Nursing Delegation

J Nurs Care Qual Vol. 33, No. 2, pp. 187–193 Copyright c© 2018 Wolters Kluwer Health, Inc. All rights reserved.

Improving Patient Care Outcomes Through Better Delegation-Communication Between Nurses and Assistive Personnel

Elissa A. Wagner, DNP, RN

In acute care settings, registered nurses need to delegate effectively to unlicensed assistive person- nel to provide safe care. This project explored the impact of improved delegation-communication between nurses and unlicensed assistive personnel on pressure injury rates, falls, patient satisfac- tion, and delegation practices. Findings revealed a tendency for nurses to delay the decision to delegate. However, nurses’ ability to explain performance appraisals, facilitate clearer communica- tion, and seek feedback improved. Patient outcomes revealed decreased falls and improved patient satisfaction. Key words: assistive personnel, communication, delegation, nursing delegation, unlicensed assistive personnel

OVER the last 2 decades as health caresystems have implemented processes to improve communication and team ef- fectiveness, much attention has been given to nurse-physician and nurse-patient com- munication strategies. This is evidenced by guidelines such as SBAR (situation, back- ground, assessment, recommendation) to im- prove communication as well as goal set- ting for patient-centered care. Professional or- ganizations such as the Institute for Health Care Improvement,1 The Joint Commission,2

Author Affiliation: University of Michigan School of Nursing, Ann Arbor, Michigan.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com).

The author declares no conflicts of interest.

Correspondence: Elissa A. Wagner, DNP, RN, Univer- sity of Michigan School of Nursing, 400 N. Ingalls, Room 2344, Ann Arbor, MI 48109 (elliewa@umich.edu).

Accepted for publication: June 7, 2017

Published ahead of print: August 1, 2017

DOI: 10.1097/NCQ.0000000000000282

and the Agency for Healthcare Research and Quality3 have widely supported the use of SBAR to improve effectiveness of communica- tion. However, less attention has been given to the delegation effectiveness between regis- tered nurses (RNs) and unlicensed assistive personnel (UAP) in acute care settings. To meet expected outcomes, care delivery mod- els frequently include UAP in the provision of direct care and require nurses to be ac- countable for the care they deliver.4-8 With the addition of UAP and their written job de- scriptions, nurses are often unsure about del- egation aspects and roles and responsibilities of the UAP.5,6,9 Ultimately, safe care depends on safe delegation and that requires nurses to appropriately plan and execute the dele- gated task. Failure to safely and appropriately delegate care activities could result in poor pa- tient outcomes.7 With the emphasis on quality and safety, connections between delegation, safety, and outcomes need to be evaluated.

PURPOSE

The purpose of this quality improvement (QI) project was to determine whether

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

187http://www.jncqjournal.commailto:elliewa@umich.edu

188 JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2018

improving the delegation-communication practices among nurses and UAP influenced effective delegation techniques, reduced falls and pressure injury rates, and improved pa- tient satisfaction with care on an adult acute care pulmonary/medical-surgical unit.

LITERATURE REVIEW

Despite the addition of UAP, nurses con- tinue to struggle with which tasks they can delegate because of the many different lev- els of UAP including nursing assistants, tech- nicians, aides, and patient care assistants.8

Furthermore, contributing factors to dele- gation difficulties between nurses and UAP include role uncertainty, lack of trust, ac- countability, fears of reciprocity, lack of com- munication, staffing mixes, and attitudes.8,10

Common themes from the literature iden- tified that poor delegation-communication resulted in missed care and poor patient out- comes, leading to longer lengths of stay; in- creased potential for pressure injuries, falls, catheter-associated urinary tract infections, and deep vein thrombosis; and poor glycemic control.4,8,10

One of the most compelling findings in the literature was the determination of 9 essential areas of missed care by nurses and assistive personnel on medical-surgical units. Kalisch11

identified common missed care as ambulation, turning, feeding, patient teaching, discharge planning, emotional support, hygiene, intake and output documentation, and surveillance. Many of these are tasks commonly delegated to UAP and can have a significant impact on patient outcomes. Also identified were several reasons for the missed care, which included poor delegation practices.11

Use of good communication techniques is the foundation for effective delegation be- tween nurses and UAP and leads to safe and ef- fective care. Research related to patient safety frequently cites communication breakdown as the number 1 factor leading to errors. For nurses to enhance safety in what has become a very complex health delivery system, they need to use good communication and dele-

gation techniques with the interdisciplinary team.

