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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022.

Nursing Management and Professional Concepts [Internet].

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Chapter 4 - Leadership and Management

4.1. leadership & management introduction, learning objectives.

• Compare and contrast the role of a leader and a manager

• Examine the roles of team members

• Identify the activities managers perform

• Describe the role of the RN as a leader and change agent

• Evaluate the effects of power, empowerment, and motivation in leading and managing a nursing team

• Recognize limitations of self and others and utilize resources

As a nursing student preparing to graduate, you have spent countless hours on developing clinical skills, analyzing disease processes, creating care plans, and cultivating clinical judgment. In comparison, you have likely spent much less time on developing management and leadership skills. Yet, soon after beginning your first job as a registered nurse, you will become involved in numerous situations requiring nursing leadership and management skills. Some of these situations include the following:

• Prioritizing care for a group of assigned clients
• Collaborating with interprofessional team members regarding client care
• Participating in an interdisciplinary team conference
• Acting as a liaison when establishing community resources for a patient being discharged home
• Serving on a unit committee
• Investigating and implementing a new evidence-based best practice
• Mentoring nursing students

Delivering safe, quality client care often requires registered nurses (RN) to manage care provided by the nursing team. Making assignments, delegating tasks, and supervising nursing team members are essential managerial components of an entry-level staff RN role. As previously discussed, nursing team members include RNs, licensed practical/vocational nurses (LPN/VN), and assistive personnel (AP).[ 1 ]

Read more about assigning, delegating, and supervising in the “ Delegation and Supervision ” chapter.

An RN is expected to demonstrate leadership and management skills in many facets of the role. Nurses manage care for high-acuity patients as they are admitted, transferred, and discharged; coordinate care among a variety of diverse health professionals; advocate for clients’ needs; and manage limited resources with shrinking budgets.[ 2 ]

Read more about collaborating and communicating with the interprofessional team; advocating for clients; and admitting, transferring, and discharging clients in the “ Collaboration Within the Interprofessional Team ” chapter.

An article published in the  Online Journal of Issues in Nursing  states, “With the growing complexity of healthcare practice environments and pending nurse leader retirements, the development of future nurse leaders is increasingly important.”[ 3 ] This chapter will explore leadership and management responsibilities of an RN. Leadership styles are introduced, and change theories are discussed as a means for implementing change in the health care system.

4.2. BASIC CONCEPTS

Organizational culture.

The formal leaders of an organization provide a sense of direction and overall guidance for their employees by establishing organizational vision, mission, and values statements. An organization’s  vision statement  defines why the organization exists, describes how the organization is unique from similar organizations, and specifies what the organization is striving to be. The  mission statement  describes how the organization will fulfill its vision and establishes a common course of action for future endeavors. See Figure 4.1 [ 1 ] for an illustration of a mission statement. A  values statement  establishes the values of an organization that assist with the achievement of its vision and mission. A values statement also provides strategic guidelines for decision-making, both internally and externally, by members of the organization. The vision, mission, and values statements are expressed in a concise and clear manner that is easily understood by members of the organization and the public.[ 2 ]

Mission Statement

Organizational culture  refers to the implicit values and beliefs that reflect the norms and traditions of an organization. An organization’s vision, mission, and values statements are the foundation of organizational culture. Because individual organizations have their own vision, mission, and values statements, each organization has a different culture.[ 3 ]

As health care continues to evolve and new models of care are introduced, nursing managers must develop innovative approaches that address change while aligning with that organization’s vision, mission, and values. Leaders embrace the organization’s mission, identify how individuals’ work contributes to it, and ensure that outcomes advance the organization’s mission and purpose. Leaders use vision, mission, and values statements for guidance when determining appropriate responses to critical events and unforeseen challenges that are common in a complex health care system. Successful organizations require employees to be committed to following these strategic guidelines during the course of their work activities. Employees who understand the relationship between their own work and the mission and purpose of the organization will contribute to a stronger health care system that excels in providing first-class patient care. The vision, mission, and values provide a common organization-wide frame of reference for decision-making for both leaders and staff.[ 4 ]

Learning Activity

Investigate the mission, vision, and values of a potential employer, as you would do prior to an interview for a job position.

Reflective Questions

1. How well do the organization’s vision and values align with your personal values regarding health care?

2. How well does the organization’s mission align with your professional objective in your resume?

Followership

Followership  is described as the upward influence of individuals on their leaders and their teams. The actions of followers have an important influence on staff performance and patient outcomes. Being an effective follower requires individuals to contribute to the team not only by doing as they are told, but also by being aware and raising relevant concerns. Effective followers realize that they can initiate change and disagree or challenge their leaders if they feel their organization or unit is failing to promote wellness and deliver safe, value-driven, and compassionate care. Leaders who gain the trust and dedication of followers are more effective in their leadership role. Everybody has a voice and a responsibility to take ownership of the workplace culture, and good followership contributes to the establishment of high-functioning and safety-conscious teams.[ 5 ]

Team members impact patient safety by following teamwork guidelines for good followership. For example, strategies such as closed-loop communication are important tools to promote patient safety.

