Delegation and Staff Management Notes

Definition: Delegation is assigning a task along with the responsibility and accountability for its completion to another person.
Direction: Delegation should always be done downwards in a hierarchical structure.
- Example: A Registered Nurse (RN) delegates to a Licensed Practical Nurse (LPN), who in turn delegates to Unlicensed Assistive Personnel (UAP) or an aide.
Assignment vs. Delegation:
- Delegation is to someone below you in the hierarchy.
- Assignment is to someone at the same level, such as one RN assigning a patient to another RN.

The following tasks should not be delegated to LPNs:

Starting IVs: LPNs generally cannot start IVs.
- Even if an LPN has IV certification, for the NCLEX, assume they do not.
Hanging or Mixing Medications: LPNs are not allowed to hang or mix medications.
Evaluation: LPNs cannot evaluate patients; this is the role of the RN.
IV Push Medications: LPNs should not administer IV push medications.
Blood Transfusions: LPNs cannot administer blood transfusions, though they may assist with the process.
Admission, Discharge, or Transfer Assessments: LPNs should not perform these assessments, especially in a hospital setting where patients are considered unstable.
- Exception: LPNs may perform transfer assessments in stable settings like nursing homes.
Planning of Care: LPNs cannot be involved in planning patient care, as this is an RN-only task.
Developing or Performing Teaching: LPNs cannot develop or perform initial teaching sessions.
- However, they can reinforce and review teaching that has already been provided by an RN.
State Regulations: Restrictions on LPNs may vary by state, but the above restrictions are generally applicable across all states and therefore tested on the NCLEX.

Assessments: Do not delegate assessments to UAPs.
- Exception: UAPs can take vital signs on stable patients.
Charting: UAPs cannot chart about the patient; however, they can document the tasks they performed.
- UAPs can document actions where "I" (the aide) is the subject (e.g., "I changed bed linens").
- They cannot document observations where the patient is the subject (e.g., "patient seems anxious").
Medications: UAPs cannot administer medications, with a limited exception.
- Exception: UAPs can apply over-the-counter topical skin creams as long as they are not pain or allergy medications.
Treatments: UAPs are generally not allowed to perform treatments, except for non-sterile procedures performed at home.
- Examples:
  - Tube feedings: Cannot be delegated in the hospital but can be delegated at home because tube feedings are non-sterile at home.
  - Intermittent catheterization: Cannot be delegated in a nursing home, but can be performed in the home because, while catheterization is sterile in the hospital, it is non-sterile at home.
  - Tracheostomy suctioning: Non-sterile at home, so UAPs can do it.
  - Central line dressing changes: Not delegatable because sterile at home.
  - Wound dressing changes: Delegatable at home because wound dressing changes at home are non-sterile.
Allowed Tasks: UAPs can perform Activities of Daily Living (ADLs).
- Examples: Bathing, dressing, ambulating, feeding, and showering.

General Rule: Do not delegate safety responsibilities to family members.
- Example: If a family member asks to remove restraints while they are present, this should be refused because the nurse is responsible for the patient's safety.
Allowable Actions: Family members can only perform tasks that they have been taught and deemed competent to do.
- Example: A mother can give her child insulin shots in the hospital if she completes the same competency checklist as the staff.
- This competency must be documented in the electronic medical record.
- Note: Families cannot change medication dosages, as that constitutes prescribing.

Context: These questions involve problems related to staff behavior rather than direct patient care issues.
Four Classic Options for Intervention:
- Tell supervisor.
- Intervene immediately.
- Counsel later on.
- Ignore it.
Eliminating "Ignore It": The option to ignore inappropriate behavior is almost always incorrect.
Three Questions to Determine the Correct Intervention:
- 1. Is the behavior illegal?
  - If yes, tell the supervisor.
  - Examples: A nurse diverting narcotics or an aide stealing supplies.
- 2. Is anyone in immediate danger of physical or psychological harm?
  - If yes, intervene immediately.
  - Example: An intern inserting a central line without using any anesthetic agent.
- 3. Is the problem legal, not harmful, but simply inappropriate?
  - If yes, counsel later on.
  - Example: An aide throwing an assignment sheet on the floor and expressing frustration.