Understanding Delegation (ENs Part 5)

Delegation

Delegation is the conferring (granting) of authority to perform a specific activity or activities in a specific situation, on an individual whose role and function does not have the authority to perform them autonomously.  Delegation is necessary when a nurse or other health practitioner (or unlicensed healthcare worker) is required to perform a task that is not recognised as being within their usual scope of practice or authority to perform. 

Delegation occurs when one member of multidisciplinary team delegates aspects of consumer care (which they are competent to perform and which they would normally perform themselves) to another. This may occur between or across different discipline, or to less experienced member of same discipline

Delegation occurs to meet clients’ needs and to ensure access to health care services — that is, the right person is available at the right time to provide the right service to a consumer.

The delegator retains accountability for the decision to delegate and for monitoring outcomes.

The delegation process includes clinical supervision, professional supervision, an assessment of competence, ongoing monitoring of performance and client health outcomes and a professional judgement and decision to delegate. 

The therapeutic benefit to the client is embedded in all aspects of decision-making regarding delegation. The registered nurse retains accountability for the decision to delegate as well as the process for the delegation. 

Delegation may be either the:

·       transfer of authority to a competent person to perform a specific activity in a specific context or

·       conferring of authority to perform a specific activity in a specific context on a competent person who does not have autonomous authority to perform the activity

The decision to delegate care is based on the registered nurse’s professional judgment. It includes consideration of the client’s needs, the skills/experience and the education/training requirements of the person/s providing the delegated care, the extent of supervision required and the availability and access to resources (both equipment and support infrastructure).  

It is therefore imperative to the delegation process that the registered nurse retains the authority for the decision to delegate and would use their professional judgment to determine when it was not be appropriate to delegate a health care task or duty.

A decision not to delegate a health care task or duty would include circumstances, which involve:

• a compromise to client safety and well being
• a client with unstable, unpredictable care needs
• a breach of professional or regulatory standards
• being outside of the nurses’ or midwives’ scope of practice or competence to delegate
• a breach of legislation
• a person who does not demonstrate competence or who has breached (or works outside of) their delegated responsibility.

Understanding Supervision (ENs Part 4)

Supervision

Supervision is defined as including oversight, direction, guidance or support (whether given directly or indirectly).  Supervision refers to monitoring, evaluating and directing specific activities of a specific person or group of persons, for a defined period of time and is determined by the registered nurse or midwife dependent upon the nature and complexity of the healthcare task being delegated, the environment and the nature and degree of other support infrastructures in place. 

The decision as to the extent of supervision required is based on the registered nurses’ professional judgment and is determined as part of the health and risk management assessment, prior to the decision to delegate care.

There are three types of supervision

Managerial Supervision

Managerial supervision involves the performance appraisal, rostering, staffing mix, orientation, induction, team leadership etc (eg GP/Practice Nurse, eg enrolled nurse as a manager of aged care facility).  This may mean that an enrolled nurse holds a management position and have management oversight of registered nurses.  In this scenario, the enrolled nurse does not provide professional supervision or clinical supervision.

Professional Supervision

It is the professional role and function of a registered nurse to provide professional supervision to an enrolled nurse and other registered nurses.

The registered nurse may also preceptor a student, undertaking course for entry to the profession.  Accountability for professional supervision is not delegable or transferable.

Clinical Supervision

Clinical supervision is a part of the delegation process. It requires that a registered nurse oversee and assess the clinical practice of another nurse (eg an enrolled nurse or other registered nurse) to determine that nurse’s competence to perform the clinical procedure and the level of ongoing supervision required.  Clinical supervision included education, guidance, and support to achieve a required level of competence.  It includes directing individuals’ performance, monitoring and evaluating outcomes, including client health outcomes.

There are two clear levels of supervision

These levels are about the proximity of the registered nurse to the enrolled nurse to be able to directly intervene if required.

Direct Supervision

Direct supervision means that a registered nurse is present and works with the enrolled nurse (or unlicensed healthcare worker) observing and directing his or her activities. The proximity of this supervision is such that immediate intervention is possible if problems occur. 

The registered nurse is able to observe and monitor the execution of the enrolled nurse’s activities and retains accountability for the level of supervision required. What is determined to be a reasonable level of supervision will depend on the context, the needs of the consumer and the needs of the person who is being supervised        

Indirect Supervision

Indirect supervision means the registered nurse or midwife is not present and supervision is provided by other than direct observation, of an enrolled nurse (or unlicensed healthcare worker) by a registered nurse. 

