Yoder-Wise Ch. 14: Delegating: Authority, Accountability, and Responsibility in Delegation Decisions

The charge nurse on a rehabilitation unit recognizes that due to the COVID-19 pandemic, her unit has been left with a shortage of nurses. She understands that delegating responsibilities to competent delegates will be necessary. She also is aware that for positive outcomes it is crucial to:

a. educate delegatees on how to implement a delegated responsibility.

b. allow UNP/AP's to have autonomy so the RN has less accountability.

c. never delegate to a UNP/AP.

d. delegate only the most critical patients.

a. educate delegatees on how to implement a delegated responsibility

Educating delegatees on how to implement a delegated responsibility is crucial for positive outcomes. The Research Perspective provides an exemplar of an innovative educational approach to elevate the knowledge, skills, and attitudes of delegates.

You are a member of a team assigned to care for 15 general medical/surgical clients. You have all worked well together in the past in this same type of care. If you are assigned to coordinate this team's work, your best strategy, based on the Hersey model, would be to:

a. have a list of tasks to be accomplished and tell each member of the team what he or she must do.

b. encourage people to discuss their frustrations in providing this care.

c. ignore them—they've done it before.

d. provide minimal direction and let them come to you with questions.

d. provide minimal direction and let them come to you with questions.

According to the Hersey model, when ability (skills, job knowledge) and willingness are strong, the role of the delegator is less (―delegating behavior‖).

The charge nurse is making patient assignments for the next shift on the unit. There is one critical patient on the unit, who is going to require more care than the other patients. Before delegating this patient in an assignment, what is the appropriate action by the charge nurse?

a. Delegate the admission assessment to the LPN.

b. Review the employee's performance assessment for the most recent period.

c. Assess the amount of guidance and support needed for the nursing care of the patient.

d. Create a task analysis of critical behaviors for the individual.

c. Assess the amount of guidance and support needed for the nursing care of the patient.

To delegate effectively, the charge nurse must assess the abilities required in the situation and the abilities that staff have to anticipate the amount of direction, monitoring, explanation, and independence that can be assumed.

A key advantage that a charge nurse has in terms of delegating is that:

a. clients receive less attention because too many staff make it difficult to coordinate care.

b. nurses report less pressure to perform necessary tasks themselves.

c. administration can predict overtime more accurately.

d. team skills can be used more effectively.

d. team skills can be used more effectively

The use of multilevel healthcare providers enables healthcare organizations and nursing to provide patient-centered care, with a focus on abilities and skills that can be employed to perform ―what is needed now.‖ As tasks become more complicated, delegating skills to others enables the nurse to effectively deliver a complex level of care.

The nurse on the 7-7 shift is assigning a specific component of care to an unlicensed nursing personnel (UNP) employee. The night nurse would remain:

a. accountable.

b. responsible.

c. authoritative and liable.

d. responsible and task-oriented.

a. accountable.

When a registered nurse delegates care to a UNP, responsibility is transferred; however, accountability for patient care is not transferred.

The night nurse understands that certain factors need to be considered before delegating tasks to others. These factors include the:

a. complexity of the task and the age of the delegatee.

b. potential for benefit and the complexity of the task.

c. potential for benefit and the number of staff.

d. complexity of the task and the potential for harm.

d. complexity of the task and the potential for harm.

In delegating tasks to others, the nurse considers factors such as stability of the patient, safety of the situation and of the patient, time and intensity involved, and level of critical thinking required to achieve desired outcomes.

During a fire drill, the nurse manager becomes very assertive and directive in her communications with staff. This type of situational leadership depends on: a. supportive behavior by the leader and immature followers.

b. the development level of the followers and the behavior based on the situation.

c. well-developed followers combined with a strong leader who acts quickly.

d. the leader's ability to evaluate personnel and communicate that evaluation.

b. the development level of the followers and the behavior based on the situation.

When abilities, relationships, and/or time is limited (as in a crisis situation), the leader assumes a bigger role in guiding and in making decisions, or ―telling‖ behavior. Leaders need to behavior differently and use different leadership styles in different situations.

The unit manager is working in a large metropolitan facility and is told that two UNPs are to be assigned to work with her. Delegation begins with:

a. acknowledging the arrival of the second UNP on the unit.

b. providing clear directions to both UNPs.

c. matching tasks with qualified persons.

d. receiving reports from the prior shift.

c. matching tasks with qualified persons.

In delegating to the UNPs, the nurse must consider what cannot be delegated, as well as the factors of safety, time, critical thinking, and stability of patients.

