There is no doubt that delegation skills are needed in healthcare. At its worst, delegation can be used as a form of abdication, but at its best, delegation can provide enormous benefits resulting from the optimum use of human resources (Wheeler 2001).

What Does it Mean to Delegate?

Gillen and Graffin (2010) suggest that several definitions of delegation can be found within nursing literature, but they all share the same emphasis - that even though the work is done by a junior member of staff, the accountability and responsibility remain with the delegator, who needs to ensure the work is assigned appropriately.

As the Royal College of Nursing (2015) clearly states, nurses must be accountable for their decisions to delegate tasks and duties to other people. For the delegating nurse, this means:

• You must establish that anyone you delegate to can carry out your instruction.
• You must confirm that the outcome of any delegated task meets the required standards
• You must make sure that everyone you are responsible for is supervised and supported.

Delegation should also only take place when it is in the best interests of the person receiving the care, and when a holistic assessment of need has been undertaken by the nurse who delegates. Employers also have a responsibility to ensure that practitioners to whom nurses delegate tasks have the appropriate education, training and skills to carry out those tasks.

However, the nurse who delegates the task retains the responsibility to judge the appropriateness of the delegation by:

• Reassessing the condition of the patient at appropriate intervals and determining that it remains stable and predictable
• Observing the competence of the caregiver and determining that they remain competent to perform the delegated task safely and effectively
• Evaluating whether or not to continue delegation of the task.

(RCN 2015)

Essential Components of Delegation

Matching the right person with the right expertise for the right job is a complex professional skill requiring sophisticated clinical judgment and the willingness to have final accountability for patient care (Weydt 2010). Yet, done well, delegation can significantly improve patient care outcomes.

Barrow and Sharma (2019) note the need for the three key components of responsibility, authority and accountability to be in place if delegation is going to be successful. They describe the 'five rights of delegation' as:

1. Right task
2. Right circumstance
3. Right person
4. Right supervision
5. Right direction and communication.

Others in the wider team must also be informed of the delegation, whilst the delegator should provide ongoing evaluation so that any difficulties can be eliminated (Eveleigh 2018).

How to Delegate Safely

In theory, the delegation of roles and responsibilities should be a win-win situation, creating manageable workloads while also providing patients with the care they need.

For delegation to be safe and successful, the tasks allocated must be appropriate for the skill level of the delegate. In addition to having the necessary skills and experience to work safely, they must also be able to show that they have clearly understood the task. Furthermore, they must be adequately supervised and supported to ensure a high standard of care.

As Eveleigh (2018) notes, if these elements are in place, the practitioner is not accountable for the decisions and actions of the person performing the delegated task. The person delegated then becomes accountable because:

• They have the ability (knowledge and skills) to undertake the activity or intervention
• They accept the responsibility for performing the activity
• They have the authority to perform the activity because it is within their job description
• They take social, ethical, legal and contractual accountability and are responsible for the tasks they accept.

Eveleigh (2018) also offers the following checklist to help practitioners decide if it is safe to delegate:

• Is it in the patient’s best interests to delegate this duty to another member of staff?
• Have you considered the wider situation and not just the duty itself?
• Have you thought about the clinical risks?
• Do you have the authority and appropriate clinical knowledge to delegate the duty?
• Does the person you are delegating to have the appropriate knowledge, skills and competence to perform the task?
• Does the duty lie within the other person’s job description?
• Can you provide support and supervision to the other person?
• Can you check that the outcome meets the required clinical standard?

Barriers to Delegation

The three key elements in the act of delegation include the delegator, the delegate, and finally, the situational context.

As Gillen and Graffin (2010) make clear, any of these elements, or a combination of any of them, can become a barrier to the delegation process, though most can be overcome with effective education and training. For example:

Barriers relating to delegators include:

• Their preference to work alone
• Lack of experience or insecurity
• Lack of confidence in subordinates
• Desire for control
• Lack of organisational or managerial skills
• Unwillingness to develop subordinates and help them grow in their roles.

Barriers that may arise from the perspective of the delegated practitioner include:

• Lack of experience
• Lack of competence
• Avoidance of responsibility
• Lack of organisational skills
• Excessive amounts of work.

Barriers that may arise as a result of the situational context include:

• The critical nature of decisions
• The urgency of those decisions
• Confusion relating to responsibility
• Authority and understaffing.

Critical Thinking Skills

Delegation and critical thinking skills naturally go hand-in-hand. They both require nurses to process large amounts of information and think through complex and often emergent clinical situations whilst making critical decisions about patient care, including delegation.

To gain a better understanding of this process, Bittner and Gravlin (2009) conducted a study to investigate how nurses use critical thinking to delegate care. They found that before delegating, nurses reported considering the patient’s condition, competency and experience, and the workload of the junior member of staff. They also expected the delegating nurse to report significant findings and have higher-level knowledge, including assessment and prioritising skills.

Yet, whilst all of these qualities are important, the real key to successful delegation was the relationship between the delegating nurse and the person assigned the task. In other words, successful delegation was ultimately about good communication and nursing leadership. Even so, Bittner and Gravlin (2009) reported that there were frequent instances of missed or omitted routine care that had been delegated.

Like anything else, delegation skills have to be practised to be perfected. Otherwise, standards of care can suffer and valuable resources mismanaged. As Weydt (2010) notes, resources will surely continue to shrink and care demands will surely continue to rise, increasing the risks of inappropriate delegation.

Knowing when, how and to whom you can delegate requires a deep understanding of the task at hand, as well as confidence in the process of delegation. All of this has to be balanced with the skills, experience and existing workloads of the people available.

Achieving the right balance is crucial because delegating too much may result in a loss of control while failing to delegate or not delegating enough can lead to missed or inadequate care and a demotivated or uncooperative team (Wheeler 2001). Yet, when delegation is done well, everybody wins.