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Delegation Knowledge and Practice Among Rehabilitation Nurses
Delegation is an essential process that allows nurses to function more effectively and efficicently. The Association of Rehabilitation Nurses' (ARN) Southeast Texas Chapter research committee developed a survey to study registered nurses (RN) practices and knowledge of delegation to unlicensed assistive personnel. State boards of nursing determine delegation practices, so the survey was sent only to Texas ARN members. Benners’ Novice to Expert theory was used to study delegation practices based on years of experience, certification, and education. Survey Monkey was used with a questionnaire developed by the research committee. Descriptive statistics analyzed data from the survey’s 73 respondents, and chi-square measured significance of differences based on years of experience and certification (yes or no). Data show that delegation knowledge does not necessarily translate to practice, especially when looking at specific tasks performed by certified rehabilitation registered nurses (CRRNs) and non-CRRNs. The data support continued study of this important issue; 93.7% of respondents say delegation requires further discussion.
Leadership in practice is an important nursing issue. Delegation is one leadership tool nurses use in professional practice. Knowledge regarding tasks that can be delegated—and to whom—is critical in rehabilitation nursing practice. Florence Nightingale said, “But in both hospitals and private houses, let whoever is in charge keep this simple question in her head: not how can I always do this right thing myself, but how can I provide for this right thing to be always done?” (National Council of State Boards of Nursing [NCSBN], 2005, p. 3).
The nursing profession faces critical shortages compounded by an aging nurse population and an increased need for nursing services due to changing demographics. The NCSBN states that “the profession of nursing must determine how to continue providing safe, effective nursing care with decreased numbers of nurses caring for an increased number of clients” (2005, p. 3). The American Nurses Association (ANA) recognizes that unlicensed assistive personnel (UAP) are necessary to help nurses in their practice (ANA, 1992, 2007). “More than ever, nurses need to work effectively with assistive personnel. The abilities to delegate, assign, and supervise are critical competencies for the 21st century nurse” (ANA & NCSBN, 2006, p. 1).
Numerous researchers have addressed the fine art of delegation. According to one report, “delegation is essentially a management tool for working through people to complete tasks” (ANA & Coalition of Nursing Futures, 1997, p. 5). A more recent article states, “delegation is the act of assigning a task or a series of tasks to another while retaining responsibility for the outcome” (Haynes, Boese, & Butcher, 2004, p. 442). According to the NCSBN, “All decisions related to the delegation of nursing tasks must be based on the fundamental principles of protection of the health, safety, and welfare of the public that is the underlying principle of nursing regulation” (2005, p.5). The Council also states that “decisions to delegate nursing tasks/functions/activities are based on the needs of clients, the stability of client conditions, the competency of the task, the predictability of the outcome, and the available resources to meet the needs and the judgment of the nurse” (2005, p. 5).
Each state regulates delegation for professional nursing in its Nurse Practice Act (NPA; Habgood, 2000; McInnis & Parsons, 2009; Reising & Allen, 2007). For example, in 2001 the 77th Texas Legislative Session passed House Bill 456 to review and make recommendations regarding delegation for nursing care to people with functional disabilities in independent living environments and acute care settings. According to the NCSBN, 48 state boards refer to delegation in their NPA (2005). As a process, delegation, when used appropriately, can result in effective time management and safe, efficient nursing care (Bittner & Gravlin, 2009; Kleinman & Saccomano, 2006; Sheets, 2005). Nurses must know the context of their state NPA, standards of practice, and organizational policies to delegate appropriately. In the context of the nursing shortage, delegation is of paramount importance.
Rehabilitation nurses need to understand and practice delegation in a consistent manner (ANA, 2007; ANA & NCSBN, 2006). The Association of Rehabilitation Nurses (ARN) supports rehabilitation nurses’ use of UAP to achieve patient care goals. According to ARN, “All care provided by the UAP should be delegated by a registered nurse and based on the patient’s written plan of care and the UAP’s demonstration of a level of competency” (1994, p. 1).