Read more about communication and teamwork strategies in the “ Collaboration Within the Interprofessional Team ” chapter.

Leadership and Management Characteristics

Leadership and management are terms often used interchangeably, but they are two different concepts with many overlapping characteristics.  Leadership  is the art of establishing direction and influencing and motivating others to achieve their maximum potential to accomplish tasks, objectives, or projects.[ 6 ],[ 7 ] See Figure 4.2 [ 8 ] for an illustration of team leadership. There is no universally accepted definition or theory of nursing leadership, but there is increasing clarity about how it differs from management.[ 9 ]  Management  refers to roles that focus on tasks such as planning, organizing, prioritizing, budgeting, staffing, coordinating, and reporting.[ 10 ] The overriding function of management has been described as providing order and consistency to organizations, whereas the primary function of leadership is to produce change and movement.[ 11 ] View a comparison of the characteristics of management and leadership in Table 4.2a .

Management and Leadership Characteristics[ 12 ]

View in own window

Not all nurses are managers, but all nurses are leaders because they encourage individuals to achieve their goals. The American Nurses Association (ANA) established  Leadership  as a Standard of Professional Performance for all registered nurses. Standards of Professional Performance are “authoritative statements of action and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently.”[ 13 ] See the competencies of the ANA  Leadership  standard in the following box and additional content in other chapters of this book.

Competencies of ANA’s Leadership Standard of Professional Performance

• Promotes effective relationships to achieve quality outcomes and a culture of safety

• Leads decision-making groups

• Engages in creating an interprofessional environment that promotes respect, trust, and integrity

• Embraces practice innovations and role performance to achieve lifelong personal and professional goals

• Communicates to lead change, influence others, and resolve conflict

• Implements evidence-based practices for safe, quality health care and health care consumer satisfaction

• Demonstrates authority, ownership, accountability, and responsibility for appropriate delegation of nursing care

• Mentors colleagues and others to embrace their knowledge, skills, and abilities

• Participates in professional activities and organizations for professional growth and influence

• Advocates for all aspects of human and environmental health in practice and policy

Read additional content related to leadership and management activities in corresponding chapters of this book:

• Read about the culture of safety in the “ Legal Implications ” chapter.

• Read about effective interprofessional teamwork and resolving conflict in the “ Collaboration Within the Interprofessional Team ” chapter.

• Read about quality improvement and implementing evidence-based practices in the “ Quality and Evidence-Based Practice ” chapter.

• Read more about delegation, supervision, and accountability in the “ Delegation and Supervision ” chapter.

• Read about professional organizations and advocating for patients, communities, and their environments in the “ Advocacy ” chapter.

• Read about budgets and staffing in the “ Health Care Economics ” chapter.

• Read about prioritization in the “ Prioritization ” chapter.

Leadership Theories and Styles

In the 1930s Kurt Lewin, the father of social psychology, originally identified three leadership styles: authoritarian, democratic, and laissez-faire.[ 14 ],[ 15 ]

Authoritarian leadership  means the leader has full power. Authoritarian leaders tell team members what to do and expect team members to execute their plans. When fast decisions must be made in emergency situations, such as when a patient “codes,” the authoritarian leader makes quick decisions and provides the group with direct instructions. However, there are disadvantages to authoritarian leadership. Authoritarian leaders are more likely to disregard creative ideas of other team members, causing resentment and stress.[ 16 ]

Democratic leadership  balances decision-making responsibility between team members and the leader. Democratic leaders actively participate in discussions, but also make sure to listen to the views of others. For example, a nurse supervisor may hold a meeting regarding an increased incidence of patient falls on the unit and ask team members to share their observations regarding causes and potential solutions. The democratic leadership style often leads to positive, inclusive, and collaborative work environments that encourage team members’ creativity. Under this style, the leader still retains responsibility for the final decision.[ 17 ]

Laissez-faire  is a French word that translates to English as, “leave alone.” Laissez-faire leadership gives team members total freedom to perform as they please. Laissez-faire leaders do not participate in decision-making processes and rarely offer opinions. The laissez-faire leadership style can work well if team members are highly skilled and highly motivated to perform quality work. However, without the leader’s input, conflict and a culture of blame may occur as team members disagree on roles, responsibilities, and policies. By not contributing to the decision-making process, the leader forfeits control of team performance.[ 18 ]

Over the decades, Lewin’s original leadership styles have evolved into many styles of leadership in health care, such as passive-avoidant, transactional, transformational, servant, resonant, and authentic.[ 19 ],[ 20 ] Many of these leadership styles have overlapping characteristics. See Figure 4.3 [ 21 ] for a comparison of various leadership styles in terms of engagement.