METHODS

For this project, a single-group pre-/posttest design was used to determine the effect of a delegation-communication learning inter- vention on both RNs and UAP preparedness to delegate, knowledge level, use of delega- tion, mindfulness, supervision issues, and del- egation decision making. Project outcomes focused on their ability to effectively use delegation-communication to reduce falls and incidence of pressure injuries, and improve patient satisfaction with care. The project was considered exempt by the institutional review board, and all participants were made aware of the project goals and that their participa- tion was voluntary.

Sample

The sample was drawn from all RNs (N = 51) and UAP (N = 19) who were currently em- ployed full- and part-time on a 32-bed adult, acute care inpatient unit from October 2015 to February 2016. The project unit was within a large academic hospital in the Midwest re- gion of the United States with Magnet designa- tion. Excluded were the clinical nurse special- ist, clinical supervisor, and manager because of their participation as clinical champions of this project. The patient population consisted of pulmonary disorders and medical-surgical diagnosis such as pneumonia, congestive heart failure, cystic fibrosis, lung transplant, liver disease, cancer, and pancreatic disor- ders. Care delivery usually included 8 nurses and 4 UAP with a charge nurse, unit host, and clerk. Nurses commonly have 4 patients each, and workload is determined by acuity and charge nurse report.

Current practice

To establish baseline rates of delegation practices and identify areas for potential im- provement, observation of RN/UAP interac- tion and workflow was conducted by the principal investigator (PI). An observation

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Improving Patient Care Through Better Delegation-Communication 189

guide was developed with common themes derived from the literature review and del- egation principles derived from the Ameri- can Nurses Association (ANA)12 and National Council of State Boards of Nursing (NCSBN)13

joint statements on delegation (Supplemen- tal Digital Content, Table 1 available at: http://links.lww.com/JNCQ/A361). Key ele- ments included tasks delegated, knowledge and role expectations, relationship, commu- nication techniques, omitted care, and use of ANA rights of delegation.

Baseline observations evaluated 6 RNs and 5 UAP on 2 occasions for 8 hours each, over a 2-week period. Observations included day and evening shifts, and during report times and care delivery to assess the delegation- communication practices common on the unit. Initial observations revealed that the unit had no shared shift report between RNs and UAP. Each member received report in- dependently from their corresponding peers. Patient assignments often required UAP to work with multiple RNs during a shift as well. Throughout the observation days, it was noted that care activities conducted by the RNs and UAP seemed to occur in isolation from one another. Information sharing be- tween nurses and UAP occurred only when there were changes in patient condition, spe- cific questions, or movement on/off the unit. However, the communication focused on spe- cific needs without providing a reason or rela- tionship to the patient’s condition. Frequent social discussions were observed among all staff in the unit conference room, where doc- umentation occurs and staffs commonly take breaks or eat meals.

Data collection

After the baseline observations were com- pleted, RNs and UAP were asked to participate in a pretest survey to assess delegation knowl- edge deficits, delegation competency, role knowledge, supervision issues, use of mindful communication techniques, and delegation decision making. Following the learning inter- vention, nurses and UAP completed posttest surveys to evaluate these same areas. Both sur-

veys were tailored to RNs and UAP roles and responsibilities, and took only 5 to 7 minutes to complete. Pre- and posttest surveys were developed and delivered using online survey software. Survey links were provided to all nurses and UAP on the unit through institu- tion employee e-mail as well as on 2 security enhanced I-pads placed on the unit to increase participation and access. Pretest surveys were available to nurses and UAP for a 2-month pe- riod before the learning intervention. Posttest surveys were available for 1 month, and par- ticipation on both was encouraged from the managers, supervisors, and PI.

