Delegation is defined as “the act of empowering to act for another” (Merriam-Webster [M-W], n. d. ). In nursing, it allows a nurse to instruct a co-worker to perform specific duties in his or her place. Delegation not only allows patients to interact with more members of a staff, but also allows for the patient to benefit from the expertise of various staff members. It is a skill that requires teamwork and effective communication throughout the staff members.
This essay is in response to a case study in which a nurse practitioner (NP) of a rural health care clinic failed to utilize delegation in caring for a patient, relying only on herself to provide all the education, referrals and health care for a developmentally disabled pregnant patient. Per the case study, the clinic offered a nutritionist; an RN with a BSN in community health, an LVN trained educating on labor and delivery; a social worker; and, an on-call obstetrician available for emergencies.
In this setting, the NP had at her disposal a team of staff that could assist in the patient’s care and, perhaps, expand on the quality of care provided to the patient. As a primary care provider, a NP is charged with taking health histories, providing physical examinations, diagnosing and treating acute and chronic problems, interpreting test results, managing medications and other therapies, providing health teaching and counseling and referring patients to other health professionals as needed (Mayo School of Health Sciences [Mayo], n. . ). In this role, after assessing the patient’s needs and completing a physical examination, the NP creates a plan of care that includes goals and expectations to work towards during the patient’s care. The care plan may utilize delegation to other members of the clinic team to ensure the patient receives well-rounded care and support. In fact, the “Joint Statement on Delegation” lists 10 Principles of Delegation to direct the nurse in delegation.
Two of these principles state that the nurse maintains the “responsibility and accountability for the nursing process” while “delegating components of care” (American Nurses Association (ANA) & National Council of State Boards of Nursing (NCSBN) [ANA/NCSBN], 2005). Simply put, a nurse may ask a peer or specialist to step in on a patient’s case to provide his or her area of expertise or specialized skills to the patient, while the patient’s care still remains the responsibility of the eferring nurse. Additional principles state that delegation requires “effective communication among team members” and consistent follow-up and reassessment to evaluate the effectiveness of delegation. Regardless of who provides the duties of this patient’s care, the responsibility does not solely fall on the NP. For, there is an organizational accountability for delegation as well.
Organizational accountability for delegation relates to providing sufficient resources, including…staffing [and] documenting competencies for all staff providing direct patient care [as well as] ensuring that the [NP] has access to competence information for the staff” to whom she is delegating care (ANA/NCBSN, 2005). Here we see that the accountability for delegation not only falls on the NP for continued monitoring and evaluation, but also on the nursing supervisor to ensure staff are competent and that the NP knows which staff have shown competency in which areas.
It is the duty of the nurse manager to provide training to staff, document their competencies and certifications, identify the policies and procedures for delegation and communicate all of these things to staff. Failure to do so could result in tasks being delegated to inappropriately trained staff, resulting in sub-par care, and violating their rights as a patient (American Nurses Association, 2001, prov. 3. 4). Even with the same training, one person’s fresh perspective on a case can often bring in new ideas or suggestions of improvement.
Often in nursing, the suggestion is simply calling in others to assist in the plan of care. It is for this reason the nursing supervisor also needs to develop his/her own delegation skills in order to assist staff in knowing how and when to delegate tasks. In an effort to ensure quality patient care and avoid inappropriate delegation, the supervisor needs to help direct the NP in delegating tasks to other clinic members. This can be easily accomplished by assisting in the development of a Plan of Care (POC) after the NP’s initial appointment and assessment of the patient.
For, it is during the initial visit that the NP will assess not only the patient’s state of health, but also her education level, comprehension ability, and emotional or psychosocial needs as well. After these assessments have been made, the NP can formulate goals and expectations for the POC to include. Goals for this patient may include, but are certainly not limited to the following: ·Patient maintains current weight with appropriate weight gain during pregnancy, not to exceed (x) pounds. Patient identifies ways to maintain a healthy weight in relation to food choices, cooking techniques and portion control. ·Patient’s lab values remain within expectations for pregnancy. ·Patient attends 90% of all scheduled appointments, with missed appointments rescheduled within (x) days. ·Patient verbalizes progression of pregnancy and fetal development and identifies important milestones during each term. ·Patient identifies ways to contact clinic staff if questions arise between appointments.
Each of these goals has measurable outcomes and are appropriate for the patient’s plan of care. It is after these and other goals have been identified that an interdisciplinary plan of care meeting can be arranged. At this meeting, each member of the clinic staff will have the opportunity to see and expand on each goal as related to his or her area of expertise, as well as seek clarification from the NP as to her expectations of their roles. The nursing supervisor’s presence at the meeting ensures that delegated tasks are appropriately assigned.
