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Delegation Example in a
  Healthcare Setting
   By: Oluwatosin Ola/RN
Delegation Model


• Step One
  • Assessment
  • Planning
• Step Two
  • Communication
Delegation Model (cont.)


• Step Three
  • Surveillance
  • Supervision
• Step Four
  • Evaluation
  • Feedback
Delegation Issue

     Anne a CCU nurse, is the first responder of a STAT
call at a small local community hospital. When she gets
upstairs, the primary nurse of Patient X was in the room
trying to get a pulse ox level. The patient was
unresponsive to painful stimuli, cool to touch, and his
pupils were fixed and dilated. Anne has the nurse call a
code; in which the patient is tenuously stabilized, intubated
and has to be transferred to the CCU. However there are
no available beds in the CCU.
     Stacey, the hospital supervisor assesses the situation,
stakeholders, and challenges. She must develop an action
plan and lead the key players in a successful dual transfer.
Stakeholders

• Anne, CCU nurse          • Med-surg transferring
• CCU charge nurse           nurse of Patient X
• CCU transferring         • Med-surg charge
  nurse                      nurse
• Respiratory therapy      • Med-surg receiving
• Hospital Bed               nurse
  coordinator/Supervisor   • Housekeeping
• Physician on call        • Families of Patient’s X
                             and Y.
Hierarchy of Stakeholders
                                                            Nurse sending
                                Med-surg                          X
                              charge nurse
                                                               Nurse
                                                             receiving Y
Families of X
   and Y
                                                             Anne, STAT
                                                               nurse


                                                                 Nurse
                                               CCU charge     receiving X
                                                 nurse
    Hospital Supervisor

                                                             Nurse sending
                                                                   Y

                                                Dr. X
                                                Dr. Y
                                             On Call MD

    Respiratory
     Therapy              Housekeeping
Action plan

• Notify stakeholders of
  the plan
• Move patient Y to
  med-surg
• Clean Mr. Y’s room
• Move patient X to
  CCU
• Notify both families
• Feedback/Evaluation
Recommendations

• Use phone or
  overhead paging
• Hospital supervisor
  is the leader
• Conflict resolution
• Feedback
• Evaluation
Conclusion

When delegating, use
 the Five Rights

• Right Task
• Right Circumstances
• Right Person
• Right Direction/
  Communication
• Right Supervision
References

American Nurses Association (2005). Joint Statement on Delegation by the
  American Nurses Association and the National Council of State Boards of
  Nursing. Retrieved May 3, 2009, from http://www.nursingworld.org

Hansten, R., & Jackson, M. (2004). Clinical delegation skills: A handbook for
  professional practice (3rd ed.). Sudbury, MA: Jones and Bartlett
  Publishers.

Pearce, C. (2006). 10 steps to effective delegation. Nursing Management -
  UK, 13(8), 13.

Quallich, S. A. (2005). A bond of trust: delegation. Urologic Nursing, 25(2),
  120-123.

Williams, J. K., & Cooksey, M. M. (2004). Navigating the difficulties of
  delegation. Nursing, 34(9), 12.

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Delegation Example in Healthcare

  • 1. Delegation Example in a Healthcare Setting By: Oluwatosin Ola/RN
  • 2. Delegation Model • Step One • Assessment • Planning • Step Two • Communication
  • 3. Delegation Model (cont.) • Step Three • Surveillance • Supervision • Step Four • Evaluation • Feedback
  • 4. Delegation Issue Anne a CCU nurse, is the first responder of a STAT call at a small local community hospital. When she gets upstairs, the primary nurse of Patient X was in the room trying to get a pulse ox level. The patient was unresponsive to painful stimuli, cool to touch, and his pupils were fixed and dilated. Anne has the nurse call a code; in which the patient is tenuously stabilized, intubated and has to be transferred to the CCU. However there are no available beds in the CCU. Stacey, the hospital supervisor assesses the situation, stakeholders, and challenges. She must develop an action plan and lead the key players in a successful dual transfer.
  • 5. Stakeholders • Anne, CCU nurse • Med-surg transferring • CCU charge nurse nurse of Patient X • CCU transferring • Med-surg charge nurse nurse • Respiratory therapy • Med-surg receiving • Hospital Bed nurse coordinator/Supervisor • Housekeeping • Physician on call • Families of Patient’s X and Y.
  • 6. Hierarchy of Stakeholders Nurse sending Med-surg X charge nurse Nurse receiving Y Families of X and Y Anne, STAT nurse Nurse CCU charge receiving X nurse Hospital Supervisor Nurse sending Y Dr. X Dr. Y On Call MD Respiratory Therapy Housekeeping
  • 7. Action plan • Notify stakeholders of the plan • Move patient Y to med-surg • Clean Mr. Y’s room • Move patient X to CCU • Notify both families • Feedback/Evaluation
  • 8. Recommendations • Use phone or overhead paging • Hospital supervisor is the leader • Conflict resolution • Feedback • Evaluation
  • 9. Conclusion When delegating, use the Five Rights • Right Task • Right Circumstances • Right Person • Right Direction/ Communication • Right Supervision
  • 10. References American Nurses Association (2005). Joint Statement on Delegation by the American Nurses Association and the National Council of State Boards of Nursing. Retrieved May 3, 2009, from http://www.nursingworld.org Hansten, R., & Jackson, M. (2004). Clinical delegation skills: A handbook for professional practice (3rd ed.). Sudbury, MA: Jones and Bartlett Publishers. Pearce, C. (2006). 10 steps to effective delegation. Nursing Management - UK, 13(8), 13. Quallich, S. A. (2005). A bond of trust: delegation. Urologic Nursing, 25(2), 120-123. Williams, J. K., & Cooksey, M. M. (2004). Navigating the difficulties of delegation. Nursing, 34(9), 12.

