Nursing Manual

Delegation, assignment and teaching for emergencies

Delegation

1. What is delegation? (OAR 851-47-0000 through -0040)
   Delegation means that a registered nurse authorizes an unlicensed person to perform special tasks of client/nursing care in selected situations and indicates that authorization in writing. "Special Tasks" are those tasks which require the education and training of a nurse to perform. Only RN’s are allowed to delegate special tasks.
   
2. Special considerations
   • Settings: Delegation applies only to settings where the site is not required by rule to have a regularly scheduled nurse. Delegation applies to community setting such as adult and child foster care, residential care facilities and schools. Delegation does not apply to nursing care facilities or acute care facilities where nurses are regularly scheduled, nor does it apply to care given by immediate family members.
   • Tasks: A special task can be delegated only after the RN has determined that the individual is stable and the unlicensed staff is competent and willing to perform the task. The RN must use his/her judgment to determine if the task can be performed accurately and safely.
   • Nurses judgement:It is inappropriate for employers or others to require nurses to delegate when, in the nurse’s professional judgment, delegation is unsafe and not in the individual’s best interest.
   • Nursing process: The decision to delegate should be consistent with the nursing process (appropriate assessment, planning, implementation, and evaluation). The RN who assesses the individual’s needs and plans nursing care should determine the tasks to be delegated and is accountable for that delegation.
   • Transferring delegation: Nursing delegation may be transferred from one nurse to another, provided that there is documentation that the new nurse understands and accepts the delegation.
   • Rescinding delegation: Nursing delegation may be rescinded if the nurse feels that the delegatee is no longer capable of performing the task safely or when the RN leaves the position and chooses not to transfer delegation. Rescinding documentation should be on record.
   • Sharing delegation: Two (or more) Registered Nurses may choose to complete the delegation process together, such as having a second nurse provide the ongoing supervision.
     If the delegation process is shared, all involved RNs have the responsibility to ensure that all steps were followed. Careful, detailed communication is vital to ensure that steps are not overlooked and that the documentation is complete. The RNs need to document the reason for separation of delegation and supervision from the standpoint of delivering effective client care, and not only for convenience.
   
   
3. Regulation:The Board of Nursing’s authority is over the RN who delegates. The Board of Nursing has no authority over the setting in which delegation occurs. If the setting is licensed, the authority over the setting belongs to the licensing agency.
   
4. Process of delegation: The steps in the delegation process are:
   • Assess:
     • Assess the situation and the person: Identify the needs of the person, consulting the care plan.Consider the circumstances and setting. Assure the availability of adequate resources, including supervision.
       
     • Assess the person and determine that he/she is in a stable and predictable condition and requires minimal supervision. (Hospice clients are considered stable, as the course of the illness is predictable.)
       
     • Plan for the specific task to be delegated:
       • Specify the nature of each task and knowledge and skills required to perform it.
       • Consider the nature of the task to be delegated, including the complexity of the task, the risks involved in the performance of the task and the skill required to perform the task.
     • Assure appropriate accountability:
       • As delegator, accept accountability for appropriately delegating the task.
       
       
     • Verify that the delegatee accepts the delegation and the accountability for carrying out the task correctly.
     • Assess the ability of the unlicensed staff to understand the task and their ability to safely perform the task. The task should not be delegated if, in the RN’s judgment, the unlicensed staff is unable to understand or perform the task in a safe and accurate manner.
   • Teach:
     • Teach the unlicensed staff and observe them in their performance of the task. Instruct them as to when (and under what conditions) a health care professional should be notified. The unlicensed staff is taught what signs and symptoms to watch for and when to contact the RN or primary care provider. It is not expected that the unlicensed staff always understands the meaning of the signs but just that they know they are to be reported in order that the health care professional can determine if there is a problem.
       
     • Leave written instructions regarding the task. The instructions are to be specific to the person. Instructions should be clear and concise. The entire nursing process can not be delegated.
       
     
     
   • Supervise:
     • Supervise performance of the task.
     • Provide written directions and clear expectation of how the task is to be performed.
     • Monitor performance of the task to assure compliance to established standards of practice, policies and procedures.
     
     
   • Reassess:Evaluate the entire delegation process.
     • Evaluate the person.
     • Evaluate the performance of the task.
     • Obtain and provide feedback.
     • Reassess and adjust the overall plan of care as needed. Determine and document the need and timeframe for future nursing assessments and supervisory visits. There may be a need for frequent RN visits for several days until the delegation process is complete. Assessment and supervisory visits must be made no less frequently than every 60 days (see Oregon Board of Nursing Division 47 "Standards for RN Delegation…." for exceptions up to 120 days).
       
     
     
   • Document:
     • The RN assumes responsibility for the delegation and supervision of the task.
       
     • The stability of the person’s condition based on assessment.
       
     • The ability of the unlicensed staff to understand and perform the task safely.
       
     • How the task was taught.
       
     • Teaching instructions and the teaching outcome.
       
     • Evidence that the unlicensed staff understands the risks involved in performing the task and knows the plan for dealing with the consequences.
       
     • Evidence that the unlicensed staff understands that the task is individual-specific and that they cannot teach the skill to another unlicensed staff.
       
     • The frequency of the assessment/supervisory visits.
     
     
   • Assignment
     • "Basic tasks" are tasks that may or may not require the intervention of an RN/LPN. Many of these tasks can be performed by unlicensed staff without any supervision or oversight by an RN/LPN. When a nurse is involved with these tasks, there is a process where these "basic tasks" may be assigned to unlicensed staff.
       
     • Assignment of "basic tasks" of nursing care may be carried out by an RN or Licensed Practical Nurse (LPN) at the discretion of the RN. Basic tasks are those tasks that do not require the skill of a licensed nurse to perform and may not be person specific. They are generally tasks that are taught in a certified nursing assistant curriculum. These tasks do not generally carry much inherent danger and are not necessarily ordered by a primary care provider.
       
       

Delegation and assignment comparison

Teaching for emergencies

1. Process
   • The RN must assess the probability that the unlicensed staff will encounter an emergency situation with a given person.
   • The RN teaches the emergency procedure.
   • The RN leaves step by step instructions.
   • The RN periodically evaluates the unlicensed staff’s competence regarding the anticipated emergency situation.
     
2. Documentation
   • Though the board of nursing does not spell out documentation requirements, they should include at a minimum:
     • The emergency task taught.
     • Name of the unlicensed staff.
     • Teaching method and location of instruction material.
     • Date and signature of unlicensed staff and nurse.
3. Examples:
   • Emergency injections to treat life-threatening allergies.
   • Emergency injection to treat hypoglycemia.
   • Emergency rectal administration of Diazepam (Diastat) to treat uncontrolled seizures.