The supervisor’s duties do not end with this planning meeting, however, as s/he needs to continue to follow-up on the POC and other staff members to ensure that the plan is adequately meeting the needs of the patient, staff are comfortable with their delegated tasks and the NP is comfortable with the progression. In this specific case, the client would be best served by bringing in other members of the clinic team to provide additional services.
Primarily, all clients need education throughout their care, beginning at the first visit by informing the patient of her health status, encouraging questions, providing answers, and explaining each step of the assessment process. However, education needs to continue after the first visit and is a task that can be delegated. The clinic staffs an RN with a BSN in Community Health. She is experienced in “working with individuals, groups, and families to improve overall health [and] educate about health care issues, disease prevention, nutrition, and childcare” (“Community,” 2002-2009).
This RN is the ideal person to assist the NP in providing initial education to the patient in regards to overall health. S/He can begin by assessing the patient’s understanding of female anatomy, pregnancy and fetal development, nutrition and more. S/He can also learn about the patient’s cultural beliefs to identify challenges the clinic team may encounter during the patient’s care (e. g. concept of time or keeping appointments, role of family members in health care, acceptable communication with figures of authority, etc).
From the initial RN assessment, a more detailed educational plan can be formatted, allowing the patient’s belief system and cognitive level to shape the way topics are discussed and how best to determine the patient’s understanding after each education session. The RN can then delegate further teaching on pregnancy, labor and delivery to the LVN, as she has been trained to provide such education (Nurse Practice Act, 2007). For this patient, education will need to take place at each visit, in small amounts. It would also be beneficial to allow for additional education sessions, which may include home visits if transportation is an issue.
These additional sessions would allow the patient to take information in small amounts, focusing on one or two topics each session. Because comprehension of education is vital to continuing education, each session will need to begin and end with an assessment of the patient’s understanding of previously discussed topics. There are other members of the clinic staff that can further assist in the patient’s care. First, the client would benefit from the knowledge a nutritionist can provide when reviewing a patient’s case.
The nutritionist not only has special training in the area of nutrition, but also in educating patients about their options and making nutritious choices. In general, a nutritionist can “advise individuals…on the nutritional practices that will promote good health, [and] structure and recommend diet plans for whole families…including guides to the correct preparation of meals and shopping for the right foods (Princeton Review, n. d. ). Furthermore, the clinic’s social worker can review the patient’s chart, visit with the patient and identify additional resources that would be beneficial.
These resources could include public aid programs to help with obtaining nutritional food choices or paying for healthcare provided during and after pregnancy, finding assistance for the patient inside her home, or identifying additional agencies to which a referral for the patient would be appropriate. And, finally, the clinic utilizes an on-call obstetrician, which would be able to assist in any emergency or delivery needed, should the patient need immediate assistance in this rural setting.
The obstetrician can assist the NP further by being available for phone consultations if the patient develops problems with medications or fails to espond to treatments. With the assurance of the obstetrician’s availability, the clinic staff can keep the patient at their center, rather than referring her to the larger high-risk center, allowing their carefully prepared POC to more adequately meet her needs. However, delegation has its limitations as “the decision of whether or not to delegate … is based upon the RN’s judgment concerning the condition of the patient, the competence of all members of the nursing team and the degree of supervision that will be required of the [nurse] if a task is delegated” (ANA/NCBSN, 2005).
That is, the NP must feel that the members of her clinic team are competent to perform the duties she delegates. If she does not feel that the members in her own clinic can competently carry out the duties of education or referral, it is within the rights of the NP to refer the patient to an agency or practice that can better serve her patient. This is especially important given the limited mental capacity shown in this patient and the possibility that she will need specialized personnel to assist with her education.
For example, should the patient fail to show comprehension of education presented after several different attempts and methods of communication, it would be appropriate for the patient to be referred to an outside agency that could cater to her needs, whether they be related to her limited mental capacity or a language barrier. Or, if the patient were to continue missing appointments or failed to show up on time for appointments, it would be appropriate to refer the patient to a case manager that could assist with reminders or address transportation needs.
The care of any patient revolves mostly around effective communication within a team of healthcare professionals. It requires assessment of the patient’s needs, be they physical, emotional, educational or socioeconomic, delegation of appropriate tasks with effective communication between the interdisciplinary team members, and constant evaluation of the patient’s understanding and continuing needs.
The care of the patient does not fall only on the hands-on providers, but on the organization as a whole for ensuring adequate training and policies are in place to protect the patient. Finally, it sometimes requires the ability of the primary care provider to let go of certain aspects of care and allow others to assist.