During staff-development programs, staff nurses verbalize their frustration about their workloads and having to delegate so many tasks to others. One of the main reasons that delegation has emerged as an issue is because of:

a. the amount of paperwork required to complete care.

b. the complexity of care required by patients.

c. earlier discharge practices.

d. the numbers of other disciplines present on a given unit.

b. the complexity of care required by patients.

Complexity of client care, a multilevel nursing model (registered nurses, mixed with LPNs/LVNs, and UNPs), and community-based care provide many challenges in determining the care required and outcomes desired and/or mandated, and in matching needs with various abilities and authority of regulated and unregulated healthcare providers. The nurse manager should ensure that staff is clinically competent and trained in their roles in patient safety.

The day shift nurse asks an LPN/LVN to complete a task for a patient. The day shift nurse is engaging in what function?

a. Delegating

b. Assigning

c. Sharing

d. Authorizing

b. Assigning

Delegation refers to transfer of responsibility for work; the day shift nurse retains accountability for the outcomes of patient care therefore is using assigning of the task rather than delegation.

You are working in a home health service and have three unlicensed nursing personnel (UNPs) assigned to your team. You have worked with two of them for 2 years; the third is new. The two experienced UNPs have patients with complex illnesses for whom theyprovide basic care. The third member of the team has been assigned to patients with less complex illnesses. Your best approach to supervising their care is to:

a. remain in the office and ask each UNP to check in with you upon arrival at their first patient care site.

b. ask another RN to supervise the two experienced assistants so you can be with the new person full time.

c. meet the new staff member at the first patient care site and ask the others to call if anything is unusual.

d. meet the new staff member at the first patient care site and call the others with questions to determine whether anything is unusual.

d. meet the new staff member at the first patient care site and call the others with questions to determine whether anything is unusual.

When ability and willingness are strong, the involvement of the delegator is needed less.

With delegation, responsibility and accountability remain with the:

a. physician.

b. professional who delegates.

c. individual who receives the delegation.

d. individual who previously performed the task.

d. individual who previously performed the task.

Even though the delegatee (the one who receives the delegation) receives direction from the professional who delegates a task and must have the authority to complete it, the delegator retains accountability for the overall outcome and completion of the activity. The delegatee has responsibility (obligation to engage in the task) and authority for the task.

Which of the following exemplifies accountability? Karen, the nurse manager on 5E:

a. consistently submits her budgets on time.

b. gets along well with her staff and with other managers.

c. outlines her rationale for reduction of RN coverage on nights to the Nursing Practice Committee after serious patient injury.

d. actively solicits ideas regarding scheduling from her staff.

c. outlines her rationale for reduction of RN coverage on nights to the Nursing Practice Committee after serious patient injury.

Reliability, dependability, and obligation to fulfill the roles and responsibilities of the nurse manager are consistent with responsibility. Accountability refers to being answerable for actions and results.

Which of the following indicates safe delegation?

a. The nurse supervisor for a large urban acute care department asks the unit manager to accept two new acutely ill patients, which the manager does. The unit is short two staff, and the replacement is inexperienced.

b. A unit manager agrees to release a staff from her unit to Unit B. The staff member she agrees to release is experienced on Unit B and is agreeable to the change. The unit manager's unit is fully staffed and patients are stable.

c. The nurse supervisor asks the head nurse for Unit A to make do without a replacement for an ill staff member because Unit A was originally overstaffed anyway. Patient acuity levels are very high on Unit A and two staff are orientating.

d. The nurse supervisor asks the charge nurse on Unit B to cover Unit F, which is two floors up, because the charge nurse for Unit F is ill. The charge nurse for Unit B is an experienced manager but has no experience with the nursing care required on Unit F.

b. A unit manager agrees to release a staff from her unit to Unit B. The staff member she agrees to release is experienced on Unit B and is agreeable to the change. The unit manager's unit is fully staffed and patients are stable.

When span of control (number of individuals for whom a manager is responsible) is compromised by geographic factors such as lack of proximity, instability in patients' conditions, or lack of experience, the span of control that is being delegated may lead to unsafe care

Which of the following would be most in line with Hersey model and concepts?

a. The team of caregivers on day shift are familiar with their roles and with the patients. The nurse manager decides to work on the unit budget in her office.

b. After a year of working on the unit, Shari, an LPN, is still hesitant about many policies and procedures. The charge nurse decides to challenge Shari with more difficult patients.

c. The nursing supervisor asks one of her charge nurses to lead a technology integration project. The supervisor continuously demands involvement in decisions that the charge nurse is making in the project.

d. Team members complain that Alysha, an RN, is unmotivated, and that she refuses assignments that are complex or difficult. The charge nurse suggests that Alysha is relatively new and that she needs time to adjust.

a. The team of caregivers on day shift are familiar with their roles and with the patients. The nurse manager decides to work on the unit budget in her office.