Leadership Styles

Passive-avoidant leadership  is similar to laissez-faire leadership and is characterized by a leader who avoids taking responsibility and confronting others. Employees perceive the lack of control over the environment resulting from the absence of clear directives. Organizations with this type of leader have high staff turnover and low retention of employees. These types of leaders tend to react and take corrective action only after problems have become serious and often avoid making any decisions at all.[ 22 ]

Transactional leadership  involves both the leader and the follower receiving something for their efforts; the leader gets the job done and the follower receives pay, recognition, rewards, or punishment based on how well they perform the tasks assigned to them.[ 23 ] Staff generally work independently with no focus on cooperation among employees or commitment to the organization.[ 24 ]

Transformational leadership  involves leaders motivating followers to perform beyond expectations by creating a sense of ownership in reaching a shared vision.[ 25 ] It is characterized by a leader’s charismatic influence over team members and includes effective communication, valued relationships, and consideration of team member input. Transformational leaders know how to convey a sense of loyalty through shared goals, resulting in increased productivity, improved morale, and increased employees’ job satisfaction.[ 26 ] They often motivate others to do more than originally intended by inspiring them to look past individual self-interest and perform to promote team and organizational interests.[ 27 ]

Servant leadership  focuses on the professional growth of employees while simultaneously promoting improved quality care through a combination of interprofessional teamwork and shared decision-making. Servant leaders assist team members to achieve their personal goals by listening with empathy and committing to individual growth and community-building. They share power, put the needs of others first, and help individuals optimize performance while forsaking their own personal advancement and rewards.[ 28 ]

Visit the Greenleaf Center site to learn more about  What is Servant Leadership ?

Resonant leaders  are in tune with the emotions of those around them, use empathy, and manage their own emotions effectively. Resonant leaders build strong, trusting relationships and create a climate of optimism that inspires commitment even in the face of adversity. They create an environment where employees are highly engaged, making them willing and able to contribute with their full potential.[ 29 ]

Authentic leaders  have an honest and direct approach with employees, demonstrating self-awareness, internalized moral perspective, and relationship transparency. They strive for trusting, symmetrical, and close leader–follower relationships; promote the open sharing of information; and consider others’ viewpoints.[ 30 ]

Characteristics of Leadership Styles

Outcomes of Various Leadership Styles

Leadership styles affect team members, patient outcomes, and the organization. A systematic review of the literature published in 2021 showed significant correlations between leadership styles and nurses’ job satisfaction. Transformational leadership style had the greatest positive correlation with nurses’ job satisfaction, followed by authentic, resonant, and servant leadership styles. Passive-avoidant and laissez-faire leadership styles showed a negative correlation with nurses’ job satisfaction.[ 31 ] In this challenging health care environment, managers and nurse leaders must promote technical and professional competencies of their staff, but they must also act to improve staff satisfaction and morale by using appropriate leadership styles with their team.[ 32 ]

Systems Theory

Systems theory  is based on the concept that systems do not function in isolation but rather there is an interdependence that exists between their parts. Systems theory assumes that most individuals strive to do good work, but are affected by diverse influences within the system. Efficient and functional systems account for these diverse influences and improve outcomes by studying patterns and behaviors across the system.[ 33 ]

Many health care agencies have adopted a culture of safety based on systems theory. A  culture of safety  is an organizational culture that embraces error reporting by employees with the goal of identifying systemic causes of problems that can be addressed to improve patient safety. According to The Joint Commission, a culture of safety includes the following components[ 34 ]:

• Just Culture:  A culture where people feel safe raising questions and concerns and report safety events in an environment that emphasizes a nonpunitive response to errors and near misses. Clear lines are drawn by managers between human error, at-risk, and reckless employee behaviors. See Figure 4.4 [ 35 ] for an illustration of Just Culture.
• Reporting Culture:  People realize errors are inevitable and are encouraged to speak up for patient safety by reporting errors and near misses. For example, nurses complete an “incident report” according to agency policy when a medication error occurs or a client falls. Error reporting helps the agency manage risk and reduce potential liability.
• Learning Culture:  People regularly collect information and learn from errors and successes while openly sharing data and information and applying best evidence to improve work processes and patient outcomes.

“Just Culture Infographic.png” by Valeria Palarski 2020. Used with permission.

The Just Culture model categorizes human behavior into three categories of errors. Consequences of errors are based on whether the error is a simple human error or caused by at-risk or reckless behavior[ 36 ]:

• Simple human error:  A simple human error occurs when an individual inadvertently does something other than what should have been done. Most medical errors are the result of human error due to poor processes, programs, education, environmental issues, or situations. These errors are managed by correcting the cause, looking at the process, and fixing the deviation. For example, a nurse appropriately checks the rights of medication administration three times, but due to the similar appearance and names of two different medications stored next to each other in the medication dispensing system, administers the incorrect medication to a patient. In this example, a root cause analysis reveals a system issue that must be modified to prevent future patient errors (e.g., change the labelling and storage of look alike-sound alike medications).[ 37 ]
• At-risk behavior:  An error due to at-risk behavior occurs when a behavioral choice is made that increases risk where the risk is not recognized or is mistakenly believed to be justified. For example, a nurse scans a patient’s medication with a barcode scanner prior to administration, but an error message appears on the scanner. The nurse mistakenly interprets the error to be a technology problem and proceeds to administer the medication instead of stopping the process and further investigating the error message, resulting in the wrong dosage of a medication being administered to the patient. In this case, ignoring the error message on the scanner can be considered “at-risk behavior” because the behavioral choice was considered justified by the nurse at the time.[ 38 ]
• Reckless behavior:  Reckless behavior is an error that occurs when an action is taken with conscious disregard for a substantial and unjustifiable risk. For example, a nurse arrives at work intoxicated and administers the wrong medication to the wrong patient. This error is considered due to reckless behavior because the decision to arrive intoxicated was made with conscious disregard for substantial risk.[ 39 ]

