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 Guidelines for Prioritization, Delegation,
and Assignment Decisions
Expert nurses have discovered that the most success-
ful method of approaching their practice is to maintain
a
laser-like focus on the outcomes that the patients and
their
families want to achieve. To attempt to prioritize,
delegate,
or assign care without understanding the patient’s
preferred
results is like trying to put together a jigsaw puzzle
with-
out the top of the puzzle box that shows the puzzle
picture.
Not only does the puzzle player pick up random pieces
that
don’t fit well together, wasting time and increasing
frustra-
tion, but also the process of puzzle assembly is
fraught with
inefficiencies and wrong choices. In the same way, a
nurse
who scurries haphazardly without a plan, unsure of
what
could be the most important, life-saving task to be
done
first or which person should do which tasks for this
group of
patients, is not fulfilling his or her potential to be a
channel
for healing.
Let’s visit a change-of-shift report in which a group
of nurses receives information about two patients
whose
blood pressure is plummeting at the same rate. How
would
one determine which nurse would be best to assign to
care
for these patients, which patient needs to be seen
first,
and which tasks could be delegated to assistive
person-
nel (APs), if none of the nurses is aware of each
patient’s
preferred outcomes? Patient A is a young mother who
has been receiving chemotherapy for breast cancer;
she
has been admitted this shift because of dehydration
from
uncontrolled emesis. She is expecting to regain her
nor-
mally robust good health and watch her children
gradu-
ate from college. Everyone on the health care team
would
concur with her long-term goals. Patient Z is an elderly
gentleman, 92 years of age, whose wife recently died
from
complications of repeated cerebrovascular events
and
dementia. Yesterday while in the emergency
department
(ED), he was given the diagnosis of acute myocardial
infarction and preexisting severe heart failure. He
would
like to die and join his wife, has requested a “do not
resus-
citate” order, and is awaiting transfer to a hospice.
These
two patients share critical clinical data but require
widely
different prioritization, delegation, and assignment. A
savvy charge RN would make the obvious decisions:
to
assign the most skilled RN to the young mother and to
ask APs to function in a supportive role to the primary
care RN.
The elderly gentleman needs palliative care and would
be best cared for by an RN and care team with
excellent
people skills. Even a novice nursing assistant could be
del-
egated tasks to help keep Mr. Z and his family
comfortable
and emotionally supported. The big picture on the
puzzle
box for these two patients ranges from long-term
“robust
good health” requiring immediate emergency
assessment
and treatment to “a supported and comfortable
death”
requiring timely palliative care, including supportive
emotional and physical care. Without envisioning
these
patients’ pictures and knowing their preferred
outcomes,
the RNs cannot prioritize, delegate, or assign
appropriately.
There are many times in nursing practice, however,
when
correct choices are not so apparent. Patients in all
care set-
tings today are often complex, and many have
preexisting
comorbidities that may stump the expert practitioners
and
clinical specialists planning their care. Care delivery
sys-
tems must flex on a moment’s notice as an AP arrives
in
place of a scheduled LPN/LVN and agency, float, or
travel-
ing nurses fill vacancies, while new patients, waiting
to be
admitted, accumulate in the ED or wait to be
transferred to
another setting. APs arrive with varying educational
prepa-
ration and dissimilar levels of motivation and skill.
Critical
thinking and complex clinical judgment are required
from
the minute the shift begins until the nurse clocks out.
In this book, the authors have filled an educational
need
for students and practicing nurses who wish to hone
their
skills in prioritizing, assigning, and delegating. The
scenar-
ios and patient problems presented in this workbook
are
practical, challenging, and complex learning tools.
Quality
and Safety Education for Nurses (QSEN)
competencies
are incorporated into this chapter and throughout the
ques-
tions to highlight patient- and family-centered care,
quality
and safety improvement, and teamwork and
collaboration
concepts and skills (QSEN Institute, 2019). Patient
stories
will stimulate thought and discussion and help polish
the
higher-order intellectual skills necessary to practice
as a
successful, safe, and effective nurse. The
Interprofessional
Collaboration Competency Community and
Population
Oriented Domains from the Interprofessional
Education
Collaborative (IPEC) are applied to the questions
in this book as appropriate (Interprofessional
Education
Collaborative, 2016, https://ipecollaborative.org).
Domains include Interprofessional Teamwork and
Team-
Based Practices, Interprofessional Teamwork
Practices,
Guidelines for Prioritization, Delegation,
and Assignment Decisions
Ruth Hansten, PhD, MBA, BSN, RN, FACHE
2 Guidelines for Prioritization, Delegation, and
Assignment Decisions
Introduction
PART 1
Roles and Responsibilities for Collaborative Practice,
and
Values/Ethics for Interprofessional Practice. As
reflected in
the IPEC sub-competencies, especially crucial for
patient
outcomes is the role of the RN, armed with knowledge
of
scopes of practice, successfully communicating with
team
members to delegate, assign, and supervise (IPEC,
2016).
