20

499

C H A P T E R

20

Delegation

Delegation is both an art and a science. It includes

cognitive, affective, and intuitive dimensions.

—Marjorie Barter

Delegation can be defined simply as getting work done through others or asdirecting the performance of one or more people to accomplish organizationalgoals. More complex definitions of delegation, supervision, and assignment,however, have been created by the American Nurses Association (ANA) and theNational Council of State Boards of Nursing (NCBSN) in response to theemerging complexity of delegation in today’s healthcare arena, where increasingnumbers of unlicensed and relatively untrained workers provide direct patientcare. Both the ANA and the NCBSN have defined delegation differently(Thomas, Barter, & McLaughlin, 2000). The ANA defines delegation as thetransfer of responsibility for the performance of a task from one person toanother. The NCBSN defines delegation as transferring to a competent individ-ual the authority to perform a selected nursing task in a selected situation. Thissecond definition suggests that delegation is complex, requiring insight andjudgment regarding the environment in which the delegation is to take placeand the individuals involved.

Delegation is an essential element of the directing phase of the managementprocess because much of the work accomplished by managers (first-, middle-,and top-level) occurs not only through their own efforts but also through those oftheir subordinates. For the manager, delegation is not an option but a necessity.Frequently, there is too much work to be accomplished by one person. In thesesituations, delegation often becomes synonymous with productivity.

There are many good reasons for delegating. Sometimes managers must dele-gate routine tasks so they are free to handle problems that are more complex orrequire a higher level of expertise. Managers may delegate work if someone elseis better prepared or has greater expertise or knowledge about how to solve aproblem. Delegation can also be used to provide learning or “stretching’’ oppor-tunities for subordinates. Subordinates who are not delegated enough responsi-bility may become bored, nonproductive, and ineffective. Thus, in delegating, theleader–manager contributes to employees’ personal and professional develop-ment. The leadership roles and management functions inherent in delegation areshown in Display 20.1.

COMMON DELEGATION ERRORS

Delegation is a critical leadership skill that must be learned. Barter (2002) main-tains that leaders who delegate effectively are able to synchronize the cognitive,affective, and intuitive dimensions of delegation into a seamless performance. Inother words, they are able to think about delegation, to be self-aware regardingtheir feelings about delegation, and to know certain things about delegation basedupon their intuition. Frequent mistakes made by managers in delegating includethe following.

500 UNIT 6 � Roles and Functions in Directing

Underdelegating

Underdelegating frequently stems from the manager’s false assumption that delegationmay be interpreted as a lack of ability on his or her part to do the job correctly or com-pletely. Delegation need not limit the manager’s control, prestige, and power; rather,delegation can extend the manager’s influence and capability by increasing what can beaccomplished.

Another frequent cause of underdelegating is the manager’s desire to completethe whole job personally due to a lack of trust in the subordinates; the managerbelieves that he or she needs the experience or that he or she can do it better andfaster than anyone else. It is important to remember that time spent in traininganother to do a job can be repaid tenfold in the future. In addition to increased pro-ductivity, delegation can also provide the opportunity for subordinates to experiencefeelings of accomplishment and enrichment.

An additional cause of underdelegation is the fear that subordinates will resent hav-ing work delegated to them. Properly delegated work actually increases employee sat-isfaction and fosters a cooperative working relationship between managers and staff.

501CHAPTER 20 � Delegation

Leadership Roles1. Functions as a role model, supporter, and resource person in delegating tasks to

subordinates.2. Encourages followers to use delegation as a time management strategy and team-

building tool.3. Assists followers in identifying situations appropriate for delegation.4. Communicates clearly and assertively in delegating tasks.5. Maintains patient safety as a minimum criterion in determining the most appropriate

person to carry out a delegated task.6. Is an informed and active participant in the development of local, state, and national

guidelines for UAP scope of practice.7. Is sensitive to how cultural phenomena affect transcultural delegation.

Management Functions1. Creates job descriptions and scope of practice statements for all personnel, including

UAP, that conform to national, state, and professional recommendations for ensuringsafe patient care.

2. Is knowledgeable regarding legal liabilities of subordinate supervision.3. Accurately assesses subordinates’ capabilities and motivation when delegating.4. Delegates a level of authority necessary to complete delegated tasks.5. Develops and implements a periodic review process for all delegated tasks.6. Provides recognition or reward for the completion of delegated tasks.

Leadership Roles and Management FunctionsAssociated with Delegation

Display 20.1

The right to delegateand the ability toprovide formal rewardsfor successful completionof delegated tasks are areflection of thelegitimate authorityinherent in themanagement role.

Managers also may underdelegate because they lack experience in the job or indelegation itself. Other managers refuse to delegate because they have an excessiveneed to control or be perfect. Dye (2000) states, “If leadership is a journey, thenrespect for its constituents is its fuel and good stewardship is its compass. Respectis the value that multiples each person’s desire to deliver better, harder, and consis-tently excellent performance’’ (p. 33). The manager who accepts nothing less thanperfection limits the opportunities available for subordinate growth and oftenwastes time redoing delegated tasks.

Some novice managers emerging from the clinical nurse role underdelegatebecause they find it difficult to assume the manager role. This occurs, in part,because the nurses have been rewarded in the past for their clinical expertise andnot their management skills. As managers come to understand and accept the needfor the hierarchical responsibilities of delegation, they become more productive anddevelop more positive staff relationships.