These categories of errors result in different consequences to the employee based on the Just Culture model:

• If an individual commits a simple human error, managers console the individual and consider changes in training, procedures, and processes.[ 40 ] In the “simple human error” example above, system-wide changes would be made to change the label and location of the medications to prevent future errors from occurring with the same medications.
• Individuals committing at-risk behavior are held accountable for their behavioral choices and often require coaching with incentives for less risky behaviors and situational awareness.[ 41 ]In the “at-risk behavior” example above, when the nurse chose to ignore an error message on the barcode scanner, mandatory training on using barcode scanners and responding to errors would likely be implemented, and the manager would track the employee’s correct usage of the barcode scanner for several months following training.
• If an individual demonstrates reckless behavior, remedial action and/or punitive action is taken.[ 42 ] In the “reckless behavior” example above, the manager would report the nurse’s behavior to the State Board of Nursing for disciplinary action. The SBON would likely mandate substance abuse counseling for the nurse to maintain their nursing license. However, employment may be terminated and/or the nursing license revoked if continued patterns of reckless behavior occur.

See Table 4.2c describing classifications of errors using the Just Culture model.

Classification of Errors Using the Just Culture Model

Systems leadership  refers to a set of skills used to catalyze, enable, and support the process of systems-level change that is encouraged by the Just Culture Model. Systems leadership is comprised of three interconnected elements:[ 43 ]

• The Individual:  The skills of collaborative leadership to enable learning, trust-building, and empowered action among stakeholders who share a common goal
• The Community:  The tactics of coalition building and advocacy to develop alignment and mobilize action among stakeholders in the system, both within and between organizations
• The System:  An understanding of the complex systems shaping the challenge to be addressed

4.3. IMPLEMENTING CHANGE

Change is constant in the health care environment.  Change  is defined as the process of altering or replacing existing knowledge, skills, attitudes, systems, policies, or procedures.[ 1 ] The outcomes of change must be consistent with an organization’s mission, vision, and values. Although change is a dynamic process that requires alterations in behavior and can cause conflict and resistance, change can also stimulate positive behaviors and attitudes and improve organizational outcomes and employee performance. Change can result from identified problems or from the incorporation of new knowledge, technology, management, or leadership. Problems may be identified from many sources, such as quality improvement initiatives, employee performance evaluations, or accreditation survey results.[ 2 ]

Nurse managers must deal with the fears and concerns triggered by change. They should recognize that change may not be easy and may be met with enthusiasm by some and resistance by others. Leaders should identify individuals who will be enthusiastic about the change (referred to as “early adopters”), as well as those who will be resisters (referred to as “laggers”). Early adopters should be involved to build momentum, and the concerns of resisters should be considered to identify barriers. Data should be collected, analyzed, and communicated so the need for change (and its projected consequences) can be clearly articulated. Managers should articulate the reasons for change, the way(s) the change will affect employees, the way(s) the change will benefit the organization, and the desired outcomes of the change process.[ 3 ] See Figure 4.5 [ 4 ] for an illustration of communicating upcoming change.

Identifying Upcoming Change

Change Theories

There are several change theories that nurse leaders may adopt when implementing change. Two traditional change theories are known as Lewin’s Unfreeze-Change-Refreeze Model and Lippitt’s Seven-Step Change Theory.[ 5 ]

Lewin’s Change Model

Kurt Lewin, the father of social psychology, introduced the classic three-step model of change known as Unfreeze-Change-Refreeze Model that requires prior learning to be rejected and replaced. Lewin’s model has three major concepts: driving forces, restraining forces, and equilibrium. Driving forces are those that push in a direction and cause change to occur. They facilitate change because they push the person in a desired direction. They cause a shift in the equilibrium towards change. Restraining forces are those forces that counter the driving forces. They hinder change because they push the person in the opposite direction. They cause a shift in the equilibrium that opposes change. Equilibrium is a state of being where driving forces equal restraining forces, and no change occurs. It can be raised or lowered by changes that occur between the driving and restraining forces.[ 6 ],[ 7 ]

• Step 1: Unfreeze the status quo.  Unfreezing is the process of altering behavior to agitate the equilibrium of the current state. This step is necessary if resistance is to be overcome and conformity achieved. Unfreezing can be achieved by increasing the driving forces that direct behavior away from the existing situation or status quo while decreasing the restraining forces that negatively affect the movement from the existing equilibrium. Nurse leaders can initiate activities that can assist in the unfreezing step, such as motivating participants by preparing them for change, building trust and recognition for the need to change, and encouraging active participation in recognizing problems and brainstorming solutions within a group.[ 8 ]
• Step 2: Change.  Change is the process of moving to a new equilibrium. Nurse leaders can implement actions that assist in movement to a new equilibrium by persuading employees to agree that the status quo is not beneficial to them; encouraging them to view the problem from a fresh perspective; working together to search for new, relevant information; and connecting the views of the group to well-respected, powerful leaders who also support the change.[ 9 ]
• Step 3: Refreeze.  Refreezing refers to attaining equilibrium with the newly desired behaviors. This step must take place after the change has been implemented for it to be sustained over time. If this step does not occur, it is very likely the change will be short-lived and employees will revert to the old equilibrium. Refreezing integrates new values into community values and traditions. Nursing leaders can reinforce new patterns of behavior and institutionalize them by adopting new policies and procedures.[ 10 ]