The absence of proximity of the registered nurse or midwife requires processes being in place for the direction, guidance, support and monitoring of the enrolled nurse activities. The registered nurse retains accountability for the level of supervision required.  What is determined to be a reasonable level of supervision will depend on the context, the needs of the consumer and the needs of the person who is being supervised        

Understanding Accountability (ENs Part 3)

Accountability

All nurses are answerable for her/his decisions, actions and behaviours and for the consequences of those decisions, actions and behaviours. 

All nurses are accountable for all decisions, actions and delegation decisions, the accountability for which cannot be delegated.  Professional accountability requires that the nurse considers and weighs up the interests of the client in complex, changing situations, using professional knowledge, skills and judgement to make a decision enabling them to account for their actions.

All nurses are answerable for her/his own decisions, actions and behaviours and for the consequences of these decisions, actions and behaviours. This accountability is not delegable transferable/rescindable. 

All nurses are accountable to the;

·       client

·       supervisor/manager

·       employer

·       regulator

·       profession

·       public

In meeting their accountability a nurse must be prepared to answer to others, such as health care consumers, regulatory authority, employers/public for their decisions, actions, behaviours and the responsibilities that are inherent in their roles which cannot be delegated

The registered nurse who delegates is accountable, not only for their delegation decision but also for monitoring the standard of performance of the activity by the other person, and for evaluating the outcomes of the delegation

The Registered Nurse is accountable for:

·       autonomous decision-making within their own scope of practice

·       their own decisions and actions (including the decision to delegate)

·       the consequences and outcomes of their decisions and actions

·       supervision of the enrolled nurse

·       delegation to the enrolled nurse

The Enrolled Nurse is accountable for:

·       practicing under the supervision of a registered nurse within their own scope of    practice

·       their own decisions and actions (including the decision to accept delegation)

·       the consequences of their decisions and actions

This is a pro-active and professional relationship with equal accountability for the maintenance of the professional relationship and for determining appropriate supervision and delegation.

Enrolled nurses (however called) practice under the supervision (direct or indirect) of a registered nurse. The enrolled nurse retains responsibility for their actions and remains accountable to the registered nurse for all delegated decisions and functions. However they are equally responsible for making clear decisions within their scope of practice and are accountable for these decisions and their practice.

All nurses accepting delegation must have an understanding of their professional competence and not accept delegated functions that are beyond their preparation and competence.

Therefore    

No nurse (registered or enrolled) may be directed, pressured or compelled by an employer, or any other person in a position of authority 

·       to delegate (or accept delegated) care that the nurse determines in their professional judgement is inappropriate

·       to engage in any practice that falls short of, or is in breach of any professional standard and/or code of conduct or practice

 

Scope of Practice of Enrolled Nurses is Unclear (ENs Part 2)

If I had a dollar for every time I have been asked to explain the distinction between the registered and the enrolled nurse role I would not have to work again for the rest of my life! How can we not be clear about this important relationship given our accountability and responsibility to work within regulatory, legislative and policy requirements that so specifically require us to understand it? And how can we still not understand a two professional roles and a professional relationship which has existed for decades?  So many decisions are by nurses, nurse managers and policy makes, based on a complete lack of understanding of the nature of this relationship.

If nurses, both registered and enrolled, more clearly understand the nature of accountability, supervision and delegation, many of the artificial barriers to enabling enrolled nurses to practice within their full scope of practice would be eradicated.

The core enrolled nurse practice is characterised by a supervisory relationship with the registered nurse, the nature of which is determined according to the relevant legislation, their educational preparation and experience, and the health care context.

The literature consistently agrees that the scope of practice of the enrolled nurse is unclear and often misinterpreted and misunderstood in the practice setting. The predominant causative factors of this role confusion are identified as being the varied and differing approaches to scope of practice and the different culture and ‘shared knowledge’ in an organisation. This role confusion and inconsistencies in practice are a source of frustration and concern to enrolled nurses and registered nurses alike. 

Registered nurses and enrolled nurses commonly talk to me about their concerns about their lack of understanding of the distinction between the registered nurse and enrolled nurse roles.  Nurses identify that pressures (frequently due to registered nurse shortages) to expand the role of the enrolled nurse are resulting in greater blurring of the lines between the two levels of nurses and that this blurring is creating more confusion than ever before. Registered nurses may respond to this by being cautious when delegating tasks or responsibilities as a means of protecting their role and accountability.

Enrolled nurses frequently comment express to me their frustration that their scope of practice is often determined by the registered nurse they work with rather than the enrolled nurses’ level of competence or experience. Responsibilities and functions delegated to the enrolled nurse may change from workplace to workplace, ward to ward, or shift to shift. Enrolled nurses also reported to the National Review of Nursing Education that their scope of practice differed not only between jurisdictions but between employment settings and between clinical areas.