Overdelegating

In contrast to underdelegating, which overburdens the manager, some managersoverdelegate, burdening their subordinates. Some managers overdelegate becausethey are poor managers of time, spending most of it just trying to get organized.Others overdelegate because they feel insecure in their ability to perform a task.Managers also must be careful not to overdelegate to exceptionally competentemployees, because they may become overworked and tired, which can decreasetheir productivity.

Improperly Delegating

Improper delegation includes such things as delegating at the wrong time, to thewrong person, or for the wrong reason. It also may include delegating tasks andresponsibilities that are beyond the capability of the person to whom they arebeing delegated or that should be done by the manager. See Display 20.2 for typesof delegating errors.

Delegating decision making without providing adequate information also isan example of improper delegation. If the manager requires a higher qualitythan “satisficing,’’ this must be made clear at the time of the delegation. Noteverything that is delegated needs to be handled in a maximizing mode. Inmany complex organizations, efforts have been made to delegate decision makingto middle-level managers.


UnderdelegatingOverdelegatingImproperly delegating

Common Delegating ErrorsDisplay 20.2

EFFECTIVE DELEGATING

Although some balk at the idea of sharing enough information or authority for del-egation to be effective, managers can implement a variety of strategies to ensureeffective delegation.

Plan Ahead

Plan ahead when identifying tasks to be accomplished. Assess the situation andclearly delineate the desired outcomes.

Identify Necessary Skills and Levels

Identify the skill or educational level necessary to complete the job. Often, legaland licensing statutes determine this. All nurses should be knowledgeable regard-ing their state’s nurse practice act (NPA) and know the following elements of thestate’s nurse practice act (Barter, 2002):

• The state’s NPA definition of delegation• Items that cannot be delegated• Items that cannot be routinely delegated• Guidelines for RNs about tasks that can be delegated• A description of professional nursing practice• A description of LVN/LPN nursing practice and unlicensed nursing roles• The degree of supervision required to complete a task• The guidelines for lowering delegation risks• Warnings about inappropriate delegation• If there is a restricted use of the word “nurse’’ to licensed staff

The manager should also know the official job description expectations for eachworker classification in the organization as it may be more restrictive than the statenurse practice act.

Select Most Capable Personnel

Identify the qualified person best able to complete the job in terms of capabilityand time to do so. Managers should ask the individuals to whom they are delegat-ing if they are capable of completing the delegated task but should also validate thisperception by direct observation. It also is important that the person to whom thetask is being delegated considers the task to be important.

Communicate Goal Clearly

Managers should encourage employees to attempt to solve problems themselves;however, employees often need to ask questions about the task or to clarify thedesired outcome. When this happens, the manager should clearly communicatewhat is to be done, including the purpose for doing so, and verify comprehension.


The manager should also include any limitations or qualifications that have beenimposed. Although the desired end product should be specified, it is important togive the subordinate feedback and an appropriate degree of autonomy in decidingexactly how the work can be accomplished.

Empower the Delegate

Delegate the authority and the responsibility necessary to complete the task. Noth-ing is more frustrating to a creative and productive employee than not having theresources or authority to carry out a well-developed plan.

Set Deadlines and Monitor Progress

Set time lines and monitor how the task is being accomplished; this may be donethrough informal but regularly scheduled meetings. This shows an interest on thepart of the manager, provides for a periodic review of progress, and encouragesongoing communication to clarify any questions or misconceptions.

Research by Anthony, Standing, and Hertz (2000a) suggests that more adversepatient outcomes occur when delegation communication is brief or nonspecific andwhen there is no direct supervision of the delegated task by the registered nurse.Closer, planned, and intentional supervision was more likely to be associated withpositive outcomes.

Monitoring delegated tasks keeps the delegated task before the subordinate andthe manager, so that both share accountability for its completion. Although thefinal responsibility belongs to the manager, the subordinate doing the task acceptsresponsibility for completing it appropriately and is accountable to the manager.

Model the Role: Provide Guidance

If the subordinate is having difficulty carrying out the delegated task, be availableas a role model and resource in helping identify alternative solutions. Convey a feel-ing of confidence and encouragement. Reassuming the delegated task should be amanager’s last resort because this action fosters a sense of failure in the employeeand demotivates rather than motivates.

Delegation is useless if the manager is unwilling to allow divergence in problemsolving and thus redoes all work that has been delegated. However, the managermay need to delegate work previously assigned to an employee so the employee hastime to do the newly assigned task.

Evaluate Performance

Evaluate the subordinate’s performance after the task has been completed. Includepositive and negative aspects of how the person has completed the task. Were theoutcomes achieved? Hansten and Washburn (1998) suggest that this evaluationfeedback step is so critical that when it is not done, subordinates will actually makeassumptions about the delegator’s perception of their work in an effort to close the


Responsibility is sharedwhen a task isdelegated.

feedback loop. Without this feedback, delegators and subordinates are unable tohave a mutually trusting and productive relationship.

Reward Accomplishment

Be sure to appropriately reward a successfully completed task. Dye (2000) statesthat the mark of a great leader is when he or she can recognize the excellent per-formance of someone else and allow others to shine for their accomplishments.Leaders today are often measured by the successes of those on their teams. There-fore, the more recognition team members receive, the more recognition will begiven to their leader (Dye, 2000).


A great leader canrecognize the excellentperformance of someoneelse and allow others to shine for theiraccomplishments.