Learning intervention

After the pretest surveys were completed, the PI designed a learning intervention for improving delegation-communication tech- niques on the basis of the survey results, literature review, baseline observations, and greatest knowledge deficits among the staff. The delegation-communication learning was designed using a lecture format and included information on the purpose of the project, significance to practice, brief literature re- view, techniques for mindful communica- tion, ANA12 principles of delegation, and case scenarios contrasting substandard and high- level delegation-communication examples. In- cluded in the learning intervention were links to the video “Delegating Effectively” and the “Delegation Decision Tree,” both developed by the ANA in conjunction with the NCSBN13

and available to the public on the NCSBN Web site. To increase participation and ac- cess to learning, the information was deliv- ered via several formats that included em- ployee e-mail with links to the NCSBN video, unit I-pads, and a flip chart placed in the unit conference room. Nurses and UAP could complete the lecture format learning aspect of the intervention in 10 to 15 minutes and view the “Delegating Effectively” video in 20 minutes. Participants could complete both aspects at once or separately as time allowed.

After 5 weeks of delegation learning availability, RNs and UAP were asked to

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.http://links.lww.com/JNCQ/A361

190 JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2018

participate in the posttest survey to measure delegation competency, role knowledge, supervision, use of mindful communication, and delegation decision making. Data from the National Database of Nursing Quality Indicators (NDNQI) on pressure injuries and falls, as well as Press-Ganey patient satisfaction levels, were also extracted from institutional databases during the QI period.

Instruments

Two versions of the pre- and posttest sur- veys were used for this study, 1 for the RNs and 1 for the UAP. The survey tools com- bined 2 instruments from the literature review and were modified for use in this study: the Hopkins Learning Needs Assessment and the Kærnested and Bragadóttir delegation ques- tionnaire. Aspects from the tool developed by Hopkins14 to evaluate learning needs and use of delegation were used with only the RN sample during the pretest data gathering. Four scenario questions asked for the best answer from 3 response choices in a delegation sce- nario. Means of 1.00 designated poor ability to delegate, 2.00 designated a tendency to delay the decision to delegate, and 3.00 designated a good grasp on delegation. Responses were evaluated as “has a good grasp, delays delega- tion decisions, or tends not to delegate” ac- cording to an established scoring pattern.14

Although reliability has not been established on the Hopkins tool, it was derived from a lit- erature review, has face validity, and provided a guide for tailoring learning interventions to staff needs.

A second tool developed by Kærnested and Bragadóttir15 to assess preparedness to del- egate, supervision, delegation decision mak- ing, and mindful communication techniques was modified for use in this project. Ques- tions from the tool were chosen for their specificity to the project’s purpose, and ad- ditional questions were formulated and used with both RNs and UAP. The tool had an origi- nal reported Cronbach α reliability coefficient of 0.63. Personal communication with the au- thor provided the PI with permission to use and modify the questions. The questions were

used in the pre- and posttest surveys for both RNs and UAP.

Both versions of the RN and UAP pretest surveys included 7 demographic questions; 10 questions on supervision, delegation compe- tency, and role knowledge; and 12 questions on preparedness to delegate, mindful commu- nication techniques, and delegation decision making. The 10 questions on supervision is- sues, competency, and role knowledge were answered on a 3-point Likert scale of 1 = com- pletely, 2 = partially, and 3 = not at all, with lower scores being more favorable responses. The 12 questions on preparedness to dele- gate, mindful communication techniques, and delegation decision making were given on a 5-point Likert scale, with 1 = always to 5 = never. Again, lower scores were more favorable.

The posttest RN and UAP surveys repeated the 22 delegation questions for learning mea- surement. Both RNs and UAP were asked which delegation learning interventions they completed (lecture format review, video re- view, I-pad use, or flipchart review) and to select the most effective of learning method.