Registered nurses may be reluctant to delegate tasks to enrolled nurses for fear of greater accountability. Registered nurses anecdotally use the rationale ‘if I am accountable for everything I may as well do it myself’ and a misinterpretation of that accountability results in many registered nurses being reluctant to delegate tasks to enrolled nurses even if the enrolled nurse is competent. 

Enrolled nurses are increasingly seeking to expand roles and to work within their full scope of practice and level of competence but meet but may be restricted by organisational policy or culture. Many enrolled nurses have experienced the erosion of their role and are frustrated at loosing skills and recognition of functions that were previously part of their role. With the ever shrinking health dollar, and government cutbacks of nursing positions, clarity of the enrolled nurse role has never been so important or necessary.

Clarification of professional accountability supervision and delegation will assist to remove many of these artificial barriers to enrolled nurse practice and reassure registered nurses when making decisions about delegation.

The enrolled nurse has an important and unique role as part of an appropriate staff skill mix. Enrolled nurses provide an additional level of qualified nursing support in the provision of nursing care to clients with some level of health instability. This includes recognition of normal and abnormal function in assessment, intervention and evaluation of clients’ health and functional status. 

Enrolled nurses have, by virtue of their education, training and regulation, the appropriate level of skill, knowledge and expertise to effectively assess and report changes in health and functional status to the registered nurse in a timely and informed manner.

The role of the Enrolled Nurse in Australia - Understanding Scope of Practice (ENs Part 1)

Over the last decade or more focus has increased on more clearly examining and clarifying the enrolled nurse roll and scope of practice in Australia. Several key investigative reports have made specific recommendations in relation to the enrolled nurse scope of practice in particular, in relation to administration of medication, issues of supervision, delegation and accountability and the relationship between the enrolled nurse and unlicensed healthcare workers.

Implementation of the advanced enrolled nurse education curriculum has contributed greatly to the development of the enrolled nurse roll and provided much needed and sought after formal continuing education for enrolled nurses.

The scope of practice of nursing is recognised as varied and diverse, meeting the broad range of client needs across a variety of health care settings and dependent on; client profile, environment and setting in which nursing practice occurs, field of practice and organisational policy.

Nurses (including enrolled nurses) are increasingly taking on expanded roles and activities in order to comprehensively address client needs in a timely, safe and cost effective environment. At the same time, nurses are reclaiming roles that were previously within their responsibilities. Nurses are still expected to maintain the core aspects underpinning the philosophy of care and caring.

Nursing practice is moving toward broad, enabling scope of practice frameworks that support nurses to make decisions about and within the professions’ scope of practice.  The profession has moved away from over prescriptive policy and individual certification of tasks and activities.

Diverse research over the past decade has identified the need to further clarify the role of the enrolled nurse relating to accountability, delegation, supervision and education as enrolled nurses, registered nurses report that they are frequently confused about the scope of enrolled nurse practice particularly related to accountability, delegation and supervision. This confusion has often resulted in unnecessary barriers to enabling the enrolled nurse workforce to practice within their full scope of practice.

National Research Reports that Informed Change

The following four national reviews into the nursing workforce and education focused specific discussion and recommendations in relation to the enrolled nurse. Though now nearly a decade old, it is encouraging to note that many (if not most) of the recommendations have been/or are being implemented nationally, particularly in relation to enrolled nurse education, uniformity across states and now, medication management.

What is still largely necessary is the recognition, adoption, and full implementation of these policies into workplace practice. The barriers to this being achieved remain largely with workplace policy and education of registered and enrolled nurses about these changes.

A short summary of the nature and findings of these four key reports has been included to further provide background to the changes to enrolled nurse scope of practice.

The reports include;

1. National Review of Nursing Education – Our Duty of Care 2002[1]

2. Senate Committee Affairs Reference Committee Report on the Inquiry into Nursing The Patient Profession: Time for Action 2002[2]

3. An Examination of the Role and Function of the Enrolled Nurse and Revision of Competency Standards Australian Nursing Council 2002[3]

4. The Aged Care Enrolled Nurse Working Party A Report to the Minister for Aging 2003[4]

National Review of Nursing Education – Our Duty of Care 2002

Established by the Commonwealth Government in 2001 the Review examined the future nursing educational needs and provided advice on appropriate frameworks for educational policy and funding.

Our Duty of Care (2002) identified that there are a number of barriers to nursing development, many of which flow from the fragmentation arising from the different funding and policy responsibilities of the Australian, State and Territory Governments. It also concluded that to realise the potential of nurses (and midwives), the removal of these barriers would need to occur in a coordinated, national manner.