Difficulty in DelegationIs it difficult for you to delegate to others? If so, do you know why? Areyou more apt to underdelegate, overdelegate, or delegate improperly?Think back to the last thing you delegated. Was this delegation successful?What safeguards can you build in to decrease this delegation error?

Learning Exercise 20.1

Delegation is a high-level skill essential to the manager that improves withpractice. As managers gain the maturity and self-confidence needed to delegatewisely, they increase their impact and power both within and outside the organi-zation. Subordinates gain self-esteem and increased job satisfaction from theresponsibility and authority given to them, and the organization moves a stepcloser toward achieving its goals.

DELEGATION AS A FUNCTION OF PROFESSIONAL NURSING

With the restructuring of care delivery models, RNs at all levels are increasinglybeing expected to make assignments for and supervise the work of different levelsof employees. The Pew Health Commission Report (1995) on challenges for revi-talizing the health professions in the 21st century made a strong recommendationfor integrated training across professions—an approach that encourages an inter-disciplinary team approach to care (Hansten & Washburn, 1998). The Pew reportalso suggested that the clinical management role of nursing needed to be recoveredand recognized as an “increasingly important strength of training and practice at alllevels’’ (Pew Health Commission Report, 1995, p. vi). As clinical managers, profes-sional RNs will be expected to be expert delegators.

RNs asked to assume the role of supervisor and delegator need preparation toassume these leadership tasks. Some RNs who supervise subordinates, especiallythose who practiced only in the 1980s, have experienced only total RN staffing or

primary nursing systems of care delivery. Thus, they have received little or noinstruction in personnel supervision and delegation principles. Repeated educa-tion programs on delegation principles and role clarity are necessary for RNs todemonstrate consistency in delegating appropriate role activities and to begin tofeel confident in delegating.

Nursing schools and healthcare organizations need to do a better job of preparingprofessional RNs for the delegator role. This includes educating professional nursesabout the NPA governing the scope of practice in their state; basic principles of dele-gating to the right person, at the right time, and for the right reason; and actions thatmust be undertaken when work is delegated in an inappropriate or unsafe manner.


Some experts argue thatthe RN, although welltrained in the role ofdirect care provider, isoften inadequatelyprepared for the role of delegator.

Assessing Nurses’ Comfort with DelegationInformally survey nurses in the agency in which you work or do clinicalpracticums. How many of them have received formal education on dele-gation principles? How comfortable do these nurses feel in determiningwhat should be delegated to whom? How comfortable do you feel indelegating work to other members of the healthcare team?


Delegating to Unlicensed Assistive Personnel

In an effort to contain spiraling healthcare costs, many healthcare providers in the1990s chose to eliminate RN positions or to replace licensed professional nurseswith unlicensed assistive personnel (UAP). The ANA (1992) defines UAP as unli-censed people who are trained to function in an assistive role to the licensed RN inthe provision of patient activities as delegated by the nurse. This term includes, butis not limited to, nurse extenders, care partners, nurse’s aides, orderlies, assistants,attendants, and technicians.

Almost all RNs in acute care institutions and long-term care facilities are cur-rently involved in some capacity with the assignment, delegation, and supervisionof UAP in the delivery of nursing care. The primary argument for utilizing UAP inacute care settings is cost (although the current professional nursing shortage is acontributing factor). UAP can free professional nurses from tasks and assignments(specifically, non-nursing functions) that can be completed by less extensively trainedpersonnel at a lower cost.

Assuming the role of delegator and supervisor to UAP, however, increases thescope of liability for the RN. Although nurses are not automatically held liable forall acts of negligence on the part of those they supervise, they may be held liable ifthey were negligent in the supervision of those employees at the time they com-mitted the negligent acts. Liability is based on a supervisor’s failure to determinewhich patient needs could safely be assigned to a subordinate or for failing toclosely monitor a subordinate who requires such supervision. The liability ofsupervision was discussed in Chapter 5.

In assigning tasks to UAP, then, the RN must be aware of the job description,knowledge base, and demonstrated skills of each person. RNs should recognize thatalthough the Omnibus Budget Reconciliation Act of 1987 established regulationsfor the education and certification of nurse’s aides (minimum of 75 hours of theoryand practice and successful completion of an examination in both areas), no federalor community standards have been established for training the more broadly definedUAP (Huston, 1996). Thomas et al. (2000) state that some standards and guidelinesare now required for the preparation and use of UAP in certified home health agen-cies and skilled nursing facilities, but concur that there are no required educationstandards or guidelines for the use of UAP in acute care hospitals that cross statelines and jurisdictions.

This does not imply that many UAP are uneducated and unprepared for theroles they have been asked to fill. It merely suggests that the RN, in delegating to aUAP, must carefully assess what skills and knowledge each UAP has, or riskincreased personal liability for the failure to do so.

Unfortunately, many institutions do not have distinct job descriptions for UAPthat clearly define their scope of practice. While some institutions limit the scope ofpractice for the UAP to non-nursing functions, some organizations allow the UAPto perform many skills traditionally reserved for the licensed nurse (Huston, 1997).

Gordon (1997) concurs:

UAP usually have little background in health care and only rudimentarytraining. Yet they may insert catheters, read EKGs, suction tracheotomytubes, change sterile dressings, and perform other traditional nursing func-tions. To keep patients from becoming unduly alarmed, some hospitals nowprohibit nurses from wearing name badges that identify them as RNs. Thuseveryone at the bedside is some kind of “patient care technician’’ regardless ofhow little training or experience she or he has (p. 86).