DEFINITION OF TERMS
The intellectual functions of prioritization, delegation,
and assignment engage the nurse in projecting into
the
future from the present state. Thinking about what
impact
might occur if competing decisions are chosen,
weigh-
ing options, and making split-second decisions, given
the
available data, is not an easy process. Unless
resources in
terms of staffing, budget, time, or supplies are
unlimited,
nurses must relentlessly focus on choosing which
issues or
concerns must take precedence.
Prioritization
Prioritization is defined as “ranking problems in order
of
importance” or “deciding which needs or problems
require
immediate action and which ones could tolerate a
delay
in action until a later time because they are not
urgent”
(Silvestri, 2018). Prioritization in a clinical setting is a
pro-
cess that involves clearly envisioning patient
outcomes but
also includes predicting possible problems if another
task
is performed first. One also must weigh potential
future
events if the task is not completed, the time it would
take
to accomplish it, and the relationship of the tasks and
outcomes. New nurses often struggle with
prioritization
because they have not yet worked with typical patient
progressions through care pathways and have not
expe-
rienced the complications that may emerge in
association
with a particular clinical condition. In short, knowing
the
patient’s purpose for care, current clinical picture,
and
picture of the outcome or result is necessary to be
able
to plan priorities. The part played by each team
member is
designated as the RN assigns or delegates. The “four
Ps”—
purpose, picture, plan, and part—become a guidepost
for
appropriately navigating these processes (Hansten,
2008a,
2011, 2014b; Hansten and Jackson, 2009). The four Ps
will
be referred to throughout this introduction because
these
concepts are the framework on which RNs base
decisions
about supporting patients and families toward their
pre-
ferred outcomes, whether RNs provide the care
themselves
or work closely with assistive team members.
Prioritization includes evaluating and weighing each
competing task or process using the following criteria
(Hansten and Jackson, 2009, pp. 194–196):
• Is it life threatening or potentially life threatening
if the task is not done? Would another patient be
endangered if this task is done now or the task is left
for later?
• Is this task or process essential to patient or staff
safety?
• Is this task or process essential to the medical or
nursing plan of care?
In each case, an understanding of the overall patient
goals and the context and setting is essential.
1. In her book on critical thinking and clinical judg-
ment, Rosalinda Alfaro-Lefevre (2017) suggests
three levels of priority setting: The first level is air-
way, breathing, cardiac status and circulation, and vi-
tal signs and lab values that could be life threatening
(“ABCs plus V and L”).
2. The second level is immediately subsequent to the
first level and includes concerns such as mental sta-
tus changes, untreated medical issues, acute pain,
acute elimination problems, and imminent risks.
3. The third level comprises health problems other
than
those at the first two levels, such as more long-term
issues in health education, rest, coping, and so on
(p. 171).
Maslow’s hierarchy of needs can be used to prioritize
from the most crucial survival needs to needs related
to
safety and security, affiliation (love, relationships),
self-
esteem, and self-actualization (Alfaro-Lefevre, 2017,
p. 170).
Delegation and Assignment
The official definitions of assignment have been
altered
through ongoing dialogue among nursing leaders in
various
states and nursing organizations, and terminology
distinc-
tions such as observation versus assessment, critical
thinking
versus clinical reasoning, and delegation versus
assignment
continue to be discussed as nursing leaders attempt
to
describe complex thinking processes that occur in
various
levels of nursing practice. Assignment has been
defined
as “the distribution of work that each staff member is
responsible for during a given work period” (American
Nurses Association [ANA], Duffy & McCoy, 2014, p.
22).
In 2016, the National Council of State Boards of
Nursing
(NCSBN) published the results of two expert panels to
clarify that assignment includes “the routine care,
activi-
ties, and procedures that are within the authorized
scope
of practice of the RN or LPN/LVN or part of the routine
functions of the UAP (Unlicensed Assistive
Personnel)”
(NCSBN, 2016b, pp. 6–7), and this definition was
adopted
by the ANA in 2019 in a joint statement with the
NCSBN
with the addition of the acronym AP (assistive
personnel)
(ANA & NCSBN 2019 National Guidelines for Nursing
Delegation, p. 2). Delegation was defined traditionally
as
“transferring to a competent individual the authority to
perform a selected nursing task in a selected
situation”
(NCSBN, 1995), and similar definitions are used by
some
nurse practice statutes or regulations. Both the ANA
and
the NCSBN describe delegation as “allowing a
delegate
Guidelines for Prioritization, Delegation, and
Assignment Decisions 3
Introduction
PART 1
to perform a specific nursing activity, skill, or
procedure
that is beyond the delegatee’s traditional role and is
not
routinely performed” (ANA & NCSBN 2019, p. 2).
