Delegation has widely been referred to as a key function in human resource management towards the actualization of the organizations goals and objectives. Irrespective of the sector, delegation has assisted several managers in the accomplishment of the set targets and departmental objectives. Also in the nursing profession the ability to delegate responsibilities is a major attribute of a nurse-supervisor in the ward.
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However, due to the recent increase in demand for healthcare services all over the globe, a nurse-supervisor should to able to delegate effectively, to healthcare assistants under her or him so that she will be able to concentrate on nursing work that cannot be delegated, prevent stress and overworking for nurses, bring about quick and early recovery to patient, improve competencies and self development on the part of the subordinate and improvement and efficiency on part of the healthcare system. Delegation aid the concentration of the supervisor on more important matters while the minor ones are left to be handled by the medical assistance.
According to ANA (2006), delegation is defined as the process of assigning a responsibility to another person (subordinate) to act on ones’ behalf while remained accountable for the responsibility delegated. Delegation can also be defined as authorizing an unlicensed person to provide nursing service while retaining accountability for how the unlicensed person performs the task (BNE, rules and regulation 2003, 224.4(3)). Bylgja and Helga (2012) defined delegation as the ability to work with people so as to accomplish effective outcome more than what one person can do alone. The main purpose of delegation as recognized by Patricia et al (2010) is to bring about work effectiveness and efficiency. It also helps to use time and resources effectively thereby reducing the healthcare cost, (Fisher, 2000). For nurses to be able to delegate effectively, she must consider the task to be delegated, the competency of delegate and maintain good communication within the team (Bylgja and Helga, 2012). This can be found in the Action Plan: Long term goal 3 under Short and Medium term goals.
This study will critically analyze the relevance of delegation in the nursing ward, the factors to be considered when delegating, the role of the supervisor in delegation and job distribution, the performance role of the subordinate, the step by step of effective delegation, the evaluation mechanism to be employed when considering delegating responsibilities to healthcare assistance and the attitudinal input of both supervisor and subordinates.
The action steps stated in the ACTION PLAN will be discussed adequately below, backed up with relevant literatures.
Nurse-supervisor should be conversant with the relevant rules and regulations guiding the delegation of nursing responsibilities in their country of practice, attending training or continuing education on delegation and related courses, know and read organizational job description of healthcare assistants. The role of training subordinates (nurses and healthcare assistances) cannot be over emphasized, assessing the level of understanding and competencies on the task to be delegated, supervising during execution of task, motivating the subordinates, ensuring effective communication, promoting good and active team spirit, giving feedback and being accountable for the task delegated.
To be able to ascertain the level of delegation to give the healthcare assistants, the first and most important step a nurse-supervisor undertake is to get acquainted with the relevant rules and laws governing delegation according to Nursing and Midwifery Council of the country of practice (see Action Plan: long term goal (1) under Short/medium term goal). Consulting the Nursing and Midwifery council or journals of the country will assist in determining the requirements needed to delegate task, the level of supervision and the competency required (Neuwhann, 2010). Cindy (2011) said that laws help to give information about the procedure or responsibility to be delegated to the healthcare assistant and the dos and don’ts of delegation. Bylgia and Helga (2012) also confirmed that for delegation to be effective, the register nurse who is a supervisor must know the legal job description and if the responsibility is legitimate to be delegated. Reinhard(2011); NCSBN (2005) recognized that the law of the state in which the nurse is practicing regulates the extent to which a nurse can delegate. There are some nursing responsibilities that cannot be delegated and these include- nursing assessment, nursing diagnosis, nursing care plan, health counseling, teaching, health talk, planning , evaluation, nursing judgment and referral,(Hansten and Jackson, 2010; Collin, 2011).
Checking the organizational job description of the healthcare assistant is also important (see Action Plan: long term goal (1) under Action required). This will help a nurse-supervisor to know the limit and extent of responsibility to be delegated to them, it will help to plan for them, give insight of their capability and help to prevent over delegation, (Hansten and Jackson, 2010). This will go a long way in assisting the supervisor not to overload a particular subordinate will others will be left with few duties and assignment.