The Hersey model/framework suggests that when ability (skills, job knowledge) and willingness are strong, the involvement of the delegator is less.

In delegating to a UNP in a home health setting, which of the following represents the most appropriate delegation communication?

a. ―You will be taking care of Mrs. S., who needs assistance with her bath.‖

b. ―You will need to help Mrs. S. get into and out of her shower. Ensure that you check the condition of her feet, and let me know if you have any concerns when you check in.‖

c. ―I am not sure that you know how to do this, but I am giving you Mrs. S. She is quite obese and needs skin care.‖

d. ―Mrs. S. needs help to get into and out of her bathtub. Her bath will need to be completed by 10:00. When you are helping her to dry, please check between her toes and toenails, and phone me by 10:30 if you notice nail discoloration or redness.‖

d. ―Mrs. S. needs help to get into and out of her bathtub. Her bath will need to be completed by 10:00. When you are helping her to dry, please check between her toes and toenails, and phone me by 10:30 if you notice nail discoloration or redness.‖

Delegation communication includes what is being delegated (and what is not), outcomes, specific deadlines (if applicable), specific reporting guidelines (what, when), and who may be consulted. Communication also includes conveying recognition of the authority to do what is expected

An RN colleague, who is a long-standing and collaborative member of your team, is performing a complex dressing with new orders written for the first time for the assigned patient. Which of the following would be the most appropriate communication with her?

a. ―How do you usually do this kind of dressing?‖

b. ―The dressing needs to be done today and tomorrow with the supplies on this cart.‖

c. ―Here is what you need for the dressing, and I will show you what needs to be done.‖

d. ―I know you know what you are doing. Let me know if you have any problems.‖

c. ―Here is what you need for the dressing, and I will show you what needs to be done.‖

If a situation involves a new task and the relationship is ongoing (two individuals who will usually continue to work together), the delegator explains what to do and how to do it. Hersey described the leader's behavior as explaining or persuading, which, is characterized as ―selling.‖ The RN who is assigned to the patient is an experienced nurse and team member, but is new to this specific situation. In situations where the nurse is experienced but the task is new, explain (and demonstrate) what needs to be done.

Sally is an experienced nurse on the unit and is very experienced with ICP monitoring. She is assigned David, a patient who has been admitted with a severe head injury. In communicating with Sally, what is an appropriate action by the charge nurse?

a. Provide a detailed explanation of what she needs to do with ICP monitoring.

b. Tell her when she needs to provide an update about David's status.

c. Ask her to tell you what she knows about ICP monitoring and share expectations about reporting.

d. Advise her that you are available if she needs you.

d. Advise her that you are available if she needs you.

The charge nurse and Sally have a well-established relationship and Sally has the expertise to work effectively with David; therefore, the charge nurse would need to provide little guidance but would need to communicate that they are available if needed. Hersey refers to this leader behavior as ―delegating.‖

You ask Evelyn, a new UNP, to check what is left in Mrs. N.'s inhaler when Evelyn makes visits to Mrs. N. and also to check whether Mrs. N. is receiving any positive effect from the medication. Evelyn reports for 3 weeks that Mrs. N. is using the inhaler and that there is plenty medication left in the device. The day of her last visit to Mrs. N., Mrs. N. is admitted to the hospital in severe respiratory distress. When she is admitted, she tells the physician that she has not been using the inhaler for 4 weeks. This incident is an example of:

a. incompetence of the UNP.

b. failure to follow-through.

c. skills but no motivation.

d. lack of accountability.

b. failure to follow-through.

The nurse should maintain open lines of communication and seek information, and the UNP should know how, when, and what to report. Communication of delegation of tasks includes specific information about what is being delegated, expected outcomes, and deviations (which includes what immediate action needs to be taken). This 2-way communication and follow-through allows patient care to be altered, if necessary, in a timely manner.