Example Using Lewin’s Change Theory

A new nurse working in a rural medical-surgical unit identifies that bedside handoff reports are not currently being used during shift reports.

Step 1: Unfreeze:  The new nurse recognizes a change is needed for improved patient safety and discusses the concern with the nurse manager. Current evidence-based practice is shared regarding bedside handoff reports between shifts for patient safety.[ 11 ] The nurse manager initiates activities such as scheduling unit meetings to discuss evidence-based practice and the need to incorporate bedside handoff reports.

Step 2: Change:  The nurse manager gains support from the Director of Nursing to implement organizational change and plans staff education about bedside report checklists and the manner in which they are performed.

Step 3: Refreeze:  The nurse manager adopts bedside handoff reports in a new unit policy and monitors staff for effectiveness.

Lippitt’s Seven-Step Change Theory

Lippitt’s Seven-Step Change Theory expands on Lewin’s change theory by focusing on the role of the change agent. A  change agent  is anyone who has the skill and power to stimulate, facilitate, and coordinate the change effort. Change agents can be internal, such as nurse managers or employees appointed to oversee the change process, or external, such as an outside consulting firm. External change agents are not bound by organizational culture, politics, or traditions, so they bring a different perspective to the situation and challenge the status quo. However, this can also be a disadvantage because external change agents lack an understanding of the agency’s history, operating procedures, and personnel.[ 12 ] The seven-step model includes the following steps[ 13 ]:

• Step 1: Diagnose the problem.  Examine possible consequences, determine who will be affected by the change, identify essential management personnel who will be responsible for fixing the problem, collect data from those who will be affected by the change, and ensure those affected by the change will be committed to its success.
• Step 2: Evaluate motivation and capability for change.  Identify financial and human resources capacity and organizational structure.
• Step 3: Assess the change agent’s motivation and resources, experience, stamina, and dedication.
• Step 4: Select progressive change objectives.  Define the change process and develop action plans and accompanying strategies.
• Step 5: Explain the role of the change agent to all employees and ensure the expectations are clear.
• Step 6: Maintain change.  Facilitate feedback, enhance communication, and coordinate the effects of change.
• Step 7: Gradually terminate the helping relationship of the change agent.

Example Using Lippitt’s Seven-Step Change Theory

Refer to the previous example of using Lewin’s change theory on a medical-surgical unit to implement bedside handoff reporting. The nurse manager expands on the Unfreeze-Change-Refreeze Model by implementing additional steps based on Lippitt’s Seven-Step Change Theory:

• The nurse manager collects data from team members affected by the changes and ensures their commitment to success.
• Early adopters are identified as change agents on the unit who are committed to improving patient safety by implementing evidence-based practices such as bedside handoff reporting.
• Action plans (including staff education and mentoring), timelines, and expectations are clearly communicated to team members as progressive change objectives. Early adopters are trained as “super-users” to provide staff education and mentor other nurses in using bedside handoff checklists across all shifts.
• The nurse manager facilitates feedback and encourages two-way communication about challenges as change is implemented on the unit. Positive reinforcement is provided as team members effectively incorporate change.
• Bedside handoff reporting is implemented as a unit policy, and all team members are held accountable for performing accurate bedside handoff reporting.

Read more about additional change theories in the  Current Theories of Change Management pdf .

Change Management

Change management  is the process of making changes in a deliberate, planned, and systematic manner.[ 14 ] It is important for nurse leaders and nurse managers to remember a few key points about change management[ 15 ]:

• Employees will react differently to change, no matter how important or advantageous the change is purported to be.
• Basic needs will influence reaction to change, such as the need to be part of the change process, the need to be able to express oneself openly and honestly, and the need to feel that one has some control over the impact of change.
• Change often results in a feeling of loss due to changes in established routines. Employees may react with shock, anger, and resistance, but ideally will eventually accept and adopt change.
• Change must be managed realistically, without false hopes and expectations, yet with enthusiasm for the future. Employees should be provided information honestly and allowed to ask questions and express concerns.

4.4. SPOTLIGHT APPLICATION

Jamie has recently completed his orientation to the emergency department at a busy Level 1 trauma center. The environment is fast-paced and there are typically a multitude of patients who require care. Jamie appreciates his colleagues and the collaboration that is reflected among members of the health care team, especially in times of stress. Jamie is providing care for an 8-year-old patient who has broken her arm when there is a call that there are three Level 1 trauma patients approximately 5 minutes from the ER. The trauma surgeon reports to the ER, and multiple members of the trauma team report to the ER intake bays. If you were Jamie, what leadership style would you hope the trauma surgeon uses with the team?