Some agencies interpret regulations broadly, allowing UAP a broader scope ofpractice than that advocated by professional nursing associations or state boardsof nursing. In a 1998 survey of 53 state and territorial boards of nursing, a majorityof states reported that they had regulations and guidelines for RNs who supervisedUAP and regulations that protected the use of the RN title (Thomas et al., 2000). Fewstates used the ANA or NCSBN definitions for delegation, supervision, or assign-ment. Most states, however, reported no standardized curriculum in place for UAPemployed in acute care hospitals, and more than half the states reported that no plansexisted for developing such a curriculum (Thomas et al., 2000).

Some state boards of nursing, in an effort to more clearly define the scope ofpractice for UAP, have issued task lists for UAP. However, the NCSBN warns thatby creating task lists for UAP, an unofficial scope of practice is created (Simpkins,1997). Training of UAP is not based on the notion that such individuals will beperforming activities independently. Task lists, however, suggest no need for dele-gation, as the UAP already has a list of nursing activities he or she may performwithout waiting for the delegation process. But what happens when the conditionof a client changes? Is the UAP with less than 75 hours of training astute enough torecognize there has been a change in the client’s condition and alert the RN?


In assigning tasks toUAP, the RN must be aware of the jobdescription, knowledgebase, and demonstratedskills of each person.

Research by Anthony, Standing, and Hertz (2000a) highlights another concernfor the RN in supervising UAP. Their research, which examined the congruencebetween RN and UAP perceptions of nursing practice, found significant differencesin philosophy of patient care and perceived accountability for team and patientsbetween RNs and UAP. In addition, further research by Anthony, et al. (2000a) sug-gests that while work experience for licensed nurses is associated with positive out-comes for patients, overall experience for UAP was not associated with differences inpatient outcomes. Both of these studies suggest that assumptions about the inter-changeability of RNs and UAP in the staffing mix must be examined carefully.

It is critical that the RN never lose sight of his or her ultimate responsibility forensuring that patients receive appropriate, high-quality care. This means that whilethe UAP may complete non-nursing functions such as bathing, vital signs, and themeasurement and recording of intake and output, it is the RN who must analyze thatinformation and then use the nursing process to see that desired patient outcomes areachieved. Only RNs have the formal authority to practice nursing, and activitiesthat rely on the nursing process or require specialized skill, expert knowledge, orprofessional judgment should never be delegated (Zimmerman, 2001).

The outcomes associated with the increased use of UAP are not yet known. Anincreasing number of studies suggest a direct link between decreased RN staffingand declines in patient outcomes. Some of these declines in patient outcomes notedin the literature include an increased incidence of patient falls, nosocomial infec-tions, and medication errors (Blegen, Goode, & Reed, 1998; Huston, 1997, 2001;Lichtig, Knauf, & Milholland, 1999).

Cronenwett (1995) developed a strategy assessment guide to assist nurses indetermining situations where UAP should be used to assist or substitute forlicensed nurses (Display 20.3). When scores are low, delegation to UAP can morelikely be carried out in a safe manner. As scores rise, delegation to UAP becomesmore inappropriate.

Certainly at some point, given the increasing complexity of health care and theincreasing acuity of patient illnesses, there is a maximum representation of UAP inthe staffing mix that should not be breached. Until those levels are determined,RNs can expect a continued increase in the utilization of UAP. To protect theirpatients and their professional license, RNs must continue to seek current infor-mation regarding national efforts to standardize scope of practice for UAP andprofessional guidelines regarding what can be safely delegated to UAP.

Barter (2002) states that certain professional responsibilities related to nursing caremust never be delegated.These professional responsibilities include patent assessment,nursing diagnosis, care planning, patient teaching, and patient outcome evaluation.

Subordinate Resistance to Delegation

Resistance is a common response by subordinates to delegation. One of the mostcommon causes of subordinate resistance to, or refusal of, delegated tasks is the fail-ure of the delegator to see the subordinate’s perspective. Workloads assigned toUAP are generally highly challenging, both physically and mentally. In addition,the UAP frequently must adapt rapidly to changing priorities, often imposed onhim or her by more than one delegator. If the subordinate is truly overwhelmed,



How complex is (are) Very simple Very complexthe task(s) involved? 1 2 3 4 5

What is the potential for harm Very low Very highto clients? 1 2 3 4 5

How predictable are client Very predictable Very unpredictableresponses to the 1 2 3 4 5intervention/ tasks?

How stable are the conditions Very stable Very unstableof the clients involved? 1 2 3 4 5

To what extent are problem Never required Always requiredsolving and judgment 1 2 3 4 5required during the intervention or task?

To what extent are clients Continuously Very sporadicallymonitored by other societal 1 2 3 4 5or family agents so that untoward outcomes would be observed?

To what extent would a Never Alwaysregistered nurse be held 1 2 3 4 5liable for an untoward outcome?

How soon could the Very soon (min) Very long time (hrs)unlicensed assistive 1 2 3 4 5personnel or client be in contact with a professional healthcare provider if needed?

How certain can society be Very certain Very uncertainthat the unlicensed assistive 1 2 3 4 5personnel being consideredwill have the necessarycompetencies to perform thetasks or judgments required?