The Report identified that a new approach was needed to define and regulate scope of practice that would recognise the diversity of nurses and nursing work, and the variety of settings in which nursing occurs. This should be is characterised by its:

  

• Responsiveness to change 
• Flexibility of workforce structure and work organisation and
• National approach to coverage 

The recommendations of the National Review of Nursing Education – Our Duty of Care 2002 identified 36 recommendations that encompassed such issues for the nursing and midwifery professions as recruitment and retention, skill mix and education requirements for the future. Several of the Recommendations had particular relevance in the development of an Enrolled Nurse Scope of Practice Framework.

Recommendation 4 - Nationally consistent scope of practice

To promote a professional scope of practice for nurses and greater consistency across Australia:

a) a national consistent framework should be developed to that allows all nurses to work within a professional scope of practice, including the administration of medication by enrolled nurses

b) to facilitate this development, all Commonwealth, State and Territory legislation and regulations that impact on nursing should be reviewed and reformed as required.

Recommendation 21 – Enrolled Nurse Competencies

To provide links to other training and to develop national consistency for the education and training of enrolled nurses;

a)   the Australian Nursing and Midwifery Council [ANMC] and Community Services and Health Training Australia should meet as a matter of urgency to ensure the [ANMC] competencies for enrolled nurses are incorporated into existing or new Australian National Training Authority sponsored training packages.

b)   in establishing the appropriate level of qualification, account should be taken of the training requirements for evolving models of care and changes in supervisory practice, including those related to medication administration and new enrolled nurse specialisations.

Recommendation 27 – Work organisation

Because the nursing workforce (including trained care assistants) contains arrange of experience and skills, and because it needs to adapt to an evolving care environment, work organisation throughout the health, aged and community care sectors should;

a)   constantly seek to achieve the most effective and efficient use of the total nursing workforce (including learning from best practice elsewhere)

b)   ensure that skills and expertise are matched to the work required in the particular workplace

c)    take account of the interrelationships with other health professionals

d)   ensure that nurses are encouraged to practise within their full professional capacity.

Senate Committee Affairs Reference Committee Report on the Inquiry into Nursing The Patient Profession: Time for Action 2002

The Senate Committee Affairs Reference Committee, “Report on the Inquiry into Nursing The Patient Profession: Time for Action” (2002) terms of reference identified;

a)   The shortage of nurses in Australia and the impact that this is having on the delivery of health and aged care services; and

b)   Opportunities to improve current arrangements for the education and training of nurses, encompassing enrolled, registered and postgraduate nurses.

Of its 85 recommendations, a number of recommendations related specifically to the role of the enrolled nurse. The Report Senate Committee made the following conclusion;

The Committee identified the need for national consistency in enrolled nurse education in relation to course structure, duration and content. The Committee recommended a national framework or guidelines for the education of enrolled nurses should be developed by the Australian Nursing and Midwifery Council], in conjunction with professional bodies, training providers, nurse regulatory bodies and unions. The Committee supported that educational preparation for enrolled nurses be, at a minimum, equivalent to Level IV of the Australian Qualifications Framework.

The Committee also saw that the variation between States in regards to the administration of medications by enrolled nurses needed to be addressed by the adoption of consistent legislation across all States.

Recommendation 25

That the Australian Nursing Council, in consultation with major stakeholders, develop a national framework for the education of enrolled nurses in relation to course structure, duration and content.

Recommendation 26

That State and Territory Governments develop nationally consistent legislation in relation to the administration of medications by Enrolled Nurses.(The Patient Profession: Time for Action p 86-87)

        

Further in relation to education

The Committee notes progress made in the development of articulation and recognition of prior learning between different levels of nursing. The Committee believes that formal articulation and recognition of prior learning should be further extended for enrolled nurses, unregulated healthcare workers and Aboriginal and Torres Strait Islander (ATSI) health workers.

Recommendation 22

That formal articulation arrangements and recognition of prior learning between enrolled nurse courses and registered nurse courses by universities and enrolled nurse education providers be further developed nationally.

