorities. Explain personal and family expectations and clearly state the priority that meeting those expectations has. The process may have to be repeated several times before agreement on the expectations related to roles and the priority of each expectation is found. Rewriting the unrealistic expectations to be achievable can reduce three common sources of role stress— ambiguity, overload, and conflict. Each person’s role contributes to the end result. All individuals must understand their roles, or the team may fail. Exercise 27-1 ROLES Assessment Answer these questions for a position in management that you would consider. Responsibilities • • • 1. From the position description, what are the responsibilities? 2. For what decisions are you responsible? 3. Consider information about the management position that you learned during the interview (this may be role-played). Also consider the responsibilities of managers you have observed. Are there other responsibilities to add to your list? Opportunities • • • 4. What would you like to do differently from the previous manager? 5. How could your strengths or expertise benefit the people or nursing unit you would manage? 6. Dream a little (or a lot). If a person who had been a patient on the unit were describing the nursing care to another potential patient, what would you want the first patient to say? Describe the unit as you want it to be known. Lines of Communication • 7. Draw yourself in the middle of a separate piece of paper. Now fill in the people above you and below you with whom you would co…
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