Nevertheless, the delegatee must be competent to
perform
that delegated task as a result of extra training and
skill
validation. The ANA specifies that delegation is a
transfer
of responsibility or assignment of an activity while
retain-
ing the accountability for the outcome and the overall
care
(ANA, 2014; Duffy & McCoy, p. 22).
Some state boards have argued that assignment is
the process of directing a nursing assistant to perform
a
task such as taking blood pressure, a task on which
nurs-
ing assistants are tested in the certified nursing
assistant
examination and that would commonly appear in a job
description. Others contend that all nursing care is
part
of the RN scope of practice and therefore that such a
task
would be delegated rather than assigned. Other
nursing
leaders argue that only when a task is clearly within
the
RN’s scope of practice, and not included in the role of
an
AP, is the task delegated. Regardless of whether the
alloca-
tion of tasks to be done is based on assignment or
delega-
tion, in this book, assignment means the “work plan”
and
connotes the nursing leadership role of human
resources
deployment in a manner that most wisely promotes
the
patient’s and family’s preferred outcome.
Although states vary in their definitions of the
functions
and processes in professional nursing practice,
including
that of delegation, the authors use the NCSBN and
ANA’s
definition, including the caveat present in the
sentence
following the definition: delegation is “transferring to a
competent individual the authority to perform a
selected
nursing task in a selected situation. The nurse retains
the
accountability for the delegation” (NCSBN, 1995, p.
2).
Assignments are work plans that would include tasks
the
delegatee would have been trained to do in their basic
educational program; the nurse “assigns” or
distributes
work and also “delegates” nursing care as she or he
works
through others. In advanced personnel roles, such as
when
certified medication aides are taught to administer
medi-
cations or when certified medical assistants give
injections,
the NCSBN (2016) asserts that because of the
extensive
responsibilities involved, the employers and nurse
lead-
ers in the settings where certified medication aides
are
employed, such as ambulatory care, skilled nursing
homes,
or home health settings, should regard these
procedures
as being delegated and AP competencies must be
assured
(NCSBN, 2016b, p. 7). ANA designates these certified
but
unlicensed individuals as APs rather than UAPs (ANA
&
NSCBN 2019). The differences in definitions among
states
and the differentiation between delegation and
assignment
are perplexing to nurses. Because both processes are
simi-
lar in terms of the actions and thinking processes of
the
RN from a practical standpoint, this workbook will
merge
the definitions to mean that RNs delegate or assign
tasks
when they are allocating work to competent trained
indi-
viduals, keeping within each state’s scope of practice,
rules,
and organizational job descriptions. Whether
assigning or
delegating, the RN is accountable for the total nursing
care
of the patient and for making choices about which
compe-
tent person is permitted to perform each task
successfully.
Whether the RN is delegating or assigning, depending
on
their state regulations, the expert RN will not ask a
team
member to perform a task that is beyond the RN’s own
scope of practice or job description, or a task outside
of
any person’s competencies. In all cases the choices
made to
allocate work must prioritize which allocation of work
is
optimal for the patient’s safe and effective care
(Hansten
2020, in Kelly Vana and Tazbir).
Delegation or Assignment and Supervision
The definitions of delegation and assignment offer
some
important clues to nursing practice and to the
composition
of an effective patient care team. The person who
makes
the decision to ask a person to do something (a task or
assignment) must know that the chosen person is
com-
petent to perform that task. The RN selects the
particular
task, given his or her knowledge of the individual
patient’s
condition and that particular circumstance. Because
of the
nurse’s preparation, knowledge, and skill, the RN
chooses
to render judgments of this kind and stands by the
choices
made. According to licensure and statute, the nurse is
obli-
gated to delegate or assign based on the unique
situation,
patients, and personnel involved and to provide
ongoing
follow-up.