Confidence in delegation and supervision can also be built by attending seminar, training, continuing education and workshops (see Action Plan: long term goal (2) under Short/Medium Term goal and Action required). It will help to improve knowledge on delegation, supervision and other leadership and managerial skill needed and give necessary information on what delegation entails. To support this view, Kleinman and Saccomano (2006); Byigja and Helga (2012) believed that there is need for nurses to undergo training on delegation, involve in continuing education to improve / update their skills and delegation should be included in the curriculum of nursing in their undergraduate courses. In contrast to this view, the result of the research carried out by Saccomano and pinto-zipp (2011) shows that nurse with clinical experience of 5years have more confidence to delegate responsibility than nurses with educational and training experiences alone. All these will help to prevent over delegation of responsibility and will assist nurses to take responsibilities and be held accountable for the decision made in delegation.
Empowering and training healthcare assistants is very crucial before delegating responsibility to them because it helps them to develop confidence, competence and know-how for them to be able to work effectively (see Action Plan: long term goal (2) under Action required). Empowering according to Marquis and Huston (2000) is the process in which a leader communicates their vision, employees are given the opportunity to make use of their talents and learning, creativity and exploration are encouraged. He believed that leader should train subordinates before delegating responsibility and allow the delegate to partake in the satisfaction gotten from achievement of the task. Marquis and Huston (2000) further explained that educating and training are component that help in developing a staff to do specific task and this makes them competent on the assigned duty. As recognized by Petra (2012), NMC standard of delegation required that a delegate must be trained on the procedure or task that is to be delegated and taught how to use any equipment associated with the responsibility. A key factor that contribute to quality of care rendered by healthcare assistants is to be well equipped with the necessary knowledge and skills required to for the work, (Fitzipatriols and Roberts, 2004). Training helps to give knowledge on what is to be done, give insight to the procedure at hand and help to develop boldness. Empowering subordinates also help to maintain and improve their self esteem, (Davidnizer and Shearer, 2002). Empowerment or training can be inform of teaching, discussion, demonstration, role play and all these should be organized by the nurse-supervisor (Lightfoot 11,2011).
Kleinman and Saccomano (2006) also pointed out that it is the responsibility of the nurse-supervisor to provide the adequate materials and equipment for carrying out the delegated task and expose the delegate on how to use them (see Action Plan: long term goal (2) under Action required). Singleston (2011) emphasized that all delegate should be trained effectively before responsibility is assigned to them and that induction training is a key to learning good practice and role boundaries. The education department of the organization which can also be the human resource can help in the training or organize seminar for employee i.e. healthcare assistants, (Marquis and Huston, 2000). One major constraint to empowering and training subordinate is that managers or supervisors are so occupied with their work and have little or no time for training other (summer and Nowick, 2006). Bejgja and Helga (2012) also acknowledged that time, individual obstacle which may be unwillingness on part on the subordinate and lack of resources can be constraints prevent accomplishing learning and teaching.
Assigning the right person for responsibility delegated is one of the vital decision to be taken in delegating responsibility because if the wrong person is chosen, the life and health condition of the patient may be threatened (Hudson, 2008). Before assigning responsibility, the nurse-supervisor assesses the level of understanding, knowledge and competency in the healthcare assistant (see Action Plan: long term goal (3) under Short/medium term goal). This can be done by giving them test, set written exams on what have being taught, observed them during practical and use checklist to grade them during demonstration, ask them verbal questions and allow them to ask question. All theses will help to know their competence and confidence level in executing the assigned task and it will also boost the confidence of the nurse to delegate (Neuman, 2010). This will also help to know the strength and weakness of each healthcare assistant and responsibility will be delegated based on their strength. (Hansten and Jackson , 2010). Hansten and Jackson (2010) also said that delegating responsibility based on subordinate strength will enable the patient to get the best care required and also help the delegate give out his or her best. Quallich (2005) also pointed that knowing the skills and competence of healthcare assistants will help to develop nurse confidence and erase fear of not getting work done. Zehler and Haslauer (2005) said that before any assessment, the nurse should provide procedure list for the healthcare assistants so that they can practice on their own and when demonstrating the task, the nurse should record and document all their performance.