Editor's Notes

  1. In 2005, both the American Nurses Association and the National Council of State Boards of Nursing adopted papers on delegation. Both papers presented the same message: delegation is an essential nursing skill. Delegation is so important in the healthcare setting that courses and classes are offered at almost every hospital during orientation(Pearce, 2006, p. 13).According to the National Council of State Boards of Nursing (NCSBN), delegation in healthcare is “transferring to a competent individual the authority to perform a selected nursing task in a selected situation.” (NCSBN, 1990, p. 1). Delegating a task does not mean that you have absolved yourself of the responsibility of that task. You are still the principal person in charge of the task and how well the job is done ultimately rests on you. This is why a delegation model is essential in the workplace. This presentation will identify the key phases of a delegation model, and use that model in a case study based in the healthcare setting.
  2. Assessment:In this first phase, the nurse (or delegator) assesses if the task is appropriate for delegation (Pearce, 2006, p. 13). There should be an initial assessment of the patient care needs by the nurse first. The nurse bears the responsibility of making sure that the task assigned falls under the scope of practice of the delegate and the nurse (American Nurses Association [ANA], 2005). The policies of the hospital, state, nursing board and nurse practice act are factored into this step. In addition, the nurse should assess the knowledge, abilities and skill level of the delegate.Communication: Thismust be a two-way process. The nurse should assess the delegate’s understanding on how the task is to be accomplished, when and what information should be reported, clear expectations on expected results and unique patient characteristics (ANA, 2005, p. 8). In addition, the nurse should put tasks in order of importance and determine a time frame for their completion. Although she is delegating, the nurse should remain open to helping out, and must communicate her willingness and availability to assist (Quallich, 2005, p. 120). The delegate should ask any questions, seek clarification on what they do not understand, verbalize understanding of instructions, inform the nurse once the task is done, report any outliers and be prepared for a possible emergency.
  3. Surveillance and Supervision: Since the nurse is still primarily responsible for the patient, she should monitor compliance with the standards of practice, policies and procedures. For example, when deciding on the frequency of vital signs, the nurse factors in the patient’s medical condition and status in relation to the hospital policy i.e. blood transfusion, post-op, telemetry, new admission. The nurse is also responsible for timely intervention and follow-up of problems, noting the subtle signs of change. The nurse should also supervise the timeliness of the task, and take over the reins if the delegator is unable to do so. Evaluation and Feedback: Evaluation is often the forgotten step in delegation (ANA, 2005, p. 9). The nurse should consider the effectiveness of delegation by evaluating if the task was done correctly, if there was a satisfactory outcome, if there were challenges during the process, how any problems were addressed, and make changes to the plan of care as necessary. Most importantly, the nurse should give feedback to the assistant and acknowledge the accomplishments (Quallich, 2005, p. 120). A simple thank-you goes a long way towards improving teamwork and cooperation.
  4. Todeal with this problem, a double transfer must occur. First, a patient (Mr. Y) will be transferred out of the CCU to one of the open med-surg beds. After that, the CCU room has to be cleaned, and then Patient X will be transferred from med-surg to the CCU room. The choice of which stakeholder to choose for the different steps is determined by the hospital policy. Anne will place a call to her charge nurse, who then will notify the hospital supervisor. This follows the hospital’s chain of command. Just from reading this scenario, how many stakeholders can you identify? Three? Surprisingly, there are a lot more than you think, but let us first identify the roles of the first three.Anne, CCU first responder nurse: She has her own patient in the CCU and needs to get Patient X transferred so she can return to care for her patient. She should document the STAT code and the reasons for transfer. She should stay with Patient X until he gets transferred in case he crashes again. Med-surg transferring nurse (Mr. X’s nurse): She must document the incident and her assessment. She should make sure her paperwork is up-to-date and that Patient X’s belongings are all packed. She must give report to the CCU nurse and is the best resource on the patient’s history and hospital stay. Hospital bed coordinator/supervisor Stacey: This is a small hospital, so the supervisor serves a dual function. The supervisor acts as the intermediary between the different factions and as the primary communicator. She pushes the process along to an optimum result.
  5. Each stakeholder has an essential role to the operation. Here are some others…CCU charge nurse: She is covering for Anne’s absence, and must choose which patient is getting transferred out so Patient X can get placed in. She must be knowledgeable on the patients in the CCU and pick the most stable one. Choosing an unstable patient might lead to another code on the med-surg unit, since Patient Y will be going there. CCU transferring nurse: She is going to be giving report on Patient Y to the receiving med-surg nurse. She should notify his family of the transfer and can give a brief synopsis of his hospital stay to the doctor, fill out the transfer MAR, get the patient out as speedily as possible. Respiratory therapy (RT): Since Patient X is now intubated, the RT has to monitor the patient’s oxygenation status, suction, and bag the patient continuously until a ventilator can be hooked up. Unfortunately, the only vents are used in the CCU, so the RT (or his delegate) must keep bagging Mr. X until he can be transferred. Physician on call: He responded to the CODE, and has written standing orders for patient X. The doctor must also go downstairs to the CCU to assess and write transfer orders on Patient Y. The doctor should also notify Mr. X’s family of his condition and prognosis. Med-surgcharge nurse: She is helping out her unit nurses to cope in the aftermath of a code. She must talk to the supervisor to get a bed for patient X, and assign a nurse and room to Patient Y. She should supervise Nurse X to make sure that all her documentation is in order and cover or delegate someone to watch Nurse X’s patients. Med-surg receiving nurse: She is going to get report from the nurse in the CCU on the stable patient Mr. Y. She has to inform his family that he has been transferred, and make sure all his belongings and possessions cross over. She is going to assess him, document the baseline, and fulfill whatever orders the doctor has written. Housekeeping:Must clean up the CCU room as soon as patient Y leaves so that Patient X can come in speedily. After this, she will also clean up the room on the med-surg unit.
  6. The hospital supervisor Stacey (black) is in charge of the whole operation. All stakeholders deal either directly or indirectly with her. The unit nurses (light blue) report to their charge nurses, who then either deal with the issues, or forward them to Stacey. Stacey must delegate to the charge nurses, who will then delegate to the different nurses involved. Each member is vested in the outcome, so both the charge nurses and Stacey must oversee, monitor and problem shoot to assist in speeding the process.
  7. Stacey is the leader of this project, and she should have a hand in every part of the operation. Any conflicts should be shared with her, and she has the overall decision making power. Stacey must make sure that once the plan is initiated, all persons having an understanding of which phase they are in the process and what his/her role and responsibility is. She should give measurable objectives to the charge nurses, physicians and ancillary staff. “Please give report to the CCU in the next 10 minutes,” or “please clean room 7 right now.” She should be open to suggestions on the plan, and pitch in if any member of the delegation runs into a problem. Conflicts between nurses can be resolved with charge nurses, but conflicts between units can be resolved by the supervisor. “Unchecked, conflict has the potential to divide alliances and departments. Conversely, providing an ongoing forum for differences of opinion to be voiced and understood creates an environment where expectations can be shared and ideas are more likely to be expressed openly” (Hansten & Jackson, 2004, p. 261). Stacey can also help to speed the process along and intervene if there are problems. For example, if the receiving nurse of patient Y is on her lunch break, the med-surg charge nurse should take report. If the charge nurse is busy, then the CCU can call the supervisor, who can either take report, or find another nurse who can take report. If the on call physician does not want to write transfer orders on Patient Y because he does not know the patient, the supervisor should be notified. The supervisor can then either explain the situation to him, or call Patient Y’s physician at home for transfer orders. It is important that both sets of families are updated at the earliest opportunity of the room change. Stacey should be available in case any family member has a question on why their loved one was moved. In the case of Mr. X’s family, she might also need additional resources (pastoral services) on hand to help them cope with the news of his decline.
  8. Like the team in the picture, the hospital team must work together to reach the desired outcome. Each member should pull their own weight, while Stacey engages the responsibility of all. The stakeholders will be communicated with via telephone or face to face communication. The telephone is the faster mode of communication in this scenario, especially since the stakeholders are all located in various parts of the hospital. If a key player cannot be reached, the hospital overhead paging system can be used. Feedback should be given at each step of the process to either one of the charge nurses or the supervisor. When the CCU nurse gives report on Patient Y, she can tell her charge nurse, who then notifies the supervisor. “Discussing patient outcomes with team members and giving them both positive and negative feedback along the way can result in more than double the performance effort!” (Hansten & Jackson, 2004, p. 287). Each person must leave open the communication channel to enable the timeliness of the transfer. Stacey can also call any member of the team to see where they are in the process, what challenges they face, and how she can help. Stacey is ultimately the most responsible in getting both patients transferred as safely and quickly as possible. The operation is considered successful when both patient’s X and Y are settled in their new rooms and both sets of families have been notified of the change.
  9. The guidelines in this presentation provide a decision-making process that facilitates the provision of quality care by appropriate persons in all health care settings. Use the Five Rights of Delegation…every single time and the principles of delegation will always be nearby! Delegation is a very effective means through which to take advantage of the varying skill levels of available staff. When done effectively, it can improve job satisfaction, reduce burnout, enhance time management, clarify accountability, and facilitate access to care (Quallich, 2005, p. 123). Effective communication is the key to delegation, and knowing how to say what you need done is an essential tool for any work environment. Good luck delegating!