Supervision
Whenever nurses delegate or assign, they must also
super-
vise. Supervision is defined by the NCSBN as “the pro-
vision of guidance and direction, oversight, evaluation,
and follow up by the licensed nurse for
accomplishment
of a nursing task delegated to nursing assistive
person-
nel” and by the ANA as “the active process of
directing,
guiding, and influencing the outcome of an
individual’s
performance of a task” (ANA, 2014; Duffy & McCoy,
p. 23). Each state may use a different explanation,
such
as Washington State’s supervision definition: “initial
direction... periodic inspection... and the authority to
require corrective action” (Washington Administrative
Code 246-840-010 Definitions,
https://app.leg.wa.gov/w
ac/default.aspx?cite=246-840-010). The act of
delegating
or assigning is just the beginning of the RN’s
responsibil-
ity. As for the accountability of the delegatees (or
people
given the task duty), these individuals are accountable
for a) accepting only the responsibilities that they
know
they are competent to complete, b) maintaining their
skill
proficiency, c) pursuing ongoing communication with
the
team’s leader, and d) completing and documenting
the task
appropriately (ANA and NCSBN, 2019, p. 9). For exam-
ple, nursing assistants who are unprepared or
untrained to
complete a task should say as much when asked and
can
then decline to perform that particular duty. In such a
situ-
ation, the RN would determine whether to allocate
time
4 Guidelines for Prioritization, Delegation, and
Assignment Decisions
Introduction
PART 1
to train the AP and review the skill as it is learned, to
del-
egate the task to another competent person, to do it
herself
or himself, or to make arrangements for later skill
train-
ing. The RN’s job continues throughout the
performance
and results of task completion, evaluation of the care,
and
ongoing feedback to the delegatees.
Scope of Practice for RNs, LPNs/LVNs, and APs
Heretofore this text has discussed national
recommendations
for definitions. National trends suggest that nursing is
mov-
ing toward standardized licensure through mutual
recogni-
tion compacts and multistate licensure, and as of
April 2019,
31 states had adopted the nurse license compact
allowing
a nurse in a member state to possess one state’s
license and
practice in another member state, with several states
pend-
ing (NCSBN, 2019a). Standardized and multistate
licensure
supports electronic practice and promotes improved
practice
flexibility. Each RN must know his or her own state’s
regu-
lations, however. Definitions still differ from state to
state,
as do regulations about the tasks that nursing
assistants or
other APs are allowed to perform in various settings.
For example, APs are delegated tasks for which they
have been trained and that they are currently
competent
to perform for stable patients in uncomplicated
circum-
stances; these are routine, simple, repetitive,
common
activities not requiring nursing judgment, such as
activi-
ties of daily living, hygiene, feeding, and ambulation.
Some
states have generated statutes and/or rules that list
specific
tasks that can or cannot be delegated. Nevertheless,
trends
indicate that more tasks will be delegated as research
sup-
ports such delegation through evidence of positive
out-
comes. Acute care hospital nursing assistants have
not
historically been authorized to administer
medications.
In some states, specially certified medication
assistants
administer oral medications in the community (group
homes) and in some long-term care facilities,
although
there is substantial variability in state-designated
certi-
fied nursing assistant (CNA) duties (McMullen et al.,
2015). More states are employing specially trained
nurs-
ing assistants as CMAs (certified medication
assistants)
or MA-Cs (medication assistants-certified) to
administer
routine, nonparenteral medications in long-term care
or
community settings with training as recommended by
the
NCSBN’s Model Curriculum (NCSBN, 2016, p. 7). For
over a decade, Washington state has altered the
statute and
related administrative codes to allow trained nursing
assis-
tants in home or community-based settings, such as
board-
ing homes and adult family homes, to administer
insulin
if the patient is an appropriate candidate (in a stable
and
predictable condition) and if the nursing assistant has
been
appropriately trained and supervised for the first 4
weeks
of performing this task (Revised Code of Washington,
2012). Nationally, consistency of state regulation of
AP
medication administration in residential care and
adult
day-care settings has been stated to be inadequate to
ensure RN oversight of APs (Carder & O’Keeffe, 2016).
This research finding should serve as a caution for all
prac-
ticing in these settings. Other studies of nursing
homes
and assisted living facilities show evidence of role
confu-
sion among RNs, LPN/LVNs, and APs (Mueller et al.,
2018; Dyck & Novotny, 2018). In ambulatory care set-
tings, medical assistants (MAs) are being used
extensively,
supervised by RNs, LPNs (depending on the state),
physi-
cians, or other providers, and nurses are cautioned to
know
both the state nursing and medical regulations. In
some
cases (Maryland, for example), a physician could
delegate
peripheral IV initiation to an MA with on-site
supervision,
but in some states an LPN is prohibited from this
same
task (Maningo and Panthofer, 2018, p.2).
In all states, nursing judgment is used to delegate
tasks
that fall within, but never exceed, the nurse’s legal
scope
of practice, and an RN always makes decisions based
on
the individual patient situation. An RN may decide not
to delegate the task of feeding a patient if the patient
is
dysphagic and the nursing assistant is not familiar
with
feeding techniques. A “Lessons Learned from
Litigation”
article in the American Journal of Nursing in May 2014
describes the hazards of improper RN assignment,
del-
egation, and supervision of patient feeding, resulting
in a
patient’s death and licensure sanctions (Brous, 2014).
The scope of practice for LPNs or LVNs also differs
from state to state and is continually evolving. For
exam-
ple, in Texas, LPNs are prohibited from delegating
nurs-
ing tasks; only RNs are allowed to delegate (Texas
Board
of Nursing, 2019,
http://www.bon.texas.gov/faq_delegati
on.asp#t6), whereas in Washington state an LPN
could
delegate to nursing assistants in some settings (listed
as
hospitals, nursing homes, clinics, and ambulatory
surgery
centers) (Washington Nursing Care Quality Assurance
Commission 2019,
https://www.doh.wa.gov/Portals/1/
Documents/6000/NCAO13.pdf). Although practicing
nurses know that LPNs often review a patient’s
condition
and perform data-gathering tasks such as observation
and
auscultation, RNs remain accountable for the total
assess-
ment of a patient, including the synthesis and analysis
of
reported and reviewed information to lead care
planning
based on the nursing diagnosis. In their periodic
review of
actual practice by LPNs, the NCSBN found that
assign-
ing client care or related tasks to other LPNs or APs
was
ranked sixth in frequency, with monitoring activities of
APs ranked seventh (NCSBN, 2019, p. 156). IV therapy
and administration of blood products or total
parenteral
nutrition by LPNs/LVNs also vary widely. Even in states
where regulations allow LPNs/LVNs to administer
blood
products, a given health care organization’s policies
or job
descriptions may limit practice and place additional
safe-
guards because of the life-threatening risk involved in
the
administration of blood products and other
medications.
The RN must review the agency’s job descriptions as
well
as the state regulations because either is changeable.
LPN/LVN practice continues to evolve, and in any
state, tasks to support the assessment, planning,
interven-
tion, and evaluation phases of the nursing process
can be
Guidelines for Prioritization, Delegation, and
Assignment Decisions 5

Introduction
PART 1
allocated. When it is clear that a task could possibly
be
delegated to a skilled delegatee according to your
state’s
scope of practice rules and is not prohibited by the
organi-
zation policies, the principles of delegation and/or
assign-
ment remain the same. The totality of the nursing
process
remains the responsibility of the RN. Also, the total
nursing
care of the patient rests squarely on the RN’s
shoulders, no
matter which competent and skilled individual is
asked to
perform care activities. To obtain more information
about
the statute and rules in a given state and to access
decision
trees and other helpful aides to delegation and
supervi-
sion, visit the NCSBN website at
http://www.ncsbn.org.
The state practice act for each state is linked at that
site.
ASSIGNMENT PROCESS
In current hospital environments, the process of
assigning
or creating a work plan is dependent on who is
available,
present, and accounted for and what their roles and
compe-
tencies are for each shift. Assignment has been
understood
to be the “work plan” or “the distribution of work that
each staff member is responsible for during a given
work
period” (American Nurses Association (ANA), Duffy &
McCoy, 2014, p. 22). Classical care delivery models
once
known as total patient care have been transformed
into a
combination of team, functional, and primary care
nursing,
depending on the projected patient outcomes, the
present
patient state, and the available staff. Assignments
must be
created with knowledge of the following issues
(Hansten
and Jackson, 2009, pp. 207–208, Hansten, 2020 in
Kelly
Vana and Tazbir):
• How complex is the patient’s required care?
• What are the dynamics of the patient’s status and
their stability?
• How complex is the assessment and ongoing
evaluation?
• What kind of infection control is necessary?
• Are there any individual safety precautions?
• Is there special technology involved in the care, and
who is skilled in its use?
• How much supervision and oversight will be needed
based on the staff ’s numbers and expertise?
• How available are the supervising RNs?
• How will the physical location of patients affect the
time and availability of care?
• Can continuity of care be maintained?
• Are there any personal reasons to allocate duties for
a
particular patient, or are there nurse or patient pref-
erences that should be taken into account? Factors
such as staff difficulties with a particular diagnosis,
patient preferences for an employee’s care on a previ-
ous admission, or a staff member’s need for a particu-
lar learning experience will be taken into account.
• Is there an acuity rating system that will help distrib-
ute care based on a point or number system?
For more information on care delivery modali-
ties, refer to the texts by Hansten and Jackson (2009)
or access Hansten’s webinars related to assignment
and
care delivery models at http://learning.hansten.com/
and
Alfaro-LeFevre (2017) listed in the References section.
Whichever type of care delivery plan is chosen for
each
particular shift or within your practice arena, the rela-
tionship with the patient and the results that the
patient
wants to achieve must be foremost, followed by the
plac-
ing together of the right pieces in the form of compe-
tent team members, to compose the complete picture
(Hansten, 2019).
DELEGATION AND ASSIGNMENT: THE FIVE
RIGHTS
As you contemplate the questions in this workbook,
you
can use mnemonic devices to order your thinking pro-
cess, such as the “five rights.” The right task is
assigned to
the right person in the right circumstances. The RN
then
offers the right direction and communication and the
right
supervision and evaluation (Hansten and Jackson,
2009,
pp. 205–206; NCSBN, 1995, pp. 2–3; Hansten, 2014a,
p. 70; NCSBN, 2016b, p. 8; ANA & NCSBN, 2019, p. 4).
Right Task
Returning to the guideposts for navigating care, the
patient’s four Ps (purpose, picture, plan, and part), the
right
task is a task that, in the nurse’s best judgment, is one
that
can be safely delegated for this patient, given the
patient’s
current condition (picture) and future preferred
outcomes
(purpose, picture), if the nurse has a competent
willing
individual available to perform it. Although the RN may
believe that he or she personally would be the best
person
to accomplish this task, the nurse must prioritize the
best
use of his or her time given a myriad of factors, such
as:
What other tasks and processes must I do because I
am
the only RN on this team? Which tasks can be
delegated
based on state regulations and my thorough
knowledge of
job descriptions here in this facility? How skilled are
the
personnel working here today? Who else could be
avail-
able to help if necessary?
In its draft model language for nursing APs, the
NCSBN lists criteria for determining nursing activities
that can be delegated. The following are
recommended
for the nurse’s consideration. It should be kept in
mind
that the nursing process and nursing judgment cannot
be
delegated.
• Knowledge and skills of the delegatee
• Verification of clinical competence by the employer
• Stability of the patient’s condition
• Service setting variables such as available resources
(including the nurse’s accessibility) and methods of
communication, complexity and frequency of care,
and
proximity and numbers of patients relative to staff
6 Guidelines for Prioritization, Delegation, and
Assignment Decisions
Introduction
PART 1
APs are not to be allocated the duties of the nursing
process of assessment (except gathering data),
nursing
diagnosis, planning, implementation (except those
tasks
delegated/assigned), or evaluation. Professional
clinical
judgment or reasoning and decision making related to
the manner in which the RN makes sense of the
patient’s
data and clinical progress cannot be delegated or
assigned
(ANA & NCSBN, 2019, p. 3).
Right Circumstances
Recall the importance of the context in clinical
decision
making. Not only do rules and regulations adjust
based on
the area of practice (i.e., home health care, acute
care, schools,
ambulatory clinics, long-term care), but patient
conditions
and the preferred patient results must also be
considered. If
information is not available, a best judgment must be
made.
Often RNs must balance the need to know as much as
pos-
sible and the time available to obtain the information.
The
instability of patients immediately postoperatively or
in the
intensive care unit (ICU) means that a student nurse
will
have to be closely supervised and partnered with an
experi-
enced RN. The questions in this workbook give
direction as
to context and offer hints to the circumstances.
For example, in long-term care skilled nursing
facilities,
LPNs/LVNs often function as “team leaders” with
ongo-
ing care planning and oversight by a smaller number of
on-site RNs. Some EDs use paramedics, who may be
reg-
ulated by the state emergency system statutes, in
different
roles in hospitals. Medical clinics often employ
“medical
assistants” who function under the direction and
supervi-
sion of physicians, other providers, and RNs.
Community
group homes, assisted living facilities, and other
health
care providers beyond acute care hospitals seek to
create
safe and effective care delivery systems for the
growing
number of older adults. Whatever the setting or
circum-
stance, the nurse is accountable to know the specific
laws
and regulations that apply.
Right Person
Licensure, Certification, and Role Description
One of the most commonly voiced concerns during
work-
shops with staff nurses across the nation is, “How can
I
trust the delegatees?” Knowing the licensure, role,
and
preparation of each member of the team is the first
step in
determining competency. What tasks does a patient
care
technician (PCT) perform in this facility? What is the
role
of an LPN/LVN? Are different levels of LPN/LVN des-
ignated here (LPN I or II)? Nearly 100 different titles for
APs have been developed in care settings across the
coun-
try. To effectively assign or delegate, the RN must
know the
role descriptions of co-workers as well as his or her
own.
Strengths and Weaknesses
The personal strengths and weaknesses of everyday
team
members are no mystery. Their skills are discovered
through practice, positive and negative experiences,
and
an ever-present but unreliable rumor mill. An expert
RN helps create better team results by using strengths
in
assigning personnel to make the most of their gifts.
The
most compassionate team members will be assigned
work
with the hospice patient and his or her family. The
super-
vising nurse helps identify performance flaws and
develops
staff by providing judicious use of learning
assignments.
For example, a novice nursing assistant can be
partnered
with an experienced oncology RN during the
assistant’s
first experiences with a terminally ill patient.
When working with students, float nurses, or other
tem-
porary personnel, nurses sometimes forget that the
assign-
ing RN has the duty to determine competency. Asking
personnel about their previous experiences and about
their
understanding of the work duties, as well as pairing
them
with a strong unit staff member, is as essential as
provid-
ing the ongoing support and supervision needed
through-
out the shift. If your mother was an ICU patient and
her
nurse was an inexperienced float from the
rehabilitation
unit, what level of leadership and direction would that
nurse need from an experienced ICU RN? Many
hospitals
delegate only tasks and not overall patient
responsibility,
a functional form of assignment, to temporary
personnel
who are unfamiliar with the clinical area.
Right Direction and Communication
Now that the right staff member is being delegated the
right task for each particular situation and setting,
team
members must find out what they need to do and how
the tasks must be done. Relaying instructions about
the
plan for the shift or even for a specific task is not as
simple
as it seems. Some RNs believe that a written
assignment
board provides enough information to proceed
because
“everyone knows his or her job,” but others spend
copious
amounts of time giving overly detailed directions to
bored
staff. The “four Cs” of initial direction will help clarify
the
salient points of this process (Hansten and Jackson,
2009,
pp. 287–288; Hansten, 2021 in Zerwekh and Garneau,
p. 316). Instructions and ongoing direction must be
clear, concise, correct, and complete.
Clear communication is information that is
understood
by the listener. An ambiguous question such as: “Can
you
get the new patient?” is not helpful when there are
several
new patients and returning surgical patients, and
“getting”
could mean transporting, admitting, or taking full
respon-
sibility for the care of the patient. Asking the delegatee
to
restate the instructions and work plan can be helpful
to
determine whether the communication is clear.
Concise statements are those that give enough but
not
too much additional information. The student nurse
who
merely wants to know how to turn on the chemical
strip
analyzer machine does not need a full treatise on the
tran-
sit of potassium and glucose through the cell
membrane.
Too much or irrelevant information confuses the
listener
and wastes precious time.
Guidelines for Prioritization, Delegation, and
Assignment Decisions 7
Introduction
PART 1
Correct communication is that which is accurate and
is aligned to rules, regulations, or job descriptions. Are
the
room number, patient name, and other identifiers
correct?
Are there two patients with similar last names? Can
this
task be delegated to this individual? Correct
communi-
cation is not cloudy or confusing (Hansten and
Jackson,
2009, pp. 287–288; Hansten, 2021 in Zerwekh and
Garneau, p. 318).
Complete communication leaves no room for doubt
on
the part of supervisor or delegatees. Staff members
often
say, “I would do whatever the RNs want if they would
just tell me what they want me to do and how to do it.”
Incomplete communication wins the top prize for
creat-
ing team strife and substandard work. Assuming that
staff
“know” what to do and how to do it, along with what
information to report and when, creates havoc,
rework, and
frustration for patients and staff alike. Each staff
member
should have in mind a clear map or plan for the day,
what
to do and why, and what and when to report to the
team
leader. Parameters for reporting and the results that
should
be expected are often left in the team leader’s brain
rather
than being discussed and spelled out in sufficient
detail.
RNs are accountable for clear, concise, correct, and
com-
plete initial and ongoing direction.
Right Supervision and Evaluation
After prioritization, assignment, and delegation have
been considered, determined, and communicated,
the
RN remains accountable for the total care of the
patients
throughout the tour of duty. Recall that the definition
of
supervision includes not only initial direction but also
that
“supervision is the active process of directing, guiding,
and
influencing the outcome of an individual’s
performance of
a task. Similarly, NCSBN defines supervision as “the
provi-
sion of guidance or direction, oversight, evaluation
and fol-
low-up by the licensed nurse for the accomplishment
of a
delegated nursing task by assistive personnel” (ANA,
2014,
in Duffy and McCoy, p. 23). RNs may not actually per-
form each task of care, but they must oversee the
ongoing
progress and results obtained, reviewing staff
performance.
Evaluation of the care provided, and adequate
documenta-
tion of the tasks and outcomes, must be included in
this
last of the five rights. On a typical unit in an acute care
facility, assisted living, or long-term care setting, the
RN
can ensure optimal performance as the RN begins the
shift
by holding a short “second report” meeting with APs,
out-
lining the day’s plan and the plan for each patient, and
giving initial direction at that time. Subsequent short
team
update or “checkpoint” meetings should be held
before
and after breaks and meals and before the end of the
shift
(Hansten, 2005, 2008a, 2008b, 2019). During each
short
update, feedback is often offered, and plans are
altered.
The last checkpoint presents all team members with
an
opportunity to give feedback to one another using the
step-by-step feedback process (Hansten, 2008a, pp.
79–84;
Hansten, 2021, in Zerweck and Garneau, pp. 301–
302).
This step is often called the “debriefing” checkpoint or
huddle, in which the team’s processes are also
examined. In
ambulatory care settings, this checkpoint may be
toward
the end of each patient’s visit or the end of the shift; in
home health care, these conversations are often
conducted
on a weekly basis. Questions such as, “What would
you
recommend I do differently if we worked together
tomor-
row on the same group of patients?” and “What can
we do
better as a team to help us navigate the patients
toward
their preferred results?” will help the team function
more
effectively in the future.
1. The team member’s input should be solicited
first. “I noted that the vital signs for the first four
patients aren’t yet on the electronic record. Do you
know what’s been done?” rather than “WHY haven’t
those vital signs been recorded yet?” At the end of
the shift, the questions might be global, as in “How
did we do today?” “What would you do differently if
we had it to do over?” “What should I do differently
tomorrow?”
2. Credit should be given for all that has been accom-
plished. “Oh, so you have the vital signs done, but
they aren’t recorded? Great, I’m so glad they are done
so I can find out about Ms. Johnson’s temperature
before I call Dr. Smith.” “You did a fantastic job with
cleaning Mr. Hu after his incontinence episodes;
his family is very appreciative of our respect for his
dignity.”
3. Observations or concerns should be offered. “The
vital signs are routinely recorded on the electron-
ic medical record (EMR) before patients are sent
for surgery and procedures and before the doctor’s
round so that we can see the big picture of patients’
progress before they leave the unit and to make sure
they are stable for their procedures.” Or, “I think I
should have assigned another RN to Ms. A. I had
no idea that your mother recently died of breast
cancer.”
4. The delegatee should be asked for ideas on how to
resolve the issue. “What are your thoughts on how
you could order your work to get the vital signs on
the EMR before 8:30 AM?” Or, “What would you
like to do with your work plan for tomorrow? Should
we change Ms. A.’s team?”
5. A course of action and plan for the future should
be agreed upon. “That sounds great. Practice use
of the handheld computers today before you leave,
and that should resolve the issue. When we work to-
gether tomorrow, let me know whether that resolves
the time issue for recording; if not, we will go to an-
other plan.” Or, “If you still feel that you want to stay
with this assignment tomorrow after you’ve slept on
it, we will keep it as is. If not, please let me know
first thing tomorrow morning when you awaken so
we can change all the assignments before the staff
arrive.”
8 Guidelines for Prioritization, Delegation, and
Assignment Decisions
Introduction
PART 1
PRACTICE BASED ON RESEARCH EVIDENCE
Rationale for Maximizing Nursing Leadership Skills at
the Point of Care
If the skills presented in this book are used to save
lives
by providing care prioritized to attend to the most
unsta-
ble patients first, optimally delegated to be delivered
by the right personnel, and assigned using appropriate
language with the most motivational and
conscientious
supervisory follow-up, then clinical outcomes should
be
optimal and work satisfaction should flourish. Solid
cor-
relational research evidence has been lacking related
to
“the best use of personnel to multiply the RN’s ability
to
remain vigilant over patient progress and avoid
failures
to rescue, but common sense would advise that
better
delegation and supervision skills would prevent errors
and omissions as well as unobserved patient decline”
(Hansten, 2008b, 2019).
In an era of value-based purchasing and health care
reimbursement based on clinical results with linkages
for care along the continuum from site to site, an RN’s
accountability has irrevocably moved beyond task
orienta-
tion to leadership practices that ensure better
outcomes
for patients, families, and populations. The necessity
of
efficiency and effectiveness in health care means that
RNs
must delegate and supervise appropriately so that all
tasks
that can be safely assigned to APs are completed
flawlessly.
Patient safety experts have linked interpersonal
commu-
nication errors and teamwork communication gaps as
major sources of medical errors and The Joint
Commission
associated these as root causes of 70% or more of
serious
reportable events (Grant, 2016, p. 11). Severe events
that
harm patients (sentinel events) can occur through
inad-
equate hand-offs between caregivers and along the
health
care continuum as patients are transferred (The Joint
Commission, 2017).
Nurses are accountable for processes as well as out-
comes measures so that insurers will reimburse
health care
organizations. If hospital-acquired conditions occur,
such
as pressure injuries falls with injury, and some
infections,
reimbursement for the care of that condition will be
nega-
tively impacted.

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