The post last week included a case example about a licensed practical nurse (LPN) responding to a medical emergency after an altercation between two inmates. The LPN determined that neither inmate required further medical attention. Later in the shift one of the inmates was taken to the emergency room after being found unresponsive in the cell. The inmate subsequently died of the head injury that was sustained in the altercation. This example highlighted the registered nurse’s role in the assignment and supervision of patient care. Correctional nurses use their knowledge of state regulations defining the scope of practice for personnel assisting in the delivery of patient care as well as the employers’ expectations (job description, post orders, policy and procedure) to assign and supervise these personnel.
The American Nurses Association (ANA) describes correctional nurses as responsible for direction of patient care including the assignment and delegation of tasks to others (2007). These responsibilities are unchanged in the draft of the 2013 edition of the Correctional Nursing: Scope and Standards of Practice which was posted at http://www.nursingworld.org/Comment-Correctional-Nursing.html.aspx. Delegation has been described as an essential skill and yet is one of the most difficult responsibilities of a registered nurse. It is a complex process that requires sophisticated clinical judgment about the patient care situation, the competence of staff and the degree of supervision required (Weydt, 2010; NCSBN, 2005).
There are many resources available to help nurses build skill and competency in delegation of patient care tasks. The state board of nursing is an excellent first resource as well as the National Council of State Boards of Nursing (NCSBN) website which can be accessed at https://www.ncsbn.org. A resource suggested in the Essentials of Correctional Nursing is a framework for delegation from the NCSBN referred to as the Five Rights of Delegation (1997). These are discussed in relation to the case example from last week’s post.
1. Right Task: The nurse makes an assessment of the patient or a group of patients and determines that an activity can be delegated to a specific member of the health care team. Knowledge of state practice acts and agency directives are essential when making decisions about what patient care tasks can be delegated. In the case example the registered nurse’s decision to have the LPN respond to the medical emergency was problematic because the LPN was required to assess and make a complex clinical decision about the inmate’s need for medical care.
2. Right Circumstances: The nurse’s assessment of the patient or group of patients also identifies the health care need(s) to be addressed by the delegated task(s) and the goal or outcome to be achieved. The nurse’s decision about which task(s) to delegate matches the staff’s competency and level of supervision available. The registered nurse in the case example did not assess the patient’s needs or identify the outcome to be achieved by the task that was delegated to the LPN. The nurse also made no judgment about what level of supervision or monitoring would be appropriate in the circumstance.
3. Right Person: The registered nurse considers the skills and abilities of individual personnel in making decisions about delegation of tasks. The registered nurse works with each member of the team to improve performance and implements remedies when performance is below standard. In the case example the LPN had considerable experience responding to medical emergencies at the correctional facility and had worked in the emergency department at the local hospital. The registered nurse did not understand that monitoring or supervision of the LPN’s performance was required as part of the state practice act and expected by the employer.
4. Right Communication: The registered nurse communicates specifically what, how and by when delegated tasks are to be accomplished. Communication includes the purpose and goal of the task, limitations and expectations for reporting. In the case example there was no meaningful communication that took place between the RN and LPN. The LPN was not expected to communicate assessment data to the nurse and no limitations on the LPN’s actions were stipulated. The LPN reported the conclusion that both inmates were “okay” but was asked no follow up questions by the RN to amplify the basis for the decision. The LPN did not communicate with the registered nurse when the inmate was later found unresponsive even after the “on call” physician was called.
5. Right Supervision: The registered nurse monitors and evaluates both the patient and the staff’s performance of delegated tasks. The registered nurse is prepared to intervene on behalf of the patient as necessary and provides staff feedback to increase competency in task performance. In the case example the RN had several opportunities to monitor the patient’s care and to intervene but failed to do so. The nurse was unaware of the responsibility to monitor and supervise the LPN in the performance of the delegated task. The nurse said that the LPN always provided the response to medical emergencies and did not think the RN could alter this “assignment”.
Conclusion of the Case Example: The agency policies, procedures and the description of job duties were consistent with state practice guidelines but were too general. The nurses were not familiar with the nurse practice act and had simply continued practices on the evening shift that had been in place at the time, including staff defining the duties that they were most comfortable performing. The “after action” review resulted in increased staff knowledge of the nurse practice act, coaching of the nurses on delegation of tasks, and increased communication between staff on shift about the goals and process of patient care.
Your thoughts about this subject are important to us. Have you had experience clarifying nursing scope of practice in correctional health care? What tools or resources did you find most helpful? Please share your experience and advice in the comments section of this post. For more information and discussion about correctional nursing order your copy of the Essentials of Correctional Nursing directly from the publisher. Use Promo Code AF1209 for $15 off and free shipping.
American Nurses Association. (2007). Corrections Nursing: Scope and Standards of Practice. Silver Spring, MD: Author
National Council of State Boards of Nursing and the American Nurses Association. (2006). Joint Statement on Delegation. Retrieved December 31, 2013 at https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf
National Council of State Boards of Nursing. (1997) The Five Rights of Delegation. Retrieved December 26, 2012 from https://www.ncsbn.org/fiverights.pdf
Weydt, A. (May 31, 2010). Developing delegation skills. OJIN: The Online Journal of Issues in Nursing. Vol. 15, No. 2, Manuscript 1
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Within the realm of nursing there are Five Rights of Delegation which allow licensed nurses to delegate tasks to other nurses or to unlicensed assistive personnel as long as this criteria is met and the patient’s safety and well-being is not jeopardized.
The Five Rights of Delegation are:
- Right Task
- Right Circumstances
- Right Person
- Right Directions/Communication
- Right Supervision/Evaluation
The Nurse Practice Act (NPA) allows for licensed nurses, namely RNs, to delegate tasks to LPNs, CNAs, and UAPs as long as certain criteria is met. First of all the nurse delegating the task must realize that s/he remains responsible for the task and the outcomes.
The Right Task
The RN must determine that the task is one that can be safely delegated in the first place. This includes such factors such as possessing the skills and knowledge of how to perform the task and how to evaluate the success or failure of the task. The tasks must have a predictable outcome, a minimal potential risk, and a standard, unchanging procedure.
The task must fall within the scope of practice and job description of the person to whom it is being delegated and they must have demonstrated competency in performing said task. The organizational policies and procedures of the facility must not prohibit the delegated person from performing said task.
Typically tasks which can be delegated frequently recur in the day-to-day care of patients on the unit. The tasks are not complex, and do not require critical thinking or application of the nursing process.
The Right Circumstances
The patient must be stable and the outcome predictable. The decision to delegate must be based on the nursing process and a careful analysis of the patient’s needs and circumstances prior to delegating. The person to whom the task is delegated must perform the task within their own scope of practice and job description. They are assisting the licensed nurse with the task, not replacing the nurse. If at anytime the patient’s condition changes, the nurse must reassess the situation and may rescind the delegation.
The Right Person
The licensed nurse delegating the task must ensure that the delegatee possesses and has demonstrated the knowledge base and appropriate skills and resources to perform the task and provide adequate supervision and evaluation to ensure the patient’s safety and appropriate outcome.
The Right Directions/Communication
The licensed nurse is responsible to ensure that the delegatee has the previously documented appropriate skills and knowledge base. The nurse is also expected to communicate to the delegatee specific instructions for this task. Each instance of delegation is to be specific to the patient, the nurse and the delegatee.
The nurse needs to clearly communicate the specifics and expectations of the task such as any data to be collected, the method for collecting it and the time frame for reporting results to the nurse. Any possible complications need to be communicated along with time frames for reporting them to the nurse. Further all outcomes must be reported to the nurse and the time frame needs to be pre-defined. The delegatee must agree to accept the delegated responsibility and understands the terms of the assignment.
It must be clear to the delegatee that s/he is not to make decisions or modifications to the care without first consulting with the nurse. This would be overstepping their scope of practice.
The Right Supervision/Evaluation
The nurse remains responsible for the tasks and the outcomes. The nurse is responsible to follow up and receive report on the task and outcomes if the delegatee has not done so. The nurse is responsible to ensure compliance with standards of care, and the policies and procedures of the organization. S/he is to intervene if necessary. After careful evaluation of the outcomes, the nurse also needs to ensure appropriate documentation is provided.
After the fact, the nurse needs to evaluate the patient, the outcomes, and make any necessary modifications to the plan of care. The nurse should also provide feedback to the delegatee and thank them for the assistance.
In some states, LPNs can delegate to CNAs and UAPs. However, unlicensed personnel such as CNAs and UAPs may not delegate. Anyone to whom a task has been delegated may not reassign the task to anyone else.
National Council of State Boards of Nursing
©2009 by UltimateNurse.com All Rights Reserved. By Kathy Quan RN BSN. Kathy is the author of four books including The Everything New Nurse Book. She is also the owner/author of TheNursingSite.com.
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