If the patient were your family Very comfortable Very uncomfortablemember, how comfortable 1 2 3 4 5would you be with theproposal for unlicensedassistive personnel care?

How willing are you, as a Very unwilling Very willingmember of society, to commit 1 2 3 4 5fiscal resources to ensure thata registered nurse could beavailable to cover everyperson who needed theproposed interventions?

Source: Cronenwett, W. R. (1995). The use of unlicensed assistive personnel: When to support, oppose or be neutral.Journal of Nursing Administration, 25(6), 11–12.

Strategic Assessment Guide for Nursing’sResponse to the Use of UAP

Display 20.3

additional delegation of tasks is inappropriate and the RN should reexamine thenecessity of completing the delegated task personally or finding someone else whois able to complete the task.

Some subordinates resist delegation simply because they believe they are inca-pable of completing the delegated task. If the employee is capable but lacks self-confidence, the astute leader may be able to use performance coaching to empowerthe subordinate and build self-confidence levels. If, however, the employee is trulyat high risk for failure, the appropriateness of the delegation must be questionedand a task more appropriate to that employee’s ability level should be delegated.

Another cause of subordinate resistance to delegation is an inherent resistance toauthority. Some subordinates simply need to “test the water’’ and determine what theconsequences are of not completing delegated tasks. In this case, the delegator mustbe calm but assertive about his or her expectations and provide explicit work guide-lines, if necessary, to maintain an appropriate authority power gap. It is an ongoingleadership challenge to instill a team spirit between delegators and their subordinates.

Finally, resistance to delegation may be occurring because tasks are overdelegat-ed in terms of specificity. All subordinates need to believe there is some room forcreativity and independent thinking in delegated tasks. Failure to allow for thishuman need results in disinterested subordinates who fail to internalize responsi-bility and accountability for the delegated task. The RN should try to mix the UAPmore routine, boring tasks with more challenging and rewarding assignments. Anadditional strategy is to provide the UAP with consistent, constructive feedback,both positive and negative, to foster growth and self-esteem.

When subordinates resist delegation, the delegator may be tempted to avoidconfrontation and simply do the delegated task himself or herself. This is seldomappropriate. Instead, the delegator must ascertain why the delegated task was notaccomplished and take appropriate action to eliminate these restraining forces.


Dealing with Resistance to DelegationYou are the team leader for 10 patients. An experienced LVN and nurse’saide are also assigned to the team. It is an extremely busy day, and thereis a great deal of work to be done. Several times today, you have foundthe LVN taking long breaks in the lounge or chatting socially at the frontdesk, despite the unmet needs of many patients. On those occasions, youhave clearly delegated work tasks and time lines to her. Several hourslater, you follow up on the delegated tasks and find that they were notcompleted. When you seek out the LVN, you find that she went to lunchwithout telling you or the aide. You are furious at her apparent disregardof your authority.Assignment: What are possible causes of the LVN’s failure to follow up ondelegated tasks? How will you deal with this LVN? What goal serves as thebasis for your actions? Justify your choice with rationale.


Delegating to Interdisciplinary Teams

The Joint Commission on Accreditation of Healthcare Organizations ( JCAHO)has emphasized the value of interdisciplinary patient care, whereby healthcareprofessionals from a number of care-giving areas collaborate to meet patients’healthcare needs (Thomassy & McShea, 2001). Although interdisciplinary teammembers are generally highly trained, self-directed professionals, the team musthave a leader to coordinate team members’ efforts and to facilitate communica-tion between members. The nurse leader–manager is often called upon as theindividual to coordinate such a team. In coordinating the efforts of the interdis-ciplinary team or in delegating to members of the team, the leader–managermust be sure to recognize the unique expertise of each team member and todelegate accordingly.

Welford (2002) states that transformational leadership requires a greater degreeof delegation than other leadership models. Empowerment from appropriate dele-gation can occur when transformational leaders are clear about boundaries ofresponsibility and provide adequate information and support. The interdisciplinaryteam must be managed as a team and not as individual members. There must berespect for employee’s ideas and contribution and trust must be placed in the teamto carry out assigned roles. Lastly, Welford says there must be recognition of theteam’s achievements.

Delegating to a Transcultural Work Team

Poole, Davidhizar, and Giger (1995) suggest that six cultural phenomena must beconsidered when delegating to staff from a culturally diverse background: commu-nication, space, social organization, time, environmental control, and biologicalvariations.

Communication, the first of the cultural phenomena, is greatly affected by cul-tural diversity in the workforce because dialect, volume, use of touch, context ofspeech, and kinesics such as gestures, stance, and eye movement all influence howmessages are sent and received. For example, delegation delivered in a softer tonemay be perceived as less important than delegation received in a loud tone, even ifthe delegated tasks have equal importance. Similarly, a manager may make aninappropriate assumption about a person’s inability to carry out an important del-egated task if that person represents a culture that values softer speech and morepassive behavior.

Space is another cultural phenomenon influencing delegation. In the UnitedStates, the white American middle class prefers an interpersonal space for commu-nication between people of two to three feet, whereas French and African Ameri-cans consider this amount of space to be distant and generally unacceptable (Pooleet al., 1995). It is important, then, that the delegator recognizes what each staffmember’s personal space needs are and acts accordingly. If these space needs arenot recognized and respected, the likelihood that a delegated task will be heardand followed through on appropriately will be reduced.


