Leading, Managing, and Delegating

References:

1. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition, ISBN 978-0-13-542873-3, by Audrey Berman, Shirlee J. Snyder, and Geralyn Frandsen (Ch. 18, pp. 345–359)

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Leadership, management, delegation, and change are consistent aspects of nursing. As a part of multidisciplinary teams, the nurse is often in a leadership position and frequently delegates aspects of care to others. There are opportunities in nursing to become leaders at various levels and also many situations in which the nurse functions as a manager and as a change agent.

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The Nurse as Leader and Manager

The professional nurse frequently assumes the roles of leader and manager. These two roles are linked—managers must have leadership abilities, and leaders often manage—but the two roles differ.

1. Leader: a member who influences others to work towards a specific goal. Visionary, informed, articulate, confident, self-aware. Leaders usually have outstanding interpersonal skills and are excellent listeners and communicators. They have initiative and the ability and confidence to innovate change, motivate, facilitate, and mentor others.
   • Leaders participate in and guide teams that assess the effectiveness of care, implement evidence-based practice, and construct process-improvement strategies.
   • Leaders may be employed in a variety of positions—from shift team leader to institutional president.
   • Leaders may also hold volunteer positions, such as chairperson of a professional organization, or be a member of a community board of directors.
2. Manager: a member with authority, power, and responsibility for planning, organizing, coordinating, and directing the work of others and for establishing and evaluating standards. Managers understand organizational structure and culture. They control human, financial, and material resources. Managers set goals, make decisions, and solve problems. They initiate and implement change.
   • As a manager, the nurse is responsible for (a) efficiently accomplishing the goals of the organization; (b) efficiently using the organization’s resources; (c) ensuring effective client care; and (d) ensuring compliance with institutional, professional, regulatory, and governmental standards.
   • Managers are also responsible for the development of licensed and unlicensed personnel within their work group.

Leaders	Managers
May or may not be officially appointed to the position	Are appointed officially to the position
Have power and authority to enforce decisions only as long as followers are willing to be led	Have power and authority to enforce decisions
Influence others toward goal setting, either formally or informally	Carry out policies, rules, and regulations
Are interested in risk taking and exploring new ideas	Maintain an orderly, controlled, rational, and equitable structure
Relate to individuals personally in an intuitive and empathetic manner	Relate to individuals according to their roles
Feel rewarded by personal achievements	Feel rewarded when fulfilling organizational mission or goals
May or may not be successful as managers	Are managers as long as the appointment holds
Manage relationships	Manage resources
Focus on individuals	Focus on systems

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Leadership

Leadership may be formal or informal.

• A formal (appointed) leader is selected by an organization and given official authority to make decisions and act.
• An informal leader is not officially appointed to direct the activities of others, but because of seniority, age, or special abilities, the individual is recognized by the group as its leader and plays an important role in influencing colleagues, coworkers, or other group members to achieve the group’s goals.

Leadership Theory

Early leadership theories focused on what leaders are (trait theories), what leaders do (behavioral theories), and how leaders adapt their leadership style according to the situation (contingency theories). Theories about leadership style describe the traits, behaviors, motivations, and choices used by individuals to effectively influence others.

Classic Leadership Theories

Leaders were found to often possess specific qualities and abilities, including good judgment, decisiveness, knowledge, adaptability, integrity, tact, self-confidence, and cooperativeness.

