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Clinical Delegation. Wanda Rose PhD, RN,BC. Objectives. Define delegation. Describe the role of the RN in terms of delegation. Review model for delegation decision making process. Discuss standing orders. Delegation.

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Clinical delegation

Clinical Delegation

Wanda Rose PhD, RN,BC


  • Define delegation.

  • Describe the role of the RN in terms of delegation.

  • Review model for delegation decision making process.

  • Discuss standing orders.


  • “transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome” (ANA).

  • “transferring to a competent individual the authority to perform a selected task in a selected situation. The nurse retains accountability for the delegation.” ( NCSBN).


Being accountable means being answerable for what one has done and standing behind that decision and/or action.

Clinical delegation

Delegation is not merely handing out assignments or tasks

It is entrusting and empowering the subordinate and

Sharing of both responsibility and authority. However, even when responsibility and authority are passed on, the

Registered nurse remains totally accountable for

the end results.

Nd nurse practices act chapter 43 12 1


Definition of nursing chapter 43 12 1
Definition of Nursing Chapter 43-12.1

"Nursing" means the performance of acts utilizing specialized knowledge, skills, and abilities for people in a variety of settings. The term includes the following acts, which may not be deemed to include acts of medical diagnosis or treatment or the practice of medicine as defined in chapter 43-17:

Clinical delegation

a. The maintenance of health and prevention of illness.

b. Diagnosing human responses to actual or potential health problems.

c. Providing supportive and restorative care and nursing treatment, medication administration, health counseling and teaching, case finding and referral of individuals who are ill, injured, or experiencing changes in the normal health processes.

d. Administration, teaching, supervision, delegation, and evaluation of health and nursing practices.

e. Collaboration with other health care professionals in the implementation of the total health care regimen and execution of the health care regimen prescribed by a health care practitioner licensed under the laws of this state.

Nd nurse practices act chapter 43 12 11

43-12.1-18. Nursing practice standards. The board shall adopt rules establishing standards for nursing practice.

Nd nurse practice act 43 12 1
ND Nurse Practice Act 43-12.1

43-12.1 allows the licensed nurse to delegate and supervise nursing interventions to individuals authorized by the board to perform those functions.

North dakota administrative code 54 05 02 standards of practice for registered nurses
North Dakota Administrative Code 54-05-02Standards of Practicefor Registered Nurses

  • 54-05-02-02.1 Registered nurse responsibility to implement the nursing process.

    • Implement the plan of care and the nursing interventions for the client under the RN’s care by

      • Determining the responsibilities that can properly and safely be assigned as defined in section 54-05-02-02.2

      • Determining the responsibilities that can safely be delegated as defined in chapter 54-05-04.

Chapter 54 05 04 standards for delegation
Chapter 54-05-04 Standards for Delegation

54-05-04-01Licensed nurses are directly accountable

and responsible to clients for the nature and quality

of all nursing care rendered. It is not the setting

or the position title that determines a nursing

practice role, but rather the application of nursing

knowledge. Licensed nurses provide care through

a variety of roles including:

Registered nursing
Registered Nursing

  • Practice independently and interdependently through the application of the nursing process.

  • Assigning and delegating nursing interventions that may be performed by others.

Licensed practical nurses
Licensed Practical Nurses

  • Practice dependently under the direction of RN, APRN, or licensed practitioners through the application of the nursing process and the execution of diagnostic or therapeutic regimens prescribed by licensed practitioners.

Unlicensed assistive persons
Unlicensed assistive persons

  • Complement the licensed nurse in the performance of nursing interventions.

  • May not substitute for the licensed nurse

  • Responsible to the licensed nurse

    • Includes Medication Assistant

North dakota administrative code 54 05 04 standards for delegation
North Dakota Administrative Code 54-05-04Standards for Delegation

  • 54-05-04-03 Delegation process for nursing interventions. A licensed nurse may delegate a nursing intervention to a competent unlicensed assistive person if the licensed nurse utilizes a decision-making process to delegate in a manner that protects public health, welfare, and safety.

Delegation process nd administrative code 54 05 05 03
Delegation ProcessND Administrative Code 54-05-05-03

  • Assessment of client and human and material resources.

  • Planning for delegation.

  • Implementation of the delegated nursing intervention by providing direction and supervision.

  • Evaluation of the delegated nursing intervention.

Five rights of delegation
Five Rights of Delegation process.

Right Task

Right Circumstances

Right Person

Right Direction/Communication

Right Feedback

Right task
Right Task process.

  • Can the task be delegated?

  • Is the task fairly routine with predictable outcomes?

  • Is there minimal risk?

  • Does not require nursing judgment, including assessment, planning and evaluation.