Data analysis

All univariate and multivariate statistics were computed using the Statistical Package for Social Sciences (IBM Corp, 2015, Version 23, Armonk, New York). Independent sam- ple t tests were used to compare the means for groups with a confidence level of 95%. Fre- quency distributions, means, and standard de- viations (SDs) were used to describe the data. Delegation use by RNs was evaluated from Hopkins Learning Needs Assessment Tool and described with means and SDs. Independent t tests were used to compare both RN and UAP pre- and posttest survey results on super- vision issues, role knowledge, delegation de- cision making, preparedness to delegate, and mindful communication techniques.

RESULTS

The RN sample (n = 23) included nurses who ranged in age from 20 to 59 years, 87%

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Improving Patient Care Through Better Delegation-Communication 191

were female, and 70% had a BSN-level educa- tion (Supplemental Digital Content, Table 2 available at: http://links.lww.com/JNCQ/ A362). The UAP sample (n = 14) had an age range of 18 to 59 years, 71% were female, and the majority had either a high school diploma or GED (29%) or a vocational certificate (29%) (Supplemental Digital Content, Table 3 avail- able at: http://links.lww.com/JNCQ/A363).

Pretest delegation use

Before implementation of the learning in- tervention, analysis of RN delegation use with the scenario questions revealed a tendency to delay the decision to delegate among the RN sample according to the established scoring pattern. Means for the 4 scenario questions ranged between 2.22 to 2.65. The task of delegating a bed bath for a long-term, stable patient had the highest mean (mean = 2.65; SD = 0.775). Lower means were noted in scenarios associated with receiving a new patient from the emergency department (mean = 2.22; SD = 0.951); making assign- ments to either UAP or RNs (mean = 2.43; SD = 0.788); and assigning orthostatic blood pressures to UAP (mean = 2.48; SD = 0.898). Overall, the analysis identified that the RNs tend to delay the decision to delegate and were more likely to delegate tasks usually expected in UAP job descriptions.

Preparedness for delegation

Surveys of nurses (n = 23, preinterven- tion, 45% response rate; n = 14, postinterven- tion, 27% response rate) on their prepared- ness to delegate and supervise, role knowl- edge, decision making, and use of mindful communication techniques were evaluated using independent t test to measure effec- tiveness of the learning intervention. Twenty- two items were measured, and 18 showed improvements, 2 remained unchanged, and 2 increased slightly. Four items showed signif- icant differences after the learning interven- tion: explaining performance appraisals, fa- cilitating clearer communication, explaining tasks, and seeking feedback (P < .05).

UAP (n = 14; preintervention, 73% re- sponse rate; n = 8; postintervention, 42%

response rate) had 10 items that improved with the learning intervention. However, only 1 of those showed significance: losing respect because of delegation (pretest mean = 2.86; posttest mean = 1.86; P = .039).

Patient outcomes

Patient outcomes assessed during this project included NDNQI rates of falls and pressure injury development, and Press- Ganey patient satisfaction scores for prompt- ness to call button, pain control, and staff working together to care for them. Institu- tional data from NDNQI and Press-Ganey are reported by specific unit and included dates. Baseline data were assessed 1 month before beginning the project and continued during the 4 months of implementation and 2 months postcompletion of the project. The unit fall rate was 2.17 per 1000 patient days during the month before the project was started. Falls de- creased to zero and remained at 0 for 4 months during the project and 2 months after comple- tion. Hospital-acquired pressure injury rate, stage II, before the intervention was 3.7%. The rate fluctuated during the 4 months of this project, alternating each month from 0 to 4.17. Two months following completion, the rate remained at 0. Press-Ganey data postin- tervention revealed little variation over the 4- month span of the project. One-month postin- tervention noted an improved promptness to call buttons (pre = 86.7%, post = 88.7%), slightly poorer pain control rate (pre = 86.3%, post = 85.5%), and an unchanged rate of staff working together to care for them (pre = 90.2%, post = 90.2%).

Learning intervention outcomes

All RNs reported in the postintervention survey that they completed the learning in- tervention. Half used the flip chart accessi- ble on the unit, and the online lecture format that was sent via e-mail was the second most used intervention (43%). The UAP learning in- tervention use was equally divided between the online lecture format (38%) and not com- pleting any learning intervention (38%). This could be reflective of the value of learning in

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.http://links.lww.com/JNCQ/A362http://links.lww.com/JNCQ/A362http://links.lww.com/JNCQ/A363

192 JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2018

professional nurses, the educational level of participants, or the accountability associated with delegation for nurses that supports com- pleting the learning. Results showed that, de- spite the accessibility of learning, staff chose to review the content during work hours in a hard-copy format such as a flip chart or lecture format attached to their employee e-mail.

DISCUSSION

The overall results reveal that delegation- communication difficulties are complex and occur across a variety of experience levels of nurses and UAP. Nurses tended to de- lay the decision to delegate in some circum- stances except when choices centered on vi- tal signs or bathing, which is common in job descriptions of UAP. This is similar to the find- ings from the literature review that reported nurses’ difficulty with distinguishing between delegated tasks and job description responsi- bilities. It is important for RNs and UAP to un- derstand the roles of people in their care de- livery mixes. Doing so fosters a sense of trust, builds relationships, and allows for clearer lines of communication among the team. This was also supported in the UAP postinterven- tion reduction in feeling a loss of respect because of delegation. A better understand- ing of role responsibilities of nurses and UAP and the purpose of delegation can strengthen working relationships and diminish feelings of disrespect. Similarly, delegation difficulties noted in the observations and preintervention surveys among the participants paralleled the literature in communication issues, attitudes, role uncertainty, lack of trust, and staffing mixes. There was improvement in these ar- eas after the learning intervention. Patient outcomes during the QI period reflected im- provement in fall rates and patient satisfaction during and following the intervention. Pres- sure injury rates fluctuated but remained at 0 for 2 months postlearning. That informa- tion supports findings from the literature to suggest that improving delegation practices and communication between RNs and UAP

can have a positive impact on patient out- comes and improve patient care. Nurses need to develop these skills to provide safe and ef- fective care that includes UAP. Management staffs also need to support a culture of proper delegation-communication use among nurses and UAP to maintain the quality and safety standards for patients.

Implications for practice

Implications for improving delegation- communication practice include adding this to new-hire orientation and requiring yearly practice competencies for both nurses and UAP to increase role understanding and sup- port a culture of delegation on the unit. Once staff members have foundational knowledge of delegation principles, exercises can be con- ducted using the ANA and NCSBN princi- ples of delegation, the delegation decision tree, and mindful communication techniques. Staff would benefit further from participat- ing in simulated communication and dele- gation practices to build effective skills, im- prove mindfulness, and bolster confidence in delegation-communication.

The initiation of RN and UAP huddles after reporting times would increase face-to-face interactions, promoting mindful communica- tion techniques and opportunities for sharing of salient information and delegation. Con- tinued use of independent handoff reporting maintains care activities done in isolation from one another, further contributing to poor communication practices. Finally, evaluating care delivery models that promote consistent RN and UAP assignments to build relationships and trust is also essential to improving communication techniques, delegation practices, and patient safety.

Limitations

Although this project provides some evi- dence supporting the effectiveness of a learn- ing intervention to improving delegation- communication between nurses and UAP, it is limited by its small convenience sample and short duration on a single unit. Survey ques- tions were drawn from 2 different tools, one

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Improving Patient Care Through Better Delegation-Communication 193

of which had no reported reliability testing, and selected items were used. A matched pre- and posttest design would have been ideal for more accurate measurement of learning. Be- cause of a high amount of staff turnover dur- ing the project, independent samples were used. Another factor that may have attributed to the reduction in fall rates could be the pres- ence of nursing students in their clinical rota- tion during the implementation of the project. Student presence would allow for increased surveillance, assessment, and interventions to reduce falls.

SUMMARY

This QI project revealed the complexi- ties of nurse and UAP communication tech- niques as well as barriers to effective delega- tion. Nurses and UAP need continued support and education related to proper delegation- communication for safe and effective manage- ment of care in acute care settings. Achiev- ing desired patient outcomes requires a team approach in current health care and can be improved with effective communication and delegation practices.

REFERENCES

1. Institute for Healthcare Improvement. SBAR: Sit- uation Background Assessment Recommendation. http://www.ihi.org/Topics/SBARCommunication Technique/Pages/default.aspx. Published 2017. Accessed May 15, 2017.

2. The Joint Commission. National patient safety goals. https://www.jointcommission.org/standards information/npsgs.aspx. Published 2015. Accessed 2015.

3. Agency for Healthcare Quality and Research. SBAR Technique for Communication: A Situational Briefing Model. https://innovations.ahrq.gov/qualitytools/ sbar-technique-communication-situational-briefing- model. Published 2004.

4. Anthony MK, Vidal K. Mindful communication: a novel approach to improving delegation and increas- ing patient safety. Online J Issues Nurs. 2010;15(2): 1-12.

5. Kleinman CS, Saccomano SJ. Registered nurses and unlicensed assistive personnel: an uneasy alliance. J Cont Educ Nurs. 2006;37(4):162-170.

6. Mueller C, Vogelsmeier A. Effective delegation: under- standing responsibility, authority, and accountability. J Nurs Regul. 2013;4(3):20-27.

7. Ray JD, Overman AS. Hard facts about soft skills. Am J Nurs. 2014;114(2):64-68.

8. Standing TS, Anthony MK. Delegation: what it means to acute care nurses. Appl Nurs Res. 2008;21(1): 8-14.

9. Potter P, Deshields T, Kuhrik M. Delegation practices between registered nurses and nursing assistive per- sonnel. J Nurs Manag. 2010;18(2):157-165.

10. Bittner NP, Gravlin G. Critical thinking, delegation, and missed care in nursing practice. J Nurs Adm. 2009;39(3):142-146.

11. Kalisch BJ. Missed nursing care: a qualitative study. J Nurs Care Qual. 2006;21(4):306-313.

12. American Nurses Association (ANA) and the Na- tional Council of State Boards of Nursing (NCSBN). Joint statement on delegation. https://www.ncsbn. org/Delegation joint statement NCSBN-ANA.pdf.

13. National Council of State Boards of Nursing. Delegat- ing effectively (video). https://www.ncsbn.org/378. htm. Published 2002.

14. Hopkins DL. Evaluating the knowledge deficits of reg- istered nurses responsible for supervising nursing as- sistants: a learning needs assessment tool. J Nurses Staff Dev. 2002;18(3):152-156.

15. Kærnested B, Bragadóttir H. Delegation of registered nurses revisited: attitudes towards delegation and pre- paredness to delegate effectively. Nordic J Nurs Res. 2012;32(1):10-15.

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.http://www.ihi.org/Topics/SBARCommunicationTechnique/Pages/default.aspxhttp://www.ihi.org/Topics/SBARCommunicationTechnique/Pages/default.aspxhttps://www.jointcommission.org/standards_information/npsgs.aspxhttps://www.jointcommission.org/standards_information/npsgs.aspxhttps://innovations.ahrq.gov/qualitytools/sbar-technique-communication-situational-briefing-modelhttps://innovations.ahrq.gov/qualitytools/sbar-technique-communication-situational-briefing-modelhttps://innovations.ahrq.gov/qualitytools/sbar-technique-communication-situational-briefing-modelhttps://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdfhttps://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdfhttp://www.ncsbn.org/378.htmhttp://www.ncsbn.org/378.htmhttps://www.ncsbn.org/378.htm