According to Kelly (2008), delegation is more than a learned skill. Nursing professionals need to discuss the concerns, knowledge, and responsibilities associated with delegation. To clearly understand delegation issues for rehabilitation nurses, a Texas ARN chapter initiated a study to determine the practice and knowledge of delegation by ARN members in the state. The following research questions were posed:
Methods of Study
ARN’s Texas chapter research committee developed a questionnaire for this descriptive study using Benner’s Theory of Novice to Expert (Benner, 1984). Benner’s theory supports expertise in nursing that correlates with experience; nurses begin as novices and progress to experts through experience in the workforce. One of the present study’s questions sought to determine whether experience increased nurses’ knowledge of delegation policies and practice. According to previous research, “identification of clinical grasp and clinical forethought enriched the understanding of clinical judgment” (Tomey & Alligood, 2002, p. 170).
Content validity was established through expert review. The questionnaire was administered to several ARN members with varying levels of expertise (educator, administrator, staff nurse). This test resulted in revisions to the final questionnaire. A letter was sent to the national ARN Board requesting e-mail addresses for all of the ARN members in Texas. Prospective participants received a letter that included details about the project and an assurance that they were free to choose whether or not to participate and that any responses would be anonymous and reported as aggregate data. The national ARN Board granted us permission to use the list for the project. Survey Monkey was used to send out the questionnaire and collect data. There were no direct risks or benefits to survey participants. Using Survey Monkey, 243 people were sent an e-mail message with a cover letter explaining the study and the questionnaire. Twelve messages were returned, with six recipients asking to be removed from the list. There were 73 respondents; with a response rate of 32.4%.
The Statistical Package for Social Sciences was used for data analysis. The data were compiled using percentages and a tally of responses. The results were reviewed by the research team. Chi-square was used to determine significant differences between groups.
Throughout the literature review, the committee referred to the Texas NPA. Rules 224.4 and 225.4 in the Texas NPA define delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task (Texas Board of Nursing, 2003). The Texas NPA definition does not include situations in which an unlicensed person is directly assisting an RN by carrying out nursing tasks in the presence of an RN.
According to the Texas Board of Nursing, how one delegates differs from Rules 224.1 and 225.1. Rule 224.1 applies to situations in which a client has an acute health condition that is unstable or unpredictable in an acute care environment in which nursing services are continuously provided including, but not limited to, hospitals, rehabilitation centers, skilled nursing facilities, clinics, and private physician offices (Board of Nurse Examiners for the State of Texas, 2007). According to this rule, the tasks that can be delegated to UAP are noninvasive and nonsterile treatments; the collecting, reporting, and documentation of data (i.e., vital signs, intake and output, height, weight, patient or family comments and behaviors); assistance with ambulation, positioning, and turning; providing personal hygiene; feeding; and other activities of daily living. Tasks that usually are not within the scope of sound, professional judgment for nurses to delegate according to this rule include sterile procedures, nonsterile wound procedures, invasive procedures such as inserting tubes into a body cavity and/or instilling substances into an indwelling tube, and care of broken skin other than minor abrasions or cuts (Board of Nurse Examiners for State of Texas).
Rule 225.1 applies to situations in which a client resides in an independent-living environment and the task is to achieve a stable, predictable condition as defined by Rule 225.4 (Board of Nurse Examiners for State of Texas, 2007). This rule states that a reasonable and prudent nurse should delegate the following tasks: assistance with activities of daily living; health maintenance activities; noninvasive and nonsterile treatments posing low risk for infection; collection and documentation of data; reinforcement of health teaching provided by registered nurses; insertion of tubes into a body cavity or instilling or inserting substances into an indwelling tube; tracheal care and suctioning of a tracheostomy with routine supplemental oxygen administration; care of broken skin at low risk for infection; sterile procedures involving a wound or a site that potentially could become infected; and administration of medications including oxygen and insulin subcutaneously, nasally, or via insulin pump. Tasks that are not permitted to be delegated under this rule include nursing tasks that are not within the scope of sound professional nursing judgment to delegate (i.e., assessment, formulation of a nursing care plan, client health teaching, and administration of IV medications; Board of Nurse Examiners for State of Texas).