Right circumstance
Right Circumstance process.

  • Does the complexity of the task match the competency of the delegate?

  • How available is supervision?

    • Direct supervision

    • Indirect supervision

Right person
Right Person process.

  • Is the person competent to perform this task?

    • Training

    • Experience

    • Competency

      How will you know?

    • Teach

    • Observe

    • Verify

Right direction communication
Right Direction/Communication process.





Is there access to written instructions?

Does it identify the specific task?

Does it identify the timeline?

Does it identify the outcome you would like?

Right feedback supervision
Right Feedback/Supervision process.

How are you monitoring performance?

Are you available for follow-up or questions?

What provisions do you have for feedback?

How will you measure client’s response and goal attainment related to delegated interventions?

Do you give feedback based on outcome of the task?

Did you document your findings?

54 07 05 01 medication administration
54-07-05-01 process.Medication Administration

Unlicensed assistive persons who have completed a prescribed training program in medication administration or who have been delegated the delivery of a specific medication for a specific client may perform the intervention of giving or applying routine, regularly scheduled medications to the client. The medication assistant III may perform the intervention of administering medications to the client in an ambulatory health care setting. The licensed nurse must be available to monitor the client’s progress and effectiveness of the prescribed medication regimen. Delegation of medication administration in acute care settings or for individuals with unstable or changing nursing care needs is specifically precluded by these rules.

54 07 05 04 medication administration supervision
54-07-05-04 process.Medication AdministrationSupervision

  • 1. In a licensed nursing facility, the licensed nurse must be on the unit and available for immediate direction.

  • 2. In an ambulatory health care setting where the licensed nurse delegates

    the intervention of giving medications to another individual, the licensed nurse must be available for direction.

  • 3. In any other setting where the licensed nurse delegates the intervention of giving medications to another individual, the licensed nurse must

    establish in writing the process for providing the supervision in order to provide the recipient of the medication appropriate safeguards.

Summary process.

Delegation is a legal and management concept

and a process that involves assessment, planning,

intervention, and evaluation in which selected

nursing tasks are transferred from one person in

authority to another person, involving trust,

empowerment, and the responsibility and authority

to perform the task. In delegation, communication

is succinct, guidelines are clearly delineated in advance

and progress is constantly monitored in which

the person in authority remains accountable for the

final outcomes.

Standing orders
Standing Orders process.

  • Written protocol/instruction

    • Details of condition

    • Patient/population to whom it applies

    • Dosage and administration guidelines

    • Contraindications to the medications

    • Instructions to be given

    • Follow-up

  • Non patient/client specific

  • Approved and signed by medical director

Standing orders1
Standing Orders process.

Based on established clinical practice guidelines .

Suited for routine situations.

Enable nurses to assess the care needs of their patients and to initiate appropriate action without delays that may occur when physician contact is required.

Empower nurses to implement certain procedures and activities on behalf of physicians, enabling more immediate interventions, and ultimately improving patient care.

Save valuable time for patients, physicians and nurses.

Advantages of standing orders
Advantages of Standing Orders process.

Increases patient access to treatment.

Provide a safe and effective method of extending the role of the nurse.

Efficient and effective tools for routine situations.

Barriers to standing orders
Barriers to Standing Orders process.

Deviations occur

Lack of communication when deviation occurs

Lack of knowledge and skills of health practitioner following the standing orders.

Standing order protocol development
Standing Order/Protocol Development process.

1. Determine a common clinical issue that would benefit from a standing order.

2. Establish a multidisciplinary team.

3. Review national and individual practice guidelines.

4. Complete a literature search for articles centered on evidence based practice.

5. Contact the state board of nursing to review state laws regarding standing orders.


Figure 1. Steps to Initiate a Standing Order

Note. Based on information from Maxwell, 2005.

Standing order protocol cont
Standing Order/Protocol cont. process.

6. Contact the facility’s continuous quality-improvement committee for facility guidelines.

7. Meet regularly as a work group to review the process.

8. Develop the standing order.

9. Pilot test.

10. Finalize the standing order.

11. Obtain administrative approval.

12. Provide ongoing, focused staff and patient education.

13. Audit and update standing orders on a regular basis

Implementing standing orders recommendations
Implementing Standing Orders process.Recommendations

Preprinted order sets.

Must be documented as an order in the patient’s medical record (Centers for Medicare & Medicaid Services, Oct. 24, 2008)

Place copy of the standing orders in the chart.

Signed by the practitioner responsible for the care of the patient after implementation of standing order


Summary process.

Finally, for successful implementation and

long-term adherence, healthcare professionals should develop a plan to educate staff and patients about use of the standing order and audit and update the order regularly.