In a stressful clinical care situation, where rapid action and direction are needed, an autocratic leadership style is most effective. There is no time for debating different approaches to care in a situation where immediate intervention may be required. Concise commands, direction, and responsive action from the team are needed to ensure that patient care interventions are delivered quickly to enhance chance of survival and recovery.

4.5. LEARNING ACTIVITIES

Learning activities.

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activities are provided as immediate feedback.)

Sample Scenario

An 89-year-old female resident with Alzheimer’s disease has been living at the nursing home for many years. The family decides they no longer want aggressive measures taken and request to the RN on duty that the resident’s code status be changed to Do Not Resuscitate (DNR). The evening shift RN documents a progress note that the family (and designated health care agent) requested that the resident’s status be made DNR. Due to numerous other responsibilities and needs during the evening shift, the RN does not notify the attending physician or relay the information during shift change or on the 24-hour report. The day shift RN does not read the night shift’s notes because of several immediate urgent situations. The family, who had been keeping vigil at the resident’s bedside throughout the night, leaves to go home to shower and eat. Upon return the next morning, they find the room full of staff and discover the staff performed CPR after their loved one coded. The resident was successfully resuscitated but now lies in a vegetative state. The family is unhappy and is considering legal action. They approach you, the current nurse assigned to the resident’s care, and state, “We followed your procedures to make sure this would not happen! Why was this not managed as we discussed?”[ 1 ]

1. As the current nurse providing patient care, explain how you would therapeutically address this family’s concerns and use one or more leadership styles.

2. As the charge nurse, explain how you would address the staff involved using one or more leadership styles.

3. Explain how change theory can be implemented to ensure this type of situation does not recur.

IV. GLOSSARY

The process of altering or replacing existing knowledge, skills, attitudes, systems, policies, or procedures.[ 1 ]

Anyone who has the skill and power to stimulate, facilitate, and coordinate the change effort.

Organizational culture that embraces error reporting by employees with the goal of identifying systemic causes of problems that can be addressed to improve patient safety. Just Culture is a component of a culture of safety.

The upward influence of individuals on their leaders and their teams.

A culture where people feel safe raising questions and concerns and report safety events in an environment that emphasizes a nonpunitive response to errors and near misses. Clear lines are drawn between human error, at-risk, and reckless employee behaviors.

The art of establishing direction and influencing and motivating others to achieve their maximum potential to accomplish tasks, objectives, or projects.[ 2 ],[ 3 ]

Roles that focus on tasks such as planning, organizing, prioritizing, budgeting, staffing, coordinating, and reporting.[ 4 ]

An organization’s statement that describes how the organization will fulfill its vision and establishes a common course of action for future endeavors.

The implicit values and beliefs that reflect the norms and traditions of an organization. An organization’s vision, mission, and values statements are the foundation of organizational culture.

A set of skills used to catalyze, enable, and support the process of systems-level change that focuses on the individual, the community, and the system.

The concept that systems do not function in isolation but rather there is an interdependence that exists between their parts. Systems theory assumes that most individuals strive to do good work, but are affected by diverse influences within the system.

The organization’s established values that support its vision and mission and provide strategic guidelines for decision-making, both internally and externally, by members of the organization.

An organization’s statement that defines why the organization exists, describes how the organization is unique and different from similar organizations, and specifies what the organization is striving to be.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 4 - Leadership and Management.
• PDF version of this title (18M)

In this Page

• LEADERSHIP & MANAGEMENT INTRODUCTION
• BASIC CONCEPTS
• IMPLEMENTING CHANGE
• SPOTLIGHT APPLICATION
• LEARNING ACTIVITIES

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Assignment/Delegation

Assignment and delegation are essential components of leadership and management in nursing, ensuring safe and efficient patient care delivery. For the NCLEX-RN®, understanding these concepts helps nurses prioritize tasks, utilize team members effectively, and maintain accountability. Assignment involves distributing tasks based on scope of practice, while delegation requires transferring responsibilities while ensuring proper oversight. Mastering these skills enables nurses to make informed decisions, promote teamwork, and enhance patient outcomes, all of which are critical for success in the NCLEX-RN® exam.

Learning Objectives

In studying “Leadership & Management: Assignment/Delegation” for the NCLEX-RN® exam, you should learn to understand the principles of assigning and delegating tasks among healthcare team members. Analyze the Five Rights of Delegation and how they ensure safe, effective patient care. Evaluate the roles and scope of practice for RNs, LPNs, and UAPs to prioritize and allocate care activities appropriately. Explore frameworks like Maslow’s Hierarchy of Needs and the ABCs to guide decision-making. Apply these concepts to clinical scenarios, ensuring accountability, effective communication, and supervision, and interpret questions that test these principles in practice passages to enhance exam readiness.