The literature shows that nurses lack knowledge about tasks that can be delegated according to their individual board of nurse examiners (Bittner & Gravlin, 2009; Brooks, 2009; Kleinman & Saccomano, 2006; McInnis & Parsons, 2009; Williams & Cooksey, 2004). Approved in 1997 by the Delegate Assembly, the NCSBN identified The Five Rights of Delegation, which delineate accountability at all levels of nursing. These rights are right task, right circumstances, right person, right directions and communication, and right supervision and evaluation (ANA 2005; ANA & NCSBN, 2006; NCSBN, 1997, 2005).
A literature search identified numerous descriptive articles on delegation to UAP, but only a few articles related to delegation practices. One study reviewed a national survey of licensed nurses that described factors associated with patient outcomes when nursing activities were delegated to UAP. This article had implications for education that focused on strengthening the delegation skills of licensed nurses (Anthony, Standing, & Hertz, 2000). Standing and Anthony (2008) reported on a qualitative study to describe nurses’ experiences of delegation. Seventeen interviews were conducted with both experienced and novice nurses. This study, which examined the meaning of delegation from the perspectives of acute care nurses, revealed that nurses define delegation in a variety of ways. To some nurses, delegation to UAP meant explicit delegation (delegation of a specific task), and to others delegation was both explicit and implicit (implicit meaning delegation of vital signs, etc.). This demonstrated that many nurses are unclear about what delegation entails and their role in the delegation process. This study also suggested that nurses experienced difficulty asking or telling a UAP to perform or complete a task. The authors stated, “interventions are needed to improve the relationship and communication between the nurse and the UAP to ensure quality of care” (Standing & Anthony, p. 13). In a study by Potter and Grant (2004), their institution conducted a qualitative study that involved focused sessions with separate groups of RNs and UAP. Thirteen RNs and nine UAP representatives participated. They were asked to tell their stories of “good” and “bad” working relationships and describe the working conditions on their units. As a result of the study, a task force was convened to consider the recommendations. The task force developed a one-to-one RN and UAP assignment method, with RNs mentoring UAP. They cultivated successful working relationships, an improvement in care delivery, and improved patient outcomes.
Delegation Survey Data Results
Demographic data are presented in Figure 1. Among respondents, 47% were ages 50–59, 95% were women, and 74% were White. The education level of the respondents is presented in Figure 2. Of respondents, 73% reported having a baccalaureate or higher, and 56.2% were CRRNs (Table 1).
Years of experience (Figure 3) confirm the aging of the nursing workforce. Among respondents, 82.2% had 16 or more years of experience, and 15.1% had more than 36 years of experience.
An assessment of practice roles indicated that 75% of responding nurses work as managers, administrators, consultants, and educators (Figure 4).
If nurses are to delegate appropriately to UAP, they must know the policies for delegation in their employment area. There also must be consistency between the state’s NPA and each facility’s policies (Steefel, 2007). Respondents were asked if their facility had a delegation policy; 52.1% said yes, 20.5% said no, and 27.4% were unsure. Table 2 details actual delegation practices of the respondents. Suctioning, continuous tube feeding, and intermittent tube feeding were least likely to be delegated. Respondents also were asked if these same tasks could be delegated according to the rule of the Board of Nurse Examiners (Table 3; Table 4 lists trure-false statements). These statements were intended to determine differences between actual practice and knowledge about what the Board of Nursing rule states about delegation policy. It is worth noting the decreased number of respondents for these true-false questions. Data indicated that Functional Independence Measure (FIM) scoring and skin assessment were skills that were delegated with the least frequency.
True/false questions were asked to determine nurses’ knowledge of the practice of delegation. All 64 respondents agreed that the RN who delegates a task is responsible for the nursing care given to a patient. Ninety-seven percent agreed that if delegation continues over time, the RN is responsible for periodically evaluating delegated tasks.