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Before assigning responsibility to healthcare assistants, NMC(2012) pointed that nurses must consider the needs of the people in their care, the stability of the people being cared for, the complexity of the task being delegated, the expected outcome of the delegated task, the availability of the resources to meet those needs and the judgment of the nurse. The Action Plan: Long term goal (3) under Action required (i) talked about that. NCSBN (2005) also recognized that before a nurse delegate responsibility he or she must consider the right task, right circumstance i.e patient condition, setting and resource, right person i.e competent delegate, right direction and communication and right supervision. Nurses should always remember that responsibility delegated should be within the scope of practice of the delegate and responsibility should be delegated based on their competence in education and demonstration (Lightfoot 11, 2011). Knowing all these, the nurse-supervisor will know how to assign responsibility to healthcare assistant (Kleinman and Saccomano, 2006).
Evaluation can be done in regular interval as said by Robert (2011). Curtis and Nicholl (2004) believe that evaluation during performance of responsibility by delegator can help prevent mistakes, improve cordial relationship and bring about effective communication.
Communication when delegating is very important (see Action Plan: long term goal (3) under Short/medium term goal). Communication can affect the outcome of the work or task delegated by a nurse-supervisor to healthcare assistants. Wilson (2010) asserted that communication involves providing and sharing adequate information required for the expected or the desired outcome and the deadline for the responsibility. When a nurse-supervisor communicates effectively with the healthcare assistants during delegation of task, it encourages them to ask questions and creates an opportunity for the nurse to provide clarification (Saccomano, 2007). As discussed by Potter et al (2010), communication must be clear, complete and constant because it has effect on both healthcare assistants and the patient involved in the care. The healthcare assistants must understand what the job entails, the expectations, the parameter involved and how to report the responsibility (Potter et al, 2010). The nurse-supervisor must explain in the language the healthcare assistants understand, make the instruction simple for them to comprehend and absorb and allow them to ask questions (Hansten and Jackson, 2010). As endorsed by Potter et al (2010), there is a necessity that both nurse and healthcare assistants to be involved in training and continuing education on communication skills so that success will be achieve in execution and implementation of the delegated responsibilities.
The constraint of assessing healthcare assistant can be fear of losing job if they do not perform well and nurse-supervisor need to reassure them constantly (Summer and Nowicki,2006). This can be found in the Action Plan: Long Term Goal 3 under constraints. The fear on the part of the subordinate of being punished or queried if they don’t execute the assignment as expected can be wiped off by the supervisor through flexibility and accommodating words.
To ensure accuracy and completeness of responsibility, supervision, motivation and team work is highly necessary (see Action Plan: long term goal (4) under Short/medium term goal). Supervision is the process of overseeing a particular task and responsibility so as to ensure completeness of the assignment. It is a fundamental method applied by management and supervisory staff in ensuring that employees/subordinates are guided on the step to step action on the assignment. Though, this is not meant to override freedom of the subordinates in executing the assignment but designed in a way that corrective measures can be employed even before the final completion of the task. However, this is shouldn’t be done frequently as it may run down the morale of the executing office. As recognized by Livni et al (2012), clinical supervision is an important quality control mechanism used to make sure that patient receive adequate and appropriate care. Supervision is always required in delegated responsibility and should be done in all responsibility delegated, it can be direct/general and the degree depend on the judgment of the nurse, the nature of responsibility delegated, the condition of the patient involved and the competency of the delegate (Lightfoot 11,2011; Eaton,2009; Neumann, 2010). Quallich (2005) reported that supervising delegate during execution of task help the nurse-supervisor guide against legal challenges. During supervision, the nurse-supervisor provide direction, correction, give explanation on how the task should be done, monitor performance of the delegate, ensure the work is done according to standard of procedure, give helping hand, intervene where necessary and ensure proper documentation of the procedure done (Kleinman and Saccomano,2006). Touchstone (2009) supported this view in his article by saying that supervision helps the nurse to correct any error or mistake that can jeopardize or endanger the health condition of the patient involved. Also, Williams and Cooksey (2004) said that the nurse can provide information on any change in plan of the patient to the delegate during supervision. Supervision also help to develop relationship and communication between the nurse and delegate (healthcare assistants) thereby bringing about better care for patient involve and work satisfaction for the healthcare assistants (Currie, 2008; Wegdlt , 2010). Avoiding over supervision and stepping back a little to allow delegate perform their responsibility help them to prevent fear of being looked on, erase fear of insecurity, help increase their morale and promote effectiveness (Summer and Nowicki , 2006; Davidhizar and Shearer, 2002).