An Examination of the Role and Function of the Enrolled Nurse and Revision of Competency Standards Australian Nursing Council 2002

This Study was commissioned by the Australian Nursing and Midwifery Council (ANMC) as the first national research into the role and function of the enrolled nurse. The project brief was to;

• identify the generic role expected of enrolled nurses on entry to practice in Australia 
• Revise the enrolled nurse competency standards to reflect the contemporary role and function of the enrolled nurse in Australia including articulation with the competency standards for the registered nurse 
• Validate the revised competency standards
• Identify, from the data collected on enrolled nurse practice, the issues concerning the ongoing and evolutionary development of the role, function, and educational preparation of enrolled nurses
• Recommend the educational preparation required for enrolled nurses to achieve the validated and revised competency standards

The project was undertaken based on the underpinning assumptions that;

• Enrolled nurses provide a valued contribution to Australian health care delivery 
• The revision of the enrolled nurse competency standards was necessary for the regulation of nursing practice in Australia
• Differences in state legislation would inform, and not drive, the nationally applicable outcomes of the project
• Collaboration between the project team and nurse regulatory authorities was essential to the success of the project 
• There would be wide consultation with and involvement of relevant stakeholders, including, enrolled and registered nurses, employers and consumers of nursing services, professional and industrial organisations, educational providers, health departments, and nurse regulatory authorities in all states and territories.

Of the 12 Recommendations made as a result of the study 3 recommendations relate most specifically to enrolled nurse scope of practice.

Recommendation 3

·       That the [ANMC] facilitate further research to clarify the scope of enrolled nursing practice.

Recommendation 4

·       That the [ANMC] facilitate research into nationally applicable decision-making frameworks

Recommendation 5

·       That the [ANMC] facilitate the development and dissemination of a nationally applicable statement about delegation and supervision in relation to nursing practice

Recommendation 5

·       That the [ANMC] require that educational preparation of enrolled nurses be at a minimum of Certificate IV level of the Australian Qualification Framework

The Aged Care Enrolled Nurse Working Party A Report to the Minister for Aging 2003

The Aged Care Enrolled Nurse Working Party was convened to investigate how an enhanced scope of practice for enrolled nurses (regarding the administration of medications by enrolled nurses) in aged care might be implemented on a national level and to ensure endorsement of this enhanced scope of practice by nursing regulatory authorities.

The then Minister for Aging the Hon Kevin Andrews, in response to ‘Our Duty of Care’ established the Aged Care Enrolled Nurse Working Party to report on:

What barriers exist in preparing enrolled nurses to administer medications;

How these barriers might be addressed nationally to ensure the endorsement of an enhanced scope of practice for enrolled nurses by relevant nursing regulatory authorities; and

What implications an enhanced scope of practice for enrolled nurses in the aged care sector will have on the broader health system.

Of the 13 Recommendations made by the Report 4 recommendations relate most specifically to enrolled nurse scope of practice.

Recommendation 2

·       The National Review of Nursing Education Implementation Taskforce coordinate a meeting of [ANMC] and State and Territory Nurse Regulatory Authorities to progress national consistency in relation to pre-enrolment enrolled nurse courses – specifically nomenclature and educational preparation that supports administration of Schedule 4 medications in the enrolled nurse  scope of practice should be addressed

Recommendation 3

·       The [ANMC] work with Nurse Regulatory Authorities to achieve nationally consistent definitions of direct and indirect supervision through the adoption of the [ANMC] proposed definitions in all jurisdictions

Recommendation 4

·       All Nurse Regulatory Authorities consider adopting a decision-making framework to provide guidance in regard to the delegation aspects of nursing care, and in particular, the administration of medications by enrolled nurses

Recommendation 5

·       Nurse Regulatory Authorities ensure courses leading to registration/enrolment include appropriate education/training on the rights and responsibilities of enrolled nurses in relation to scope of practice

In summary the recommendations across the reports were implementation of a nationally consistent

1.   decision-making framework should be developed to that allows all nurses to work within a professional scope of practice

2.   enrolled nurse education, allowing articulation and recognition of prior learning to degree based education and an advanced enrolled nurse program 

3.   enrolled nurse workforce and the enabling of enrolled nurses to work within their full scope of practice

4.   framework for enrolled nurses to be fully educated and enabled in administration of medications

5.   statements in relation to direct and indirect supervision and delegation

All of these recommendations in relation to expanding and enhancing the enrolled nurse role have been implemented.  The workplace adoption of policy and practice that enables enrolled nurses to work within their full scope of practice, including administration of medication, relies on employers, managers, policy makers and supervising registered nurses to fully understand the enrolled nurse scope of practice and decision making and to support this though appropriate supervision and delegation.  This requires further education in the workplace.

[1] Australian Government Department of Education, Science and Training , Archive www.dest.gov.au/archive/highered/nursing/pubs/duty_of_care

[2] Parliament of Australian Senate www.aph.gov.au/senate/committee/clac_ctte/completed_inquiries/2002-04/nursing/report

[3] National Library of Australia trove.nla.gov.au/work/16736415?selectedversion=NBD26828943

[4] Australian Government Department of Health and Aging www.health.gov.au/internet/main/publishing.nsf/Content/ageing-workforce-enfinal