You ask Evelyn, a new UNP, to check what is left in Mrs. N.'s inhaler when Evelyn makes visits to Mrs. N. and also to check whether Mrs. N. is receiving any positive effect from the medication. Evelyn reports for 3 weeks that Mrs. N. is using the inhaler and that there is enough medication left in the device. The day of her last visit to Mrs. N., Mrs. N. is admitted to the hospital in severe respiratory distress. When she is admitted, she tells the physician that she has not been using the inhaler for 4 weeks. Before assigning Evelyn to Mrs. N.'s care, the most appropriate action of the care coordinator would have been to:

a. determine Evelyn's educational background and preparation for this role.

b. ask Evelyn if she has worked with inhalers before and to describe what she knows about them.

c. advise that if Evelyn has any questions about what to do with the inhaler, she should come to the coordinator.

d. advise Evelyn that working the inhaler is not really complicated and that she should ask the patient how to check medication levels in the inhaler.

b. ask Evelyn if she has worked with inhalers before and to describe what she knows about them.

When delegating tasks, in addition to specifying the task to be completed, outcomes, priorities, time lines, deviations, report time frames, monitoring, and resources, asking the delegatee to give examples of each is helpful in ensuring that communication is clear and has been understood. Preparation of UNPs lacks consistency; therefore, the safest practice is to determine the knowledge and skill level of the UNP in relation to the skill and the patient before delegating.

You ask Evelyn, a new UNP, to check what is left in Mrs. N.'s inhaler when Evelyn makes visits to Mrs. N. and also to check whether Mrs. N. is receiving any positive effect from the medication. Evelyn reports for 3 weeks that Mrs. N. is using the inhaler and that there is enough medication left in the device. The day of her last visit to Mrs. N., Mrs. N. is admitted to the hospital in severe respiratory distress. When she is admitted, she tells the physician that she has not been using the inhaler for 4 weeks. Determination of Evelyn's educational preparation and certification is related to the concept of:

a. accountability.

b. authority.

c. role performance.

d. assignment.

b. authority.

Authority refers to the right to do and may be designated by law, educational preparation, or job description.

Nurses can use four elements to determine the abilities of the UNP/AP to perform the task or activity when delegating. These four elements are:

a. ability, attitude, acuity, and authority.

b. skill, diet, communication, and agility.

c. accountability, time management, organizational skills, and degree.

d. safety, critical thinking, stability, and time.

d. safety, critical thinking, stability, and time.

To assist with the challenges of delegating, nurses can use four elements to determine the abilities of the UNP/AP to perform the task or activity. These four elements are safety, critical thinking, stability, and time.

County Hospital has position descriptions for all staff, including RN Team Leaders. Sarah, a team leader on the rehab unit, assesses the needs of the patients in her area, assesses the skills and backgrounds of each of the individuals on her team, and then assigns and delegates the appropriate care provider to each patient and task. Sarah provides Colleen, her RN colleague with details regarding the patients to whom Colleen has been assigned on the day shift. This is an example of:

a. accountability.

b. responsibility.

c. assignment.

d. delegation.

c. assignment.

When an RN assigns care to another RN, it is termed an assignment and not delegation, because both accountability and responsibility are transferred.

Leslie, a UNP, transfers a patient while using improper technique. The patient is injured, and as a result, a suit is launched in which both Sarah (the delegator) and Leslie (the delegatee) are named. Sarah is named in the suit because she:

a. retains accountability for the care of the patient.

b. worked the same shift as Leslie.

c. has passive accountability for delegation.

d. retains accountability for the outcomes of care for the patient.

d. retains accountability for the outcomes of care for the patient.

Whenever care is provided by someone other than a registered nurse, accountability for care remains with the manager/delegator even though others provide aspects of care.

An example of a nursing care activity that would not be delegated by an RN to a UNP is: (Select all that apply.)

a. teaching self-catheterization to a patient with paraplegia who has limited English.

b. basic care for a patient with a head injury who is rapidly deteriorating.

c. one-to-one observation with a suicidal patient.

d. assessment of patients being admitted through the Emergency Department. e. basic hygienic care for a patient who is post MI and stable.

a. teaching self-catheterization to a patient with paraplegia who has limited English.

b. basic care for a patient with a head injury who is rapidly deteriorating.

d. assessment of patients being admitted through the Emergency Department. e. basic hygienic care for a patient who is post MI and stable.

Functions such as assessment, diagnosis, planning, and evaluation cannot be delegated. In addition, stability, critical thinking, time, and safety are factors that are considered in assessing whether or not to delegate care to a UNP. Teaching self-catheterization to a patient with limited English requires critical thinking; basic care for a patient who is rapidly deteriorating exemplifies concern with stability; and assessment of patients through Emergency is related to the factor of time. An exception to safety and stability in which patients may be delegated to UNPs is when patients are placed on suicide precautions.