Motivation is the ability, in which a person is being encouraged, arouses, geared up to do a particular responsibility in other to achieve desire or expected goal (see Action Plan: long term goal (4) under Short/medium term goal). It is the responsibility of a nurse-supervisor to encourage and provide professional support to the delegate (healthcare assistants). Motivation as believed by Wilson (2010) increases the productivity and the overall performance of the delegate. He emphasized that saying ”thank you” to delegates when carrying out the assignment always go a long way in motivating them to work effectively and acknowledging their performance no matter how small or large their contribution may be is very necessary. Uttering encouraging words, praising them for a job well done and offering helping hand motivates subordinate and increase their morale (Williams and Cooksey, 2004). Teamwork is also important. Potter et al (2010) reported that teamwork bring about effectiveness in delegation and a nurse-supervisor should recognize it and provide assistance when they don’t have urgent work to do thereby rendering support to the delegate (healthcare assistants). Motivation can come in different form: words, giving or actions. It goes a long way in sending a message across to the executing staff that they are appreciated for what they are doing.
Feedback in any given responsibility is very important and most delegator omits this step in delegation (see Action Plan: long term goal (5) under Short/medium term goal). Feedback is the process of giving report on responsibility done by the supervisor to the subrodinate . Feedback gives information about the success or failure of assigned responsibility (Hansten and Jackson, 2010). When giving feedback, the nurse correct any mistakes that couldn’t be corrected during supervision, praise delegate on a job well done, avoid rebuke for mistake done so as not to kill their morale and self esteem. Giving feedback also help to bring about cordial communication between the nurse and the delegate (healthcare assistants), (Curtis and Nicholl, 2004).
Fisher (2000) defined accountability as a means of being responsible for action and outcome of responsibility delegated to a person. This can be found in Action Plan: long term goal (5) under Short/medium term goal). According to the NMC guidance on accountability written in Harrison(2007) article, registrant who delegate aspect of care to another remain accountable for the appropriateness of that delegation and will be held accountable for the appropriateness of that delegation and will be held accountable for the actions of the person carrying out the delegated task. This means that the nurse is accountable for the job or task delegated to the healthcare assistants. In the same view, the nurse is accountable for the assessment, planning implementation and evaluation of the patient and the responsibility delegated therefore the nurse must train, provide necessary information and equipment, choose a competent person for execution of task and make sure the work is done adequately and effectively (Belcourt and Downie,2012; Cornock,2008; Haansten and Jackson, 2008). Cornock (2008) mentioned that the delegate (healthcare assistant) is accountable to the nurse for the execution and completion of task while the delegator (nurse-supervisor) is accountable for the overall outcome of the job delegated. The nurse is accountable for the performance well done, credit gotten from decision making, correction of mistake made, making adjustment for patient care if mistake is involved, follow up, mentoring of delegate and evaluation of delegate (Hansten and Jackson,2008).
In summary, since every job cannot be executed by the superior officers, there will be an absolute need for duties to be delegated to the subordinate officers. Though, it must be carefully executed so as to reduce the possibility of devastating the assignment.
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