Social organization refers to the importance of a group or unit in providingsocial support in a person’s life. For many cultures, the family unit is the singlemost important social organization. In some cultures, the duty to family alwaystakes precedence over the needs of the organization. In other cultures, this val-ues ranking is less clear, and the employee may experience great intrapersonalconflict in prioritizing delegated work tasks and obligations to the family unit. Itis important, then, that the delegator be aware that employees’ values differ andbe sensitive in delegating critical tasks to employees experiencing stress in thefamily unit.

Time is also a cultural phenomenon affecting delegation. Cultural groups can bepast-, present-, or future-oriented. Past-oriented cultures are interested in preservingthe past and maintaining tradition. Present-oriented cultures focus on maintainingthe status quo and on daily operations. Future-oriented cultures focus on goals to beachieved and are more visionary in their approach to problems. For example, strate-gic planning might best be delegated to a person from a future-oriented culture,although the leader–manager should always be alert for opportunities to create newinsight and stretching opportunities for subordinates.

Environmental control, the fifth cultural phenomenon, refers to the person’s per-ception of control over his or her environment (internal locus of control). Somecultures believe more strongly in fate, luck, or chance than other cultures, and thismay affect how a person approaches and carries out a delegated task. The personwho believes he or she has an internal locus of control is more likely to be creativeand autonomous in decision making.

The last phenomenon, biological variations, refers to the biopsychosocial differencesbetween racial and ethnic groups, such as susceptibility to disease and physiologicaldifferences. See Display 20.4 for a summary of considerations when delegating to atranscultural work team.

All of these cultural phenomena have the potential to affect the relationshipbetween the delegator and his or her subordinates as well as the understanding andimplementation of the delegated task. Recognizing that cultural diversity may be asignificant factor in delegation is a critical first step. Applying transcultural sensi-tivity in delegation is, however, what is ultimately needed to create a productive,multicultural work team.


Communication: especially dialect, volume, use of touch and eye contactSpace: interpersonal space differs between culturesSocial organization: family unit of primary importance in some culturesTime: cultures tend to be past, present or future orientedEnvironmental control: cultures often have either internal or external locus of control Biological variations: susceptability to diseases (e.g., Tay-Sachs) and physiological differ-

ences (e.g., height, color)

Cultural Phenomena to Consider When Delegating to a Transcultural Team

Display 20.4

INTEGRATING LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS IN DELEGATION

The right to delegate and the ability to provide formal rewards for successful com-pletion of delegated tasks reflect the legitimate authority inherent in the manage-ment role. Delegation provides a means of increasing unit productivity. It is also amanagerial tool for subordinate accomplishment and enrichment. Delegation,however, is not easy. It requires high-level management skills. Novice managersoften make delegation errors such as delegating too late, not delegating enough,delegating to the wrong person or for the wrong reason, and failing to provideappropriate supervision and guidance of delegated tasks. Delegation also requireshighly developed leadership skills such as sensitivity to subordinates’ capabilitiesand needs, the ability to communicate clearly and directly, the willingness to sup-port and encourage subordinates in carrying out delegated tasks, and the vision tosee how delegation might result in increased personal growth for subordinates aswell as increased unit productivity.

With the increased use of UAP in patient care, the need for nurses to have high-ly developed delegation skills has never been greater. The ability to use delegationskills appropriately will help to reduce the personal liability associated with super-vising and delegating to UAP. It will also ensure that clients’ needs are met andtheir safety is not jeopardized.


Cultural Considerations in DelegationYou are a new charge nurse working on a surgical unit. Today you haveone of the recently hired Korean travel nurses working on your unit.This is the end of her second week of orientation on the unit. She alsoreceived a month of classroom orientation and enculturation when shewas first hired. Today you assign her as one of your team leaders,responsible for a team of LVNs and CNAs. She has been working withanother team leader for over a week but this is her first day to have herteam totally to herself.

You check with her several times during the morning to see how thingsare going. She speaks shyly without making eye contact and says “every-thing is okay.’’ About noon one of the LVNs comes to you and says thatthe new nurse has not delegated tasks appropriately and is trying to dotoo much of the work herself. Additionally, some of the other members ofthe team find her unsmiling behavior and lack of eye contact unsettling.Assignment: Do you feel that you made an appropriate assignment? Sincethings do not seem to be going well, what should you do now? In a smallgroup develop a plan of action with the following goals: 1) ensure patientcare is accomplished safely, 2) build self-esteem in the Korean nurse, and3) be a cultural bridge to staff.


The right to delegateand the ability toprovide formal rewardsfor successful completionof delegated tasksreflect the legitimateauthority inherent in themanagement role.

❊ Key Concepts

• Professional nursing organizations and regulatory bodies are activelyengaged in clarifying the scope of practice for unlicensed workers anddelegation parameters for registered nurses.

• Delegation is not an option for the manager—it is a necessity.• Delegation should be used for assigning routine tasks and tasks for which

the manager does not have time. It also is appropriate as a tool for problemsolving, changes in the manager’s own job emphasis, and building capabilityin subordinates.

• In delegation, managers must clearly communicate what they want done,including the purpose for doing so. Limitations or qualifications that havebeen imposed should be delineated. Although the manager should specifythe end product desired, it is important that the subordinate have an appro-priate degree of autonomy in deciding how the work is to be accomplished.

• Managers must delegate the authority and the responsibility necessary tocomplete the task.