Key Concepts of Assignment and Delegation

1. Assignment

• Assignment involves allocating patient care tasks to nursing staff based on their qualifications, skills, and job descriptions.
• Tasks assigned must align with the individual’s scope of practice and legal parameters as outlined in the Nurse Practice Act.
• Assignments are patient-centered, focusing on the needs of the individual while optimizing the efficiency of the care team.
• RNs typically handle patients with critical or complex needs, while LPNs and UAPs manage stable patients requiring predictable care.

2. Delegation

• Delegation is the process of transferring responsibility for a task to another individual while retaining accountability for the results.
• Right Task : Only delegate tasks that can safely be performed by another individual within their scope of practice.
• Right Circumstance : Delegate only when the patient’s condition is stable and predictable.
• Right Person : Choose a delegatee who possesses the necessary skills and training.
• Right Direction/Communication : Provide clear, detailed instructions, including the expected outcomes and any necessary follow-up.
• Right Supervision/Evaluation : Monitor the task’s completion and evaluate outcomes to ensure quality care.
• Delegation Challenges : Miscommunication, lack of training, or unclear expectations can compromise patient safety. Effective leadership is essential to prevent such issues.

Principles in Assignment

1. Understanding Scope of Practice

• Assign tasks based on the legal and professional scope of the team members.
• Ensure tasks align with the Nurse Practice Act and job descriptions.
• Recognize that RNs manage patients with complex needs, while LPNs/LVNs handle routine care, and UAPs assist with non-clinical tasks.

2. Patient Needs

• Match the complexity of patient care with the skill and competence of the assigned staff.
• Critical or unstable patients should remain under the care of an RN.
• Stable patients with predictable outcomes can be assigned to LPNs or UAPs.

3. Prioritization Frameworks

• Use Maslow’s Hierarchy of Needs, ABCs (Airway, Breathing, Circulation), and Safety to assign tasks that ensure immediate life-threatening conditions are addressed first.
• Ensure all assignments reflect patient safety and continuity of care.

4. Legal and Ethical Considerations

• Assignments must comply with institutional policies and state regulations.
• Avoid overloading staff, as this can compromise patient safety and quality of care.
• Ensure that assignments are equitable and promote teamwork.

5. Communication

• Provide clear, concise, and detailed instructions regarding the expectations of the assigned tasks.
• Include necessary patient-specific information, such as care plans, goals, and timelines.

6. Evaluation and Follow-Up

• Continuously monitor and evaluate the outcomes of the assigned tasks.
• Provide constructive feedback to the team and address any issues that arise.
• Ensure tasks are completed as per standards, and make adjustments to assignments if necessary to maintain patient safety and care quality.

Principles in Delegation

1. The Five Rights of Delegation

• Right Task : Ensure the task is appropriate for delegation based on patient condition and staff competence.
• Right Circumstance : Only delegate when the patient’s condition is stable and the task does not require clinical judgment.
• Right Person : Delegate to individuals who have the necessary training, knowledge, and skills.
• Right Direction/Communication : Provide clear, specific instructions and expectations, ensuring the delegatee fully understands.
• Right Supervision/Evaluation : Monitor the delegatee’s progress, provide feedback, and assess outcomes.

2. Accountability and Responsibility

• The RN retains accountability for the overall care plan and the outcomes of the delegated task.
• Delegate tasks only to individuals who are competent and confident in performing them.
• Ensure continuous supervision and support, intervening as necessary.

3. Building Trust and Teamwork

• Delegation requires a relationship of mutual trust between the RN and team members.
• Promote an environment where staff feel comfortable seeking clarification or reporting challenges.
• Use delegation as an opportunity to develop team members’ skills and confidence.

4. Recognizing Limitations

• Avoid delegating tasks requiring critical thinking, clinical judgment, or nursing assessments.
• Do not delegate activities that require specialized knowledge, such as patient education or managing a deteriorating patient.

5. Effective Supervision

• Regularly check on progress and provide guidance as needed.
• Evaluate outcomes and use them as a basis for improving future delegation practices.
• Offer feedback and acknowledgment to foster staff motivation and growth.

Example 1: Prioritizing Care in a Multi-Patient Assignment

An RN is managing a medical-surgical unit with a mix of stable and unstable patients. The RN assigns the care of two stable postoperative patients to the LPN. These patients require routine medication administration and basic wound care. The RN retains responsibility for a critically ill patient who requires frequent monitoring, titration of IV medications, and assessments. This prioritization ensures that complex tasks requiring clinical judgment are handled by the RN, while routine care is safely assigned to the LPN.

Example 2: Delegating Non-Clinical Tasks to UAPs

During a busy shift, the RN delegates non-clinical tasks such as assisting patients with bathing, feeding, and ambulation to the UAP. The RN provides clear instructions, such as reporting any changes in the patient’s condition (e.g., difficulty breathing during ambulation). This delegation allows the RN to focus on higher-priority clinical tasks, such as administering medications and assessing unstable patients.

Example 3: Managing a Patient Discharge

The RN is preparing a patient for discharge. The RN retains responsibility for providing discharge teaching, including medication instructions and follow-up care, as this task requires clinical judgment and patient education. The RN delegates the task of gathering the patient’s belongings and escorting them to their transportation to the UAP. This ensures efficient workflow while maintaining high-quality patient care.