Respondents were asked to identify which of the following tasks could be delegated within the scope of professional nursing judgment (1) formulation of the nursing care plan, (2) responsibility and accountability for client health teaching and counseling, and (3) physical assessment that requires professional nursing follow-up. All respondents said formulation of the nursing care plan could not be delegated. One respondent stated that tasks 2 and 3 could be delegated. However, 62 of the 63 respondents said none of these activities could be delegated.
Because Benner’s Novice to Expert theory was used as a basis for this study, the researcher examined the delegation tasks and compared CRRNs to non-CRRNs to determine if differences could be explained by years of experience. Tables 5 and 6 show these results.
A chi-square analysis was completed on the practice and knowledge of delegation tasks by those with 0–15 years of experience to those with 16+ years of experience (Tables 7 and 8). Chi-square found no significant differences.
Respondents also were asked if delegation was an important professional issue for nurses to study or discuss, and 93.7% said yes. Those who believed that delegation was not an important issue had roles as case manager, nurse liaison, and nurse consultant—roles for which delegation is less of an issue.
Many issues remain unclear regarding the practice of delegation. One study limitation was that it would have been helpful to define and differentiate between the UAP to whom tasks could or could not be delegated. The survey did not distinguish between rehabilitation aides, certified nursing assistants, personal care assistants, or nurses’ aides. These roles were not defined and may have resulted in confusion for participants when answering the questionnaire. Another limitation was a failure to identify the type of setting in which the respondent was employed, such as acute care, long-term care, or home healthcare. Because there are differences in delegatable tasks for different care settings in Texas (independent living environments vs. inpatient), this could make a difference in responses and delegation practices. The answers may reflect nurses’ different practice settings and the tasks their institution/setting allowed for UAP. The questionnaire also may have been too long, which was evidenced by the decline in the number of respondents as they progressed through Survey Monkey.
The data support the conclusion that Texas rehabilitation nurses lack familiarity with the delegation rules within the Texas NPA. Study findings reflect a gap between practice and knowledge of delegation rules.
After reviewing the results, the committee discussed the findings as they related to the research questions.
Table 2 indicates actual delegation practice of the 73 respondents. The question identified a task and asked whether the task was delegated and, if so, to whom it would be delegated. Data review reveals that few tasks on the provided list are not delegated by rehabilitation nurses; suctioning, continuous tube feeding, and intermittent tube feeding are least likely to be delegated.
Specialty-certified rehabilitation nurses were more knowledgeable about delegation related to FIM scoring and intermittent tube feedings than noncertified rehabilitation nurses.
An initial review of the literature revealed few studies on delegation. Studies on delegation among all nurses (not just rehabilitation nurses) should be conducted to determine knowledge and inconsistencies of delegation practice in all healthcare settings.
“The topic of delegation has never been timelier. Delegation is a process that, used appropriately, can result in safe and effective nursing care. Delegation can free the nurse for attending more complex patient care needs, develop the skills of nursing assistive personnel, and promote cost containment for the healthcare organization” (ANA & NCSBN, 2006, p. 4). This study indicates an urgent need to educate rehabilitation nurses about delegation standards and discuss delegation practice among nurses. This increased knowledge can lead to better patient outcomes and more efficient use of staff while promoting better teamwork between nurses and UAP. These findings can serve to launch discussions of delegation practices for rehabilitation nurses.
About the Authors
Mary Joe White, PhD RN, is an associate professor of nursing at the University of Texas Health Science Center at the Houston School of Nursing at Houston, TX. Address correspondence to her at Mary.J.White@uth.tmc.edu.
Ann Gutierrez, MSN RN CBIS CRRN, is an education resource specialist at TIRR Memorial Hermann in Houston, TX.
Kerry Davis, BSN RN CBIS CRRN, is a clinical nurse manager in the Brain Injury and Stroke Unit at TIRR Memorial Hermann in Houston, TX.
Rhonda Olson, MS RN CRRN, is a rehabilitation nurse consultant for RS Consulting in Houston, TX.
Celeste McLaughlin, MS CNS RN CRRN, is director of nursing at the Quentin Mease Community Hospital, Harris County Hospital District in Houston, TX.
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