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Decision Tree

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DECISION TREE Nurse Delegation to Nursing Assistive Personnel (NAP)
Step One – Assessment and Planning
Are there laws and rules/regulations in place that support the delegation? [NMAC 16.12.2] Yes Is the task within the scope of practice of the delegating nurse? [NMAC 16.12.2] Yes Has there been assessment of the client’s needs? Yes No Do not delegate. No If not in the licensed nurse’s scope of practice, he/she should not delegate to NAP. Authority to delegate varies from state-to-state; licensed nurses should check the local jurisdiction’s statutes and administrative rules/regulations.

No

Assess client’s needs; then proceed to a consideration of delegation.

Does the delegating nurse have competencies to make the delegation decisions required? Yes

No

Do not delegate until evidence of competency is obtained and is documented; then reconsider delegation.

Does the procedure/task meet all the following recommended criteria for delegating to NAP? • • • • • • • Task/procedure is within the range of approved functions for the NAP. Task/procedure frequently recurs in daily care of client or group of clients. Task/procedure is performed according to an established sequence of steps. Task/procedure involves little or no modification from one client-care situation to another. Task/procedure may be performed with a predictable outcome. Task/procedure does not inherently involve ongoing assessment, interpretation, or decision-making which cannot be logically separated from task/procedure itself. Task/procedure does not endanger a client’s life or well-being.

No

Do not delegate.

Yes Does the NAP have the appropriate knowledge, skills and abilities (KSA) to accept delegation and does the ability of NAP match the care needs of the client? Yes Are there agency policies, procedures and/or protocols in place regarding this task/activity? Yes Is appropriate supervision available? Yes PROCEED WITH DELEGATION. *
* Nurse is accountable for decision to delegate, to implement steps of the delegation Process, and to assure that the delegated task/function/action is completed. 1

No

Do not delegate until evidence of competency is obtained and documented; then reconsider delegation.

No

Do not proceed without evaluation of need for policy, procedures and/or protocol or with the determination that it is in the best interest of the client to proceed with delegation.

No

DO NOT DELEGATE.

Step Two – Communication
Communication must be a two-way process.
The nurse:
• assesses the NAP’s understanding of how the task is to be accomplished, when and what information is to be reported including o expected observations to report and record o specific client and concerns that would require prompt reporting; individualizes for NAP and client situation; addresses any unique client requirements and characteristics and clear expectations of NAP; assesses NAP’s understanding of expectations, providing clarification as needed; communicates willingness and availability to guide and support NAP; assures appropriate accountability by verifying that NAP accepts delegation and accompanying responsibility.

The NAP:
• • • • • • asks questions regarding delegation and seeks clarification of expectations as needed; informs nurse if NAP has not performed a delegated task/function/activity or if performance has been infrequent; asks for additional training or supervision; affirm understanding of expectations; determines communication method between NAP and nurse; determines communication and plan of action in emergency situations.

Documentation:
• • • should be timely, complete and an accurate account of the care provided; facilitates communication with other members of health care team; records nursing care provided.

• • • • •

Step Three – Surveillance and Supervision
The purpose of surveillance and monitoring is related to nurse’s responsibility for client care within context of a client population. The nurse supervises the delegation by monitoring the performance of the task or function and assures compliance with standards of practice, policies and procedures. Frequency, level and nature of monitoring vary with needs of client and experience of assistant.
The nurse considers:
• • • • • client’s health care status and stability of condition; predictability of responses and risks; setting where care occurs; availability of resources and support infrastructure; complexity of task being performed.

The nurse determines:
• frequency of onsite supervision and assessment based on needs of client; complexity of delegated function/task/activity proximity of supervising nurse.

The nurse is responsible for:
• timely intervention and follow-up on problems and concerns that might include alertness to subtle signs and symptoms that allows Nurse and NAP to be proactive before client’s condition deteriorates significantly; awareness of NAPs difficulties completing delegated activities; providing adequate follow-up problems and/or changing situations as a critical aspect of delegation.

Step Four – Evaluation and Feedback

Evaluation is often the forgotten step in delegation.
The nurse addresses the following questions in considering the effectiveness of delegation.
• Was the delegation successful? Was the task/function/activity performed correctly? Was the client’s desired and/or expected outcome achieved? Was the outcome optimal, satisfactory or unsatisfactory? Was communication timely and effective? What went well; what was challenging? Were there any problems or concerns; if so, how were they addressed? Is there a better way to meet the client need? Is there a need to adjust the overall plan of care, or should this approach be continued? Were there any “learning moments” for NAP and/or nurse? Was appropriate feedback provided to NAP regarding performance of the delegation? Was the NAP acknowledged for accomplishing the task/activity/function?

• • • • •

2 Adapted from Business Book, NCSBN 2005 Annual Meeting

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