Example 4: Handling a Code Situation

During a cardiac arrest in the unit, the RN takes charge of the situation, directing the resuscitation efforts and administering critical medications. The RN delegates tasks such as compressions to a trained UAP and asks an LPN to monitor and document the patient’s vital signs and response during the event. Effective communication and supervision ensure that each team member performs their role appropriately, contributing to the patient’s survival.

Example 5: Delegating Routine Procedures

The RN assigns the task of inserting a urinary catheter for a stable patient to the LPN, as this task falls within the LPN’s scope of practice. The RN ensures the LPN understands the procedure and the expected outcomes. After the task is completed, the RN evaluates the patient’s response to the intervention, maintaining accountability for the overall care.

Practice Questions

A registered nurse (RN) is delegating tasks to a licensed practical nurse (LPN) and unlicensed assistive personnel (UAP). Which task should the RN delegate to the UAP?

A. Administering oral medications to a stable patient B. Performing a sterile dressing change on a post-operative patient C. Assisting a patient with ambulation to the bathroom D. Conducting a focused assessment on a patient with chest pain

Answer: C. Assisting a patient with ambulation to the bathroom

Explanation:

• UAP Scope of Practice : UAPs are trained to perform non-clinical, routine tasks that do not require clinical judgment, such as ambulating, bathing, and feeding patients.
• LPN Responsibilities : Administering oral medications (A) and performing sterile dressing changes (B) fall within the scope of LPN practice.
• RN Responsibilities : Conducting focused assessments (D) involves clinical judgment, which is the responsibility of the RN.
• Delegating ambulation to the UAP allows the RN to focus on tasks requiring higher-level decision-making.

The RN on a medical-surgical unit is assigning patients to the care team. Which patient should the RN assign to the LPN?

A. A patient admitted with unstable angina who is scheduled for a stress test B. A patient receiving IV chemotherapy with a history of allergic reactions C. A patient requiring frequent blood glucose monitoring and insulin administration D. A patient newly diagnosed with a pulmonary embolism receiving IV heparin

Answer: C. A patient requiring frequent blood glucose monitoring and insulin administration

• Stable Patient : LPNs can care for stable patients with predictable outcomes, such as monitoring blood glucose and administering subcutaneous insulin.
• Critical and Complex Care : Patients with unstable angina (A), potential chemotherapy reactions (B), or a new pulmonary embolism on IV heparin (D) require ongoing assessment and critical thinking, which are within the RN’s scope.
• Assigning stable patients to the LPN ensures safe delegation and prioritizes the RN’s role in handling higher-acuity cases.

Which of the following statements indicates the RN understands the “Right Supervision/Evaluation” principle of delegation?

A. “I will provide detailed instructions to the LPN and let them complete the task independently.” B. “I will verify that the task was completed correctly and provide feedback as necessary.” C. “I will assume the LPN knows how to handle the task because they are experienced.” D. “I will only follow up with the LPN if the patient complains about the task.”

Answer: B. “I will verify that the task was completed correctly and provide feedback as necessary.”

• Right Supervision/Evaluation : Delegation requires the RN to monitor the task’s completion, ensure it was performed correctly, and provide guidance or feedback as needed.
• Option A : While detailed instructions are important, supervision and follow-up are still necessary.
• Option C : Assumptions about the delegatee’s experience without verification can compromise patient safety.
• Option D : Waiting for a patient complaint to evaluate task performance neglects the RN’s responsibility for oversight.

3.1 Delegation & Supervision Introduction

Learning objectives.

• Explain principles of delegation
• Evaluate the criteria used for delegation
• Apply effective communication techniques when delegating care
• Determine specific barriers to delegation
• Evaluate team members’ performance based on delegation and supervision principles
• Incorporate principles of supervision and evaluation in the delegation process
• Identify scope of practice of the RN, LPN/VN, and unlicensed assistive personnel roles
• Identify tasks that can and cannot be delegated to members of the nursing team

As health care technology continues to advance, clients require increasingly complex nursing care, and as staffing becomes more challenging, health care agencies respond with an evolving variety of nursing and assistive personnel roles and responsibilities to meet these demands. As an RN, you are on the front lines caring for ill or injured clients and their families, advocating for clients’ rights, creating nursing care plans, educating clients on how to self-manage their health, and providing leadership throughout the complex health care system. Delivering safe, effective, quality client care requires the RN to coordinate care by the nursing team as tasks are assigned, delegated, and supervised. Nursing team members include advanced practice registered nurses (APRN), registered nurses (RN), licensed practical/vocational nurses (LPN/VN), and unlicensed assistive personnel (UAP). [1]

Unlicensed assistive personnel (UAP)  are any assistive personnel trained to function in a supportive role, regardless of title, to whom a nursing responsibility may be delegated. This includes, but is not limited to, certified nursing assistants or aides (CNAs), patient-care technicians (PCTs), certified medical assistants (CMAs), certified medication aides, and home health aides. [2] Making assignments, delegating tasks, and supervising delegatees are essential components of the RN role and can also provide the RN more time to focus on the complex needs of clients. For example, an RN may delegate to UAP the attainment of vