Copyright © 2015. F.A. Davis CompanyDelegation, Priorit.docx

Copyright © 2015. F.A. Davis Company
Delegation, Prioritization, and Decision Making
Chapter 7
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Delegation of Client Care: Definition
The reassigning of responsibility for the performance of a job
from one person to another.
(ANA, 1996)
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Concepts of DelegationThe responsibility of the task is
transferred.Accountability remains with the
delegator.Delegation may be direct or indirect.

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Direct DelegationUsually verbal directionRN decides which
staff member is capable of performing a specific task.
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Indirect DelegationContained in an approved listing of tasks
established by an institutionPermitted tasks may vary from
institution to institution
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Assigning TasksThe RN may assign a more skilled individual to
perform a task.The RN may not assign an individual to perform
an activity outside a job description or the scope of practice.
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Delegation vs. Supervision
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SupervisionSupervision is usually more direct than delegation.It
requires directly overseeing the work or performance of
others.It includes checking with individuals during the day.It
may entail delegation of tasks and activities.The nurse manager
performs both.
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The Nursing Process and Delegation
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AssessmentAssess client needs.Set client-specific goals.Match
the personnel with the appropriate skills to care for the client.

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PlanningMentally identify who is best suited for the task or
activity.Planning prevents later problems.
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ImplementationAssign the appropriate personnel who have the
level of expertise necessary to deliver the care or carry out the
activities.
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EvaluationOversee the care or activities.Determine if client care
needs have been met.Allow for feedback.
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Coordinating
Assignments
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Methods to Help Organize Care Critical pathwaysComputerized
information sheetsPersonalized worksheetsDelegation tree
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Tips for Organizing CarePlan time around activities that must
be performed at a certain time.Perform high-priority activities
first.Cluster activities that may be performed together.Consider
your peak time when performing optional activities.
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The Need for Delegation
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Changes in the Health-Care EnvironmentNursing
shortageHealth-care reformIncreased need for nursing
servicesDemographic trendsUse of unlicensed assistive
personnel
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Unlicensed Assistive Personnel (UAPs)Individuals trained to
function in an assistive role to the nursePerform delegated
tasksUnder direct supervision of the RNMay or may not be
certified
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Delegation to UAPs

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Examples of TasksVital signsSkills learned through special
trainingBlood drawingECGsMeasuring intake and outputNon-
nursing duties
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Safe Delegation
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Criteria for Safe DelegationPotential for harmComplexity of the
taskProblem-solving and innovation necessary to complete the
task or activity
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Considerations for Safe DelegationAbility of the
individualFairness of the task
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Guidelines for
Delegationhttps://www.ncsbn.org/delegation_grid_NEW.pdfhttp
s://www.ncsbn.org/contcaregrid.pdfhttps://www.ncsbn.org/Work
ing_with_Others.pdf
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Task-Related Concerns
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Primary Concern
Does the individual assigned to the task have the ability to
perform the task?

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Other Task-Related
ConcernsAbilityPrioritiesEfficiencyAppropriateness
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Relationship-Oriented ConcernsFairnessLearning
opportunitiesHealthCompatibilityPreferences
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Summary of Expectations of ProfessionalsRespect of othersA
reasonable workloadAppropriate wagesDetermining his/her own
prioritiesAsk for what he/she wantsAccountabilityGive and
receive information as a professional
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Barriers to Delegation
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BarriersExperienceLicensureQuality of careAssigning work to
others
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The Five Rights of DelegationRight taskRight
circumstancesRight personRight direction/communicationRight
supervision/evaluation
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Conclusion

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Points to ConsiderDelegation is not new.The role is essential
for good working relationships.Organizational skills are a
prerequisite for delegation.Understanding client needs is
essential for appropriate delegation.
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The RN Needs to UnderstandThe State Nurse Practice ActThe
capabilities of each staff memberThe tasks that may be
delegatedThe concept of accountability in delegation
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Chapter 4 Healing Quickly When Focused on Resolution In this
chapter, I discuss two cases where the clients healed themselves
quickly by focusing on the resolution rather than wasting time
talking about their problems. Problem saturated talk is useless.
When you lead the client to talk about what she wants and how
to achieve it, powerful things begin to happen. People can cure
themselves quickly and effectively of long standing problems.
Presbury, Echterling & McKee (2008, p. 260) suggest that the
major positive impact of therapy takes place in the first six to

eight sessions. They point out that in one study seventy-eight
percent of clients stated that their problems were “better” to
“much better” after one session. Littrell (1998, p. 174) states
that one to two sessions can be quite successful for a number of
clients. Most counseling is done in a single session according to
Presbury, Echterling and McKee (2002, p
209). Guterman (2006, p. 7) wrote, “If a significant change does
not happen in the first or second session, then it is unlikely that
I will be of much help to my client.” My experience is that if
significant change does not happen in the first four sessions,
then it is unlikely that I will be of much help to the client. The
following story is an example of a client quickly and effectively
curing herself. The One-session Cure Fran was a 20-year-old
college student who came to see me because of anxiety and
panic attacks. She reported that she had her first panic attack
when she was 7 and had experienced three or four a week since
her first one 13 years before. She said that she constantly
fidgeted, developed red splotches on her chest and arms and
picked at her arms to the point of having sores. As we talked,
she reported that her anxiety was a 9 on a 10 point scale. As I
talked with Fran, I asked her to pay attention to her anxiety and
tell me what she was experiencing. One of the phenomena she
mentioned was that she was seeing a picture in her mind of an
experience that caused her to feel anxious. I asked her to
describe the picture. Was it in color or black and white? Was it
moving or a still snapshot? What size was it? Where was it
located? She described the picture as in color, a moving picture,
life-size and only a few inches from her face. Based on this
small amount of information, how would you assist Fran in
healing herself? Of course, as you work with Fran and gain
more information from her, you might alter the direction of the
therapy. Always alter the therapy to fit the client rather than
attempting to change the client to fit the therapy. After
brainstorming as many directions as possible that you might
take, write them down before reading further. I asked Fran to
create a picture of a situation when she felt calm and to describe

the submodalities of the picture. It was in color, a still snapshot,
an 8 X 10 and about 10 feet away, down and to her left. Then I
asked her to see the anxious picture and gradually move the
anxious picture to the location of the calm picture and to change
it to a still snapshot, and to shrink it to an 8 X 10. She was able
to do this with relative ease. Then I asked her to repeat what she
had just done, but to do it five times as fast as she could. After
each time, she was to see a white screen, then the anxious
picture in its original form and then to move it and change it.
After this exercise, she reported that her anxiety had dropped to
a 2. Her homework assignment was to practice this exercise
daily a minimum of five times. We set an appointment for the
next week. When she returned she reported that she had no
panic attacks since we had seen each other the week before; her
red splotches were gone, and the sores on her arms had healed.
This experience shows the possibility for healing oneself
quickly of even a long-standing problem; of course, not
everyone with panic attacks can heal so easily, nor would this
technique work effectively in every case. Every person is
unique and the treatment must be tailored to the person. In
Fran’s case, though, the cure was quick and easy. My training in
NLP taught me the power of altering the sub-modalities of our
five senses. I used a modification of the Swish Technique
(Bandler, 1985) in this example. (To learn other NLP
techniques, refer to Andreas & Andreas, 1987 & 1989). Perhaps
you have not been trained in NLP. If so, the approaches you
thought of earlier might have worked as effectively. The point
to remember is that healing can occur quickly. This next case
shows that the resolution rarely relates directly to the problem.
This is why problem talk is unnecessary. Usually the resolution
to the problem has no direct relation to the problem. “Starting
counseling with a solution-focused approach does not mean that
problems should not or are not discussed. It does mean that we
do not assume that the answers to clients’ problems lie in their
aproblems. The last place answers may lie are in problems”
(Littrell, 1998, p. 65). Presbury, Echterling and McKee (2008,

p. 266) wrote, “You don’t need to probe where it hurts. Clients
will tell you all you need to know. Instead of focusing on your
client’s painful recollections, you can move the dialogue to a
discussion of goals and emphasize past successes that will be
helpful in working toward change.” In essence, it is far more
effective and efficient to focus on resolutions than to focus on
the problem, and its cause, because most problems are too
complex to have a single cause. Chevalier claimed, “The
complexity of human relationships makes it extremely difficult
to say with certainty that one event caused another or that one
set of events produced another set. The search for causes can
become an endless chase, and the client’s goal may be lost in
the process” (Chevalier, 1995, p. 17). You could spend hours
looking for the cause and not discover it; furthermore, a
revelation of the cause might not make a difference in finding a
resolution. The following story illustrates this point. The Little
Girl Inside Jane was depressed. She reported that she was
consistently a 7 or 8 on a 10 point SUDS (subjective units of
discomfort) scale. Though not suicidal, she was always
miserable. Jane told me that her parents divorced when she was
young, and her father never indicated that he loved her or that
she had any value to him. She indicated that she did not enjoy
being alone because bad memories from her childhood would
flood her mind. When I asked her how old she felt most of the
time, she said that she felt like a girl of 7 or 8. What approach
would you have taken with Jane? Would you have focused on
her depression, her childhood, her negative memories, her lack
of love from her father, or some other aspect? Write down what
your focus would have been and which alternatives you might
have used to address this focus. I did two things with Jane. First
I used the Gestalt empty chair technique (Hatcher & Himelstein,
1976; Perls, 1969). I asked her to put the little girl in an empty
chair, and I initiated a conversation between the adult Jane and
the little girl Jane. Moving back and forth from chair to chair,
Jane had this conversation between the two parties. From this
conversation, the adult Jane promised the little girl that she

would love her, take care of her and always be there for her.
Secondly, I asked Jane to describe the sub-modalities of the
most horrible picture from her childhood. She described the
picture as being in color, moving, life-sized and about six
inches from her face. I asked her to change it from color to
black & white, a still snapshot, 8X10 and about 10 feet from
her. When she made the changes, the picture lost its power and
no longer caused her pain. Intrigued by this activity, Jane was
amazed that she could control how the picture made her feel by
changing its characteristics. After I gave her the homework of
talking to the little girl for at least 10 minutes each day and of
practicing this ability to change the negative pictures, we set an
appointment for two weeks later. When Jane returned in two
weeks, she was obviously happier. She had a smile on her face;
her posture was more erect and she made good eye contact.
After reporting that she had been happy over the past two
weeks, Jane added that she had spent time alone without having
the negative memories. This situation shows that focusing on
the resolution is more effective than focusing on the problem.
We did not spend much time discussing the problem. Instead,
we quickly moved to finding a resolution. By learning to love
herself (the little girl inside of her) and learning how to change
the pictures in her mind, she could be happy regardless of her
unhappy childhood.
Many times when people feel pain caused by the past, they feel
the age that they were when the event occurred. By setting up a
situation where the present-aged person can love and support
the younger-aged person, healing can take place. Exercise:
Think of a situation that causes you to feel anxious. Create a
picture of this experience in your mind. Notice the sub-
modalities of the picture. Experiment with changing them until
you find the combination that takes the power away from the
picture. Think of situations where this technique might be
useful with your clients.

Communicating With Others and Working With the
Interprofessional Team
Chapter 6
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CommunicationGiving information is only a small part of
communication.Occurs on several levelsInvolves different
factorsRequires active listening skills
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Factors Affecting CommunicationEmotional state of
individualsOutside distractionsCultural backgroundSuperficial
listeningIndividual attitudes regarding the content of the
communication

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Assertiveness in CommunicationAllows people to stand up for
themselvesRespects the rights of othersClearly states an
individual’s positionUses “I” statementsAssumes a greater
importance in the interprofessional environment
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Interpersonal CommunicationMost daily communication falls
into this category.Interactions that occur on a personal
levelProcess that gives individuals the opportunity to construct
personal knowledgeUsed to establish relationshipsDiffers from
general communication
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Interpersonal Communication (cont'd)Occurs on a more intimate
levelSystematic processIndividuals hold a specific role within
the communicationDynamic and ongoing process