• RNs asked to assume the role of supervisor and delegator need preparationto assume these leadership tasks.

• Assuming the role of delegator and supervisor to UAP increases the scopeof liability for the RN.

• Although the Omnibus Budget Reconciliation Act of 1987 establishedregulations for the education and certification of “nurse’s aides’’ (mini-mum of 75 hours of theory and practice and successful completion of anexamination in both areas), no federal or community standards have beenestablished for training the more broadly defined UAP.

• The RN always bears the ultimate responsibility for ensuring that the nurs-ing care provided by his or her team members meets or exceeds minimumsafety standards.

• When subordinates resist delegation, the delegator must ascertain why thedelegated task was not accomplished and take appropriate action to removethese restraining forces.

• Transcultural sensitivity in delegation is needed to create a productive multi-cultural work team.


More Learning Exercises and Applications


Need for Immediate DelegationYou are the charge nurse on the 7 AMAM to 3 PMPM shift in an oncology unit.Immediately after report in the morning, you are overwhelmed by thefollowing information:• The nursing aide reports that Mrs. Jones has become comatose and is

moribund. Although this is not unexpected, her family members are notpresent, and you know they would like to be notified immediately.

• There are three patients who need 0730 parenteral insulin administra-tion. One of these patients had an 0600 blood sugar of 400.

• Mr. Johnson inadvertently pulled out his central line catheter when hewas turning over in bed. His wife just notified the ward clerk by the calllight system but states she is applying pressure to the site.

• The public toilet is overflowing, and urine and feces are pouring outrapidly.

• Breakfast trays arrived 15 minutes ago, and patients are using their calllights to ask why they do not yet have their breakfast.

• The medical director of the unit has just discovered that one of herpatients has not been started on a chemotherapeutic drug she orderedthree days ago. She is furious and demands to speak to you immediately.

Assignment: The other RNs are all very busy with their patients, but youdo have the following people to whom you may delegate: yourself, award clerk, and an IV-certified LVN/LPN. Decide who should do what andin what priority. Justify your decision.



Issues with Delegating DisciplineYou are the supervisor of the oncology unit. One of your closest friendsand colleagues is Paula, the supervisor of the medical unit. Frequently,you cover for each other in the event of absence or emergency. Today,Paula stops at your office to let you know that she will be gone for sevendays to attend a management workshop on the East Coast. She asks thatyou check on the unit during her absence. She also asks that you pay par-ticularly close attention to Mary Jones, an employee on her unit. Shestates that Mary, an employee at the hospital for four years, has beencounseled repeatedly about her unexcused absences from work and hasrecently received a written reprimand specifying that she will be termi-nated if there is another unexcused absence. Paula anticipates that Marymay attempt to break the rules during her absence. She asks that you fol-low through on this disciplinary plan in the event that Mary again takesan unexcused absence. Her instructions to you are to terminate Mary ifshe fails to show up for work this week for any reason.

When you arrive at work the next day, you find that Mary called in sick20 minutes after the shift was to begin. The hospital’s policy is thatemployees are to notify the staffing office of illness no less than twohours before the beginning of their shift. When you attempt to contactMary by telephone at home, there is no answer.

Later in the day, you finally reach Mary and ask that she come in toyour office early the next morning to speak about her inadequate noticeof sick time. Mary arrives 45 minutes late the next morning. You arealready agitated and angry with her. You inform her that she is to beterminated for any rule broken during Paula’s absence and that thisaction is being taken in accord with the disciplinary contract that hadbeen established earlier.

Mary is furious. She states that you have no right to fire her becauseyou are not her real boss and that Paula should face her herself. She goeson to say, “Paula told me that the disciplinary contract was just a way offormalizing that we had talked and that I shouldn’t take it too seriously.’’Mary also says, “Besides, I didn’t get sick until I was getting ready forwork. The hospital rules state that I have 12 sick days each year.’’Although you feel certain that Paula was very clear about her position inreviewing the disciplinary contract with Mary, you begin to feel uncom-fortable with being placed in the position of having to take such seriouscorrective action without having been involved in prior disciplinary reviewsessions. You are, however, also aware that this employee has been break-ing rules for some time and that this is just one in a succession ofabsences. You also know that Paula is counting on you to provide consis-tency of leadership in her absence.Assignment: Discuss how you will handle the situation. Was it appropriatefor Paula to delegate this responsibility to you? Is it appropriate for onemanager to carry out another manager’s disciplinary plan? Does it mat-ter that a written disciplinary contract had already been established?



How Will You Plan this Busy Morning?You are a staff nurse who functions as a modular leader on a generalmedical-surgical unit. The group for which you are responsible isassigned patients in Rooms 401 through 409, with a maximum capacityof 13 patients.

In your unit, a modular type of patient care organization is employed,using a combination of licensed and unlicensed staff. Each module con-sists of one RN, one LVN/LPN, and one UAP. The LVN/LPN is IV certified andcan maintain and start IVs, but cannot hang piggybacks or give IV pushmedications. The LVN/LPN may give all other medications except IV med-ications. The RN gives all IV medications. The UAP, with the assistance ofhis or her modular team members, generally bathes and feeds patientsand provides other care that does not require a license.

The RN, as modular leader, divides up the workload at the beginningof the shift between the three modular team members. In addition, heor she acts as a teacher and resource person for the other members ofthe module.