1. Autocratic Leader: the authoritarian leader makes decisions for the group. Likened to a dictator, the autocratic leader determines policies, giving orders and directions to the group.
   • Principle: the autocratic leader assumes individuals are externally motivated; their driving force is extrinsic and they desire rewards from others. The group members are believed to be incapable of independent decision-making.
   • Pros: the group may feel secure as policies and procedures are well-defined and activities are predictable. Productivity may be high.
   • Cons: the group’s needs for creativity, autonomy, and self-motivation are not met. The degree of openness and trust between the leader and the group members is minimal or absent.
   • Utilization: an autocratic style is most effective when urgent decisions are necessary, such as in cardiac arrest, fire, or a terrorist attack. One person assumes the responsibility for making decisions without being challenged by other team members. It may also be effective when a project must be completed quickly and efficiently.
2. Democratic Leader: the democratic leader encourages group discussion and decision-making. This type of leader acts as a catalyst or facilitator, actively guiding a group toward achieving the group’s goals. Providing constructive feedback, offering information, making suggestions, and asking questions become the focus of the democratic leader.
   • Principle: the democratic leader assumes individuals are internally motivated; their driving force is intrinsic and they desire self-satisfaction. The group members are believed to be capable of making decisions, and value independence.
   • Pros: group productivity and satisfaction are high as group members contribute to the work effort. It allows for more self-motivation and more creativity among group members.
   • Cons: democratic leadership has been shown to be less efficient and more cumbersome than authoritarian leadership.
     • Utilization: this leadership style can be extremely effective in the healthcare setting.
3. Laissez-faire Leader: the permissive leader recognizes the group’s need for autonomy and self-regulation. The leader assumes a “hands-off” approach.
   • Principle: the leader presupposes the group is internally motivated.
   • Cons: Group members may act independently and at opposing purposes because of a lack of cooperation and coordination.
   • Utilization: a laissez-faire style is most effective for groups whose members have both personal and professional maturity—when the group has made a decision, the members become committed to it. The members then perform tasks in their area of expertise while the leader acts as a resource person.
4. Bureaucratic Leader: the bureaucratic leader does not trust self or others to make decisions. Instead, this type of leader relies on the organization’s rules, policies, and procedures to direct the group’s work efforts.
   • Cons: group members are usually dissatisfied with the leader’s inflexibility and impersonal relations with them.
5. Situational Leader: contingency theorists postulate that effective leaders adapt their leadership style to the situation. The situational leader is a popular contingency theory: the situational leader flexes task and relationship behaviors, considers the staff members’ abilities, knows the nature of the task to be done, and is sensitive to the context or environment in which the task takes place.
   • When employees are insecure or unable or unwilling to perform the task, the leader uses a highly directive style, providing specific instructions and close supervision.
   • If the group is motivated and willing but unable to perform the task, the leader again uses a highly directive style, but in this case, the leader explains decisions and provides the opportunity for clarification.
   • When the group is able but unwilling or lacking in confidence, the leader shares ideas and facilitates decision-making.
   • For a group that is willing, able, and confident to perform the task, the leader delegates, turning responsibility for decision-making and implementation over to the group.

	Autocratic	Democratic	Laissez-Faire	Bureaucratic
Degree of control	Makes decisions alone	Collaborative	No control	Strict reliance on policy
Leader activity level	High	High	Minimal	High
Assumption of responsibility	Primarily the leader	Shared	Relinquished	Leader
Output of the group	High quantity, good quality	Creative, high quality	Variable, may be of poor quality	Good quality through following standard procedures
Efficiency	Very efficient	Less efficient that autocratic	Inefficient	Efficient

Contemporary Leadership Theories

1. Charismatic Leader: A charismatic leader is rare and is characterized by having an emotional relationship with the group members. The charming personality of the leader evokes strong feelings of commitment to both the leader and the leader’s cause and beliefs.
2. Transactional Leader: The transactional leader has a relationship with followers based on an exchange for some resource valued by the follower. These incentives are used to promote loyalty and performance. For example, to ensure adequate staffing on the night shift, the nurse manager entices a staff nurse to work the night shift in exchange for a weekend shift off. This is a traditional approach, focused on the day-to-day tasks of achieving organizational goals and on understanding and meeting the needs of the group.
3. Transformational Leader: The transformational leader fosters creativity, risk taking, commitment, and collaboration by empowering the group to share in the organization’s vision. The leader inspires others with a clear, attractive, and attainable goal and enlists the group to participate in attaining the goal. The group is empowered because members and leader share values, honesty, trust, and continual learning. Independence, individual growth, and change are facilitated.
   • Servant Leadership is a subtype of transformational leadership based on the concept that leaders serve their constituencies. Members of an organization act as both servants and leaders within a work environment of mutual respect, trust, and collaboration. This can be demonstrated by both formal and informal leaders. Especially for nursing, this concept is internally consistent with a focus on caring.
4. Shared Leadership recognizes that a professional workforce is made up of many leaders. No one person is considered to have knowledge or ability beyond that of other members of the work group. Appropriate leadership is thought to emerge in relation to the challenges that confront the work group.
   • Examples of shared leadership in nursing are self-directed work teams, co-leadership, and shared governance. Shared governance distributes decision-making among a group of individuals. It provides structure by articulating a mechanism for advocacy and influence of the staff nurse through all levels of nursing.

Effective Leadership

Much has been written about effective leadership and style; some descriptive statements about effective leaders are that they:

• Use a leadership style that is natural to them.
• Use a leadership style appropriate to the task and the members.
• Assess the effects of their behavior on others and the effects of others’ behavior on themselves.
• Are sensitive to forces acting for and against change.
• Express an optimistic view of human nature.
• Are energetic.
• Are open and encourage openness, so that real issues are confronted.
• Facilitate personal relationships.
• Plan and organize activities of the group.
• Are consistent in behavior toward group members.
• Delegate tasks and responsibilities to develop members’ abilities, not merely to get tasks performed.
• Involve members in all decisions.
• Value and use group members’ contributions.
• Encourage creativity.
• Encourage feedback about their leadership style.
• Assess for and promote the use of current technology.

Effective leadership includes the principles of vision, influence, and acting as a role model.

1. Vision is a mental image of a possible and desirable future state. Leaders transforms vision into realistic goals and communicate their visions to others who accept them as their own.
2. Influence is an informal strategy used to gain the cooperation of others without exercising formal authority. Influence is exercised through persuasion and excellent communication skills; it is based on a trusting relationship with the followers.
3. An effective leader needs to show sensitivity to being a positive role model—someone who sets the example for others to follow. As is appropriate for any health and caring profession, leadership should also be humanistic; that is, leaders should act in a way that stress individuals’ dignity and worth. Being a good leader takes thought, care, insight, commitment, and energy.

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Management

The manager’s job is to accomplish the work of the organization. To this end, managers perform roles and functions that vary with the type of organization and the level of management.

Levels of Management

1. First-level Managers are responsible for managing the work of nonmanagerial personnel and the day-to-day activities of a specific work group or groups. Their primary responsibility is to motivate staff to achieve the organization’s goals. This level of manager communicates staff issues to upper administration and reports administrative messages back to staff. Titles may include team leader or charge nurse.
2. Middle-level Managers supervise a number of first-level managers and are responsible for the activities in the department they supervise. Middle-level managers serve as liaisons between first-level managers and upper-level managers. They may be called supervisors, nurse managers, or head nurses.
3. Upper-level (top-level) managers are organization executives who are primarily responsible for establishing goals and developing strategic plans. Nurse executives are registered nurses who are responsible for the management of nursing within the organization and the practice of nursing. Some nurse executives are also responsible for auxiliary units such as the pharmacy, laboratory, and dietary departments. Nurses in these positions may be called vice president for client care services, vice president for nursing, director of nursing, or chief nurse.

Management Functions

Four management functions are planning, organizing, directing, and coordinating. These four functions help to achieve the broad goal of quality client care.

Planning

Planning is an ongoing process that involves (a) assessing a situation, (b) establishing goals and objectives based on assessment of a situation or future trends, and (c) developing a plan of action that identifies priorities, delineates who is responsible, determines deadlines, and describes how the intended outcome is to be achieved and evaluated.

In short, it involves deciding what, when, where, and how to do it; by whom; and with what resources. The distribution of money, personnel, equipment, and physical space is included in the planning for resource allocation. An upper-level manager spends considerable time planning goals and services and determining the numbers and types of nurses and other personnel needed to provide these services. On the other hand, a first-level manager such as a staff nurse spends less time planning but manages individual clients by use of the nursing process.

Risk Management

Risk Management is an example of the planning function, having in place a system to reduce danger to clients and staff. The steps of risk management include:

1. Anticipating and prioritizing risks
2. Developing a plan to avoid and manager risk
3. Gathering data that indicate success at avoiding or minimizing risk
4. Evaluating and modifying risk reduction programs. Central to the process of risk management is communication among all involved individuals.

Organizing

Organizing is also an ongoing process of coordinating work. After identifying the work and evaluating human and material resources, the manager arranges the work into smaller units. Organizing involves determining responsibilities, communicating expectations, and establishing the chain of command for authority and communication. Although upper-level managers delegate much of the work and responsibility and accountability for the work to others, they need to ensure that department objectives, priorities, job descriptions, lines of communication, policies, and procedures clearly describe the expectations.

Directing

Directing is the process of getting the organization’s work accomplished. Directing involves assigning and communicating expectations about the task to be completed, providing instruction and guidance, and ongoing decision-making.

• Upper-level managers devote less time to directing than to planning, organizing, and coordinating. Directing at this level of management generally involves supervision of the next level of managers, such as those in middle management.
• Unit managers (charge nurses) and staff nurses devote more time to directing. For example, charge nurses direct shift work by assigning clients and scheduling meal and break times. Staff nurses direct the care of clients by organizing nursing care, communicating care in written care plans and shift reports, and supervising care that is given by others.

Coordinating

Coordinating is the process of ensuring that plans are carried out and evaluating outcomes. The manager measures results or actions against standards or desired outcomes and then reinforces effective actions or changes ineffective ones.

• For example, an upper-level manager evaluates the effectiveness of recruitment, staff turnover, and budget performance. The charge nurse appraises staff performance. The staff nurse determines whether nursing interventions have helped the client achieve desired outcomes.

Principles of Management

A manager has authority, accountability, and responsibility.

1. Authority is defined as the legitimate right to direct the work of others. It is an integral component of managing. Authority is conveyed through leadership actions; it is determined largely by the situation, and it is always associated with responsibility and accountability.
2. Accountability is the ability and willingness to assume ownership for one’s actions and to accept the consequences of one’s behavior. Accountability can be viewed as hierarchic, starting at the individual level, then the institutional or professional level, and finally the societal level.
   • At the individual or client level, accountability is reflected in the nurse’s ethical integrity.
   • At the institutional level, it is reflected in the statement of philosophy and objectives of the nursing department and nursing audits.
   • At the professional level, it is reflected in standards of practice developed by national nursing associations.
   • At the societal level, it is reflected in legislated nurse practice acts.
3. Responsibility is an obligation to perform a task. Managers are responsible for effective utilization of resources, communication to subordinates, and implementation of organizational goals and objectives. Responsibility for nursing actions can be transferred to another practitioner, but accountability is always shared.

Skill and Competencies of Nurse Managers

To be effective managers, nurses need to think critically, communicate well, manage resources effectively and efficiently, enhance employee performance, build and manage teams, manage conflict, manage time, and initiate and manage change.

Critical Thinking

Critical thinking is a creative process that includes problem-solving and decision-making. The nurse manager reasons with logic and explores assumptions, alternatives, and the consequences of actions.

Communicating

Managers can spend much of their day communicating. Good communication is essential and often determines the manager’s success. Managers use both verbal and written communication. Effective managers communicate assertively, expressing their ideas clearly, accurately, and honestly.

Networking

Managers use networking, a process whereby professional links are established through which individuals can share ideas, knowledge, and information; offer support and direction to each other; and facilitate accomplishment of professional goals.

Managing Resources

One of the greatest responsibilities of managers is their accountability for human, fiscal, and material resources. Budgeting and determining variances between the actual and budgeted resources are crucial skills for any manager.

Enhancing Employee Performance

Several ways of enhancing employee performance are available to managers. Managers are responsible for ensuring that employees develop by providing appropriate learning opportunities, such as in-service education; by facilitating attendance at professional workshops and conventions; and by encouraging achievement of advanced education, such as higher degrees or certifications. The nurse manager who empowers the staff by providing information, support, resources, and opportunities to participate will find that employees have greater commitment to the institution, are more effective in their role, have increased self-esteem, and are better able to meet their goals. In addition, the manager may provide day-to-day coaching or serve as a mentor or preceptor.

1. Mentor: voluntarily assists the mentee to develop values, attitudes, ethical comportment, and critical thinking and role models appropriate behavior.
2. Preceptor: describes an experienced nurse who assists the “new” nurse in improving clinical nursing skill and judgment. The preceptor also instills an understanding of the routines, policies, and procedures of the institution and the unit.

Building and Managing Teams

In addition to personnel development, managers are responsible for building and managing work teams. Familiarity with group processes facilitates a manager’s ability to lead a group and enhances the development of the group into a work team. Groups develop in stages, during which roles and relationships are established.

• The purposes of the team as a whole and the role of each member must be clear.
• Each member must feel that the manager and the other members recognize their contributions.
• In healthcare, the team may consist of any healthcare providers: nurses, therapists, assistive personnel, clergy, and so on. All members of the team need to use effective communication skills.

Managing Conflict

Conflict may arise from differing values, philosophies, or personalities. In healthcare, conflict can also arise from competition for resources, especially for funding for staff positions or equipment. Failure to manage conflict can result in the problem becoming larger and more difficult. Among the most methods of resolving conflict include compromise, negotiation, and collaboration.

Basic principles for all types of conflict management include demonstrating respect for all parties, avoiding blame, allowing full discussion, using ground rules during meetings to promote fairness, encouraging active listening, identifying the themes in the discussion, and exploring alternative solutions.

Managing Time

The effective nurse manager uses time effectively and assists others in doing the same. Many obstacles are present: ordering tasks by preference, emergencies that divert attention, and unrealistic demands from others, for example. Strategies that all nurses can use in order to use time well involve setting goals and priorities, minimizing paperwork (automating whenever possible), and using regular schedules that avoid interruptions and set time limits on activities.

Managing Change

Change is the process of making something different from what it was. This can involve knowledge, adapting practices, and skills. It is integral to nursing, especially as nurses often act as change agents—initiators, motivators, and implementers of change.

Change Agents

Change agents:

• Have excellent communication and interpersonal skills with individuals, groups, and all levels of the organization involved in change
• Have knowledge of available resources and how to use them: people, time, money, facilities, and information
• Are skilled in problem-solving
• Are skilled in teaching
• Are respected by those involved in the change
• Have the ability to encourage and nurture those going through change
• Are self-confident, are able to take risks, and inspire trust in themselves and others
• Are able to make decisions
• Have a broad base of knowledge
• Have a good sense of timing.

Types of Change

1. Planned Change: intended, purposeful attempt by an individual, group, organization, or larger social system to influence its own current status. Problem-solving skills, decision-making skills, and interpersonal skills are important factors in planned change.
2. Unplanned Change: an alteration imposed by external events or individuals. It occurs when unexpected events force a reaction. It is usually haphazard, and the results can be unpredictable. Situational, or natural, change may be considered unplanned and occurs without any control by the person or group impacted. For example, unplanned change can result from war or natural disaster. This is not necessary negative—a change in an agency’s open or close units may give a nurse the opportunity to change to a new workplace.
3. Covert Change: a hidden change that occurs without the individual’s awareness. An example is the gradual, subtle increase in the severity of the clients’ conditions on a nursing unit.
4. Overt Change: a change of which a person is aware. An example might be that a piece of equipment will no longer be available because the agency has changed suppliers. Individuals who experience overt unplanned change may experience anxiety. Overt change often necessitates behavioral changes that create conflict with the person’s needs or goals.

The Nurse’s Role in Change

In a classic work by Lewin (1951), change involves three stages:

1. Unfreezing: the need for change is recognized, driving and restraining forces are identified, alternative solutions are generated, and participants are motivated to change.
   • An important aspect of planning change is establishing the likelihood of the acceptance of the change and then determining the criteria by which that acceptance can be identified.
   • The course of acceptance is easier for individuals if they are involved in the process. If possible, change should be instituted on a small or pilot scale before full implementation.
   • To facilitate acceptance of the change, the change agent needs to identify common driving and restraining forces.
2. Moving: participants agree that the status quo is undesirable, and the actual change is planned in detail and implemented.
3. Refreezing: the change is integrated and stabilized.

Common Driving and Restraining Forces for Change

Driving forces are those that promote change.

• Perception that the change is challenging
• Economic gain
• Perception that the future will improve the situation
• Visualization of the future impact of change
• Potential for self-growth, recognition, achievement, and improved relationships

Restraining forces are those that prevent change.

• Fear that something of personal value will be lost (e.g., threat to job security or self esteem)
• Misunderstanding of the change and its implications
• Low tolerance for change related to intellectual or emotional insecurity
• Perception that the change will not achieve goals; failure to “see the bigger picture”
• Lack of time or energy
• Perceived loss of freedom to engage in particular behaviors

Change requires energy, much of which comes from those who have power. To access optimal power, use the following strategies:

1. Analyze the organizational chart; know the formal lines of authority. Identify informal lines as well.
2. Identify key persons who will be affected by the change. Pay attention to those in the chain of command immediately above and below the point of change.
3. Find out as much as possible about these key individuals. What are their “tickle points”? What interests them, gets them excited, turns them away? What is on their personal and organizational agendas? Who typically aligns with whom on important decisions?
4. Begin to build a coalition of support before you start the change process. Identify the key individuals who will most likely support your idea and those who are most likely to be persuaded easily. Talk informally with them to flush out possible objections to your idea and potential opponents. What will be the costs and benefits to them—especially in political terms? Can your idea be modified in ways that retain your objectives but appeal to more key individuals?
5. Follow the organizational chain of command when communicating with administrators. Do not bypass anyone to avoid having an excellent proposal undermined.

Guidelines for Dealing with Resistance to Change

1. Talk with those who oppose the change. Get to the root of their reasons for opposition.
2. Clarify information, and provide accurate information.
3. Be open to revisions but clear about what must remain.
4. Present the negative consequences of resistance (e.g., threats to organizational survival, compromised client care).
5. Emphasize the positive consequences of the change and how the individual or group will benefit. However, do not spend too much energy on rational analysis of why the change is good and why the arguments against it do not hold up. Individuals’ resistance frequently flows from feelings that are not rational.
6. Keep resisters involved in face-to-face contact with supporters. Encourage proponents to empathize with opponents, recognize valid objections, and relieve unnecessary fears.
7. Maintain a climate of trust, support, and confidence.
8. Divert attention by creating a different disturbance. Energy can shift to a more important problem inside the system, thereby redirecting resistance. Alternately, attention can be brought to an external threat to create a bully phenomenon. When members perceive a greater environmental threat (e.g., competition or restrictive governmental policies), they tend to unify internally.

All nurses are affected by change; nobody can avoid it. Nurses knowledgeable about the historical and current trends in nursing and current political, social, technologic, and economic issues make rational plans to deal with opportunities to initiate and guide needed change and to respond to change that affects them in the workplace, government, organizations, and the community.

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The Nurse as Delegator

Delegation is “allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and not routinely performed.” Delegation is differentiated from assignment, which consists of duties that are already within the scope of practice of the member of the nursing team (NCSBN). Assignment is the majority of care provided by nursing personnel. Care is only delegated when the delegator has determined that such care can be safely delivered by a delegatee who meets specific requirements.

1. The delegatee assumes responsibility for performance of the task.
2. The delegator retains accountability for the outcome.

Delegation is a tool that allows the delegator to focus on tasks that cannot be delegated, and allows the delegatee to build skill, ability, self-esteem, morale, and teamwork. It is a form of indirect care—the intended outcome is achieved through the work of someone supervised by the nurse.

The nurse defines the task, determines who can perform the task, describes the expectation, seeking agreement, monitoring performance, and providing feedback to the delegatee regarding performance. Registered nurses delegate components of nursing care to other members of the nursing team:

1. Other Registered Nurses (RN)
2. Licensed Vocational or Practical Nurses (LVN/LPN)
3. Assistive Personnel (AP) may be identified by a variety of titles, including certified nursing aides or assistants (Can), home health aides, medication assistants, patient care technicians, orderlies, or surgical technicians. They have had diverse degrees of training and experience. They are employees and do not include family members or friends who provide some client care.

The model state nursing practice act authored by the NCSBN states that both the RN and LVN/LPN may assign or delegate nursing interventions to implement the plan of care. The NCSBN also published five “rights” of delegation:

1. Right Task
2. Right Circumstances
3. Right Person
4. Right Directions and Communication
5. Right Supervision and Evaluation

NCSBN (2005)

The steps of the delegation process are: (mn. ACME)

1. Assessment of the client, the staff and the context of the situation
   • A specific task that can be delegated to one AP may not be appropriate to another AP, depending on each AP’s experience and individual skill sets.
   • A specific task that can be performed by one AP for one client may not be appropriate with a different client or the same client in a different context. For example, the taking of routine vital signs may be delegated to an AP for a client in stable condition but would not be delegated for the same client who has become unstable.
2. Communication to provide direction and opportunity for interaction during the completion of the delegated task
   • Once the decision has been made the delegate, the nurse must communicate clearly to the AP and verify that the AP understands the specific tasks to be done, when to perform each task, the expected outcomes for each task (including reporting variances), who can serve as a resource if needed, and when and how a report on the tasks is expected.
   • The delegatee also has the responsibility to decline to perform a task, whether delegated or assigned, if they feel unqualified to perform it.
3. Monitoring and Surveillance to assure compliance with standards of practice, policies and procedures. The delegator is not held legally responsible for the acts of the AP but is accountable for the quality of the act of delegation and has the ultimate responsibility for ensuring the proper care is provided.
4. Evaluation to consider the effectiveness of the delegation and whether the desired client outcome was attained

Principles Used by the Nurse to Determine Delegation to APs

1. The nurse must assess the individual client prior to delegating tasks.
2. The client must be medically stable or in a chronic condition and not fragile.
3. The task must be considered routine for this client.
4. The task must not require a substantial amount of scientific knowledge or technical skill.
5. The task must be considered safe for this client.
6. The task must have a predictable outcome.
7. Learn the agency’s procedures and policies about delegation.
8. Know the scope of practice and the customary knowledge, skills, and job description for each member of your team.
9. Be aware of individual variations in work abilities. Each individual caregiver has different experiences and may not be capable of performing every task cited in the job description.
10. When unsure about an assistant’s abilities to perform a task, observe while the individual performs it, or demonstrate it to the individual and get a return demonstration before allowing the individual to perform it independently.
11. Clarify reporting expectations to ensure the task is accomplished.
12. Create an atmosphere that fosters communication, teaching, and learning. For example, encourage staff members to ask questions, listen carefully to their concerns, and make use of every opportunity to teach.

In addition to delegating to AP, the RN also delegates to LVN/LPNs. Because LVN/LPNs are licensed, the nurse must know their specific scope of practice (based on agency, state, and country specifications). While LVN/LPNs require less direct supervision than APs, the nurse still retains primary responsibility and accountability for the implementation of the nursing process.

• LVN/LPNs may perform tasks generally considered the role of the RN if they have received special training. For example, specially trained LVN/LPNs they may assess intravenous infusion sites, or rarely administer IV fluids or medications, initiate IV lines, or administer parenteral nutrition. Some may even delegate to other LVN/LPNs or AP.
• The process of delegating to LVN/LPNs is the same as for APs. The nurse must still confirm that the particular LVN/LPN’s job description, education, and competency meet the needs of the specific situation.
• LVN/LPNs may perform client teaching from a standard teaching plan.

An RN can also become a delegatee. This is part of the daily routine of determining which available nurses should care for which clients or when specific additional assistance is required for one client. When delegating to RNs who are new to a particular setting—such as those recently transferred to the unit—the delegating nurse must confirm that the five rights are still met.

Examples of Common, Potential, and Undelegated Tasks to APs

Tasks that are commonly assigned to assistive personnel:

• Taking of vital signs on stable clients
• Basic hygiene techniques
• Bedmaking
• Client transfers and ambulation
• Personal care
• Food service
• Documentation
• Safety measures (including fire, safety, and disaster preparedness, and infection control)
• Performing basic life support (cardiopulmonary resuscitation [CPR])
• Basic preventative and restorative care and procedures
• Basic observation procedures such as weighing and measuring

Tasks that may be delegated to assistive personnel:

• Postmortem care
• Gastrostomy feedings in established systems
• Administering nonparenteral medications
• Administering injections
• Performing simple dressing changes
• Suctioning of chronic tracheostomies

Tasks that may not be delegated to assistive personnel:

• Assessment
• Interpretation of data
• Making a nursing diagnosis
• Creation of a nursing care plan
• Evaluation of care effectiveness
• Care of invasive lines
• Administering intravenous medications
• Insertion of nasogastric tubes
• Client education
• Performing triage
• Giving telephone advice
• Tasks requiring sterile technique
• Obtaining orders from physicians

Double Check

Delegation is a skill. It must be learned and developed over time. The nurse should not hesitate to consult with others regarding the appropriateness of the delegation.