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Transactional Models of CommunicationDiffer from earlier
linear modelsConsider all individuals communicatorsAllow that
communication among and between individuals occurs
simultaneouslyAcknowledge that “noise” occurs in all
interactionsInclude the concept of time
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Barriers to Communication Among Health-Care Providers and
Health-Care Recipients
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ChallengesLow health literacyCultural diversityCultural
competence of health-care providersLack of interprofessional
communication education among providers
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Electronic Forms of Communication
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Information SystemsCommunication through the use of health
documentsThe Health Information Technology for Economic
and Clinical Health (HITECH)Electronic Medical Records
(EMRs)Electronic Health Records (EHRs)
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Advantages of EMRTrack data over timeIdentify which patients
need preventive screenings or checkupsMonitor patient
statusEvaluate and improve overall quality
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Advantages of EHRDocuments are shared among varying

institutions/individualsFocus on the total health of a
patientProvide a more inclusive view of a patient’s care over
timeDesigned to share information with other health-care
providersAssist in maintaining patient confidentiality
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E-mailUsed both within and outside of organizationsSame
communication principles that apply to traditional letter writing
apply to e-mailRequires good writing skillsRules in the
workplace different from personal e-mail
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Text MessagingEvolved as a quick method of
communicationBrief informal methodNo “texting
rules”Business consultants predict that this communication
method will evolveImportant to follow the same rules that apply
to e-mail
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Reporting Patient Information
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Hand Off CommunicationsPreviously referred to as “change of
shift” report in nursingMove toward an interprofessional team
philosophy has changed the way reports are givenEnsures
continuity of care from one area to anotherPart of the TJC
“National Patient Safety Goals”
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Communicating With the Health-Care ProviderCommunicate
changes in patients’ conditions.Share pertinent
information.Discuss modifications in the treatment plan.Clarify
orders.
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Before Calling the Health-Care ProviderHave all the

information available. Be prepared to provide general
assessment information.Pertinent informationMost recent vital
signs and trendsLaboratory valuesMedications and times the
patient received the most recent dose
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After Calling the Health-Care
ProviderDocument time of the call in the patient
record.If the health-care provider needed to return the call,
document the time the call was returned in a health-care
provider call log.Follow the chain of command if a call is not
returned within an appropriate amount of time.
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ISBARRIntroductionSituationBackgroundAssessmentRecommen
dationRead-back
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Health-Care Provider OrdersWrittenTelephoneFaxEMR orders
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Teams
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PurposeBring professionals togetherCommon goal: quality
patient careCollaborative focus
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Teamwork
QSEN definitionThe ability to “perform effectively within
nursing and interprofessional teams, fostering open
communication, mutual respect, and shared decision making to
achieve quality patient care.”

(http://qsen.org)
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Learning to Become a Team PlayerRecognize that every
member brings value to the team.Treat each team member with
dignity and respect.Understand the role of each team
member.Support each other in achieving the team’s goals.
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Building a Working TeamIdentify the team players.Make sure
the team members understand the goals and are committed to
achieving the outcomes.Act as a role model and exhibit
expected behaviors.
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Interprofessional Collaboration and the Interprofessional Team

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Interprofessional Collaboration
“Occurs when multiple health workers from different
professional backgrounds work together with patients, families,
caregivers, and communities to deliver the highest quality
care.”
(WHO, 2010)
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Components of
CollaborationSharingPartnershipInterdependencyPower
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Interprofessional CommunicationTJC attributes a high
percentage of sentinel events to breakdowns in communication
among health-care providers.Core competency for
interprofessional collaborative practiceISBARRTeam STEPPS

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Team STEPPSLeadershipSituationMonitoringMutual
supportCommunication
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Building an Interprofessional TeamCommunicate through
conferences.Focus on the needs of the patients and/or
clients.Each member has roles and functions that contribute to
patient care.Each member contributes and the contributions are
valued.Monitor and/or evaluate effectiveness of team goals.
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Methods for the Hand-Off ReportTraditional face-to-
faceAudiotapeComputer reporting

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ConclusionCommunication skills are needed to deliver safe,
quality, and effective patient care.TJC, IOM, QSEN, and
MAGNET promote interprofessional communication. Use of
Team STEPPS and IBARR promote interprofessional team work
and communication.
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