Today is Wednesday. You have one LVN/LPN and one UAP assigned towork with you—LVN Franklin and UAP Martinez.

LVN Franklin is 26 years old and the mother of four preschool children.Her husband is a city bus driver. UAP Martinez is 53 years old and a grand-mother with no children living at home. Her husband died two years ago.She says that work keeps her “happy.’’ The patient roster this morning isas follows:

Room Patient Age Diagnosis Condition Acuity level

401 Mrs. Jones 33 Mastectomy for 2 days IIbreast CA postop/fair

402 Mrs. Redford 55 Back Pain—Pelvic Good I403 Mrs. Worley 46 Cholecystectomy 2 days postop/ III

good404-1 Mrs. Smith 83 Parkinson’s, CVD Fair II

hypertension404-2 Mrs. Dewey 26 PID Good—home I

today405-1 Mr. Arthur 71 Metastatic CA Poor—semi- IV

comatose/Chemotherapy

405-2 Mr. Vines 34 Possible peptic Good—UGI IIIulcer today

406-1 Vacant406-2 Miss Brown 24 Dilatation and To OR this a.m. III

curettage



Room Patient Age Diagnosis Condition Acuity level

407-1 Mrs. West 41 Myocardial Fair/from ICU IIIinfarction yesterday

Heparin lock/telemetry

408-1 Mr. Niles 21 Open reduction Fair/3 days IIIfemur (MVA) postop

408-2 Mr. Ford 44 Gastrectomy Fair/1 day IIIpostop

409 Mrs. Land 42 Depression Fair/BA enema IIItoday

Additional information about patients:• Mr. Niles is depressed because he believes his football career is over.• There have been problems with Mr. Ford’s IV and his nasogastric tube.

Both will need to be replaced today.• Mrs. Worley requires frequent changes (every two to three hours) of

the dressings at the laparoscopy site owing to a high volume of serousdrainage.

• Mrs. Jones will need instructions regarding her postoperative activitiesand has begun to talk about her prognosis.

• Mrs. Land began to talk with you yesterday about her husband’s recentdeath.

• The preparation for the barium enema will result in Mrs. Land’s havingfrequent toileting needs today.

• Mrs. Smith requires assistance with feeding at mealtime.• Mr. Arthur is no longer able to turn himself in bed.• Mr. Vines states that being in the same room with a critically ill patient

upsets him, and he has asked to move to a new room.Assignment: How will you make out your assignments this morning?Assign these patients to the LVN/LPN, UAP, and yourself. Be sure toinclude assessments, procedures, and basic care needs. What will you do if a patient is admitted to your team? Explain the rationale for allyour patient assignments. Sample acuity levels are provided to assist indetermining patient needs and staffing (see patient roster above).


Evaluating Staffing SafeguardsInterview a middle- or top-level manager of a local healthcare agency.Ascertain the staffing mix at his or her agency. Are there minimum hiringcriteria for UAP? Are there written guidelines for determining tasksappropriate for UAP delegation? What educational or training opportuni-ties on delegation are made available to staff who must delegate workassignments on a regular basis?

On the basis of your interview results, write an essay evaluatingwhether you believe there are adequate safeguards in place at thatagency to protect the licensed staff, unlicensed staff, and clients. Wouldyou feel comfortable working in such a facility?

Learning Exercise 20.8A

Deciding Delegation Using the Nurse Practice ActWhich of the following tasks would you be willing to delegate to a UAP?Use your state’s Nurse Practice Act as a reference for this case. Discussyour answers in small groups. Did you all agree? If not, what factors weresignificant in your differences?1. Uncomplicated wet-to-dry dressing change on patient three days

post–hip replacement2. Every-two-hour checks on patient with soft wrist restraints to assess

circulation, movement, and comfort3. Cooling measures for patient with temperature of 104ºF4. Calculation of IV credits, clearing IV pumps, and completing shift

intake/output totals5. Completing phlebotomy for daily blood draws6. Holding pressure on insertion site of femoral line that has just been

removed7. Educating a patient about components of a soft diet8. Testing stool specimens for guaiac blood9. Performing electrocardiogram testing

10. Feeding a patient with swallowing precautions (high risk of chokingpost CVA)

11. Oral suctioning12. Tracheostomy care13. Ostomy care


Web Links

RN Utilization of Unlicensed Assistive Personnelhttp://www.ana.org/readroom/position/uap/uapuse.htmPosition statement of the ANA regarding the utilization of UAP. Effective date Decem-ber 11, 1992, although ANA work on the UAP issue is ongoing.

Delegation Tipshttp://www.liraz.com/tdelegat.htmEffective delegation will not only give you more time to work on your important oppor-tunities, but you will also help others on your team learn new skills.

The Art of Delegation. By Gerald M. Blair.http://www.see.ed.ac.uk/~gerard/management/art5.htmlDelegation is a skill of which we have all heard—but which few understand.

Project Management Delegationhttp://www.see.ed.ac.uk/~gerard/MENG/ME96/Documents/Aspects/delegate.htmlDelegation—A key aspect of leadership is delegation.

The Five Rights of Delegationhttp://www.state.ma.us/reg/boards/rn/advrul/thefive.htmThe Board of Registration in Nursing (Massachusetts) presents a framework for dele-gation decision making and accountability based on a model that identifies the five keyelements of any delegated act: the right task, the right circumstances, the right person,the right direction/communication, and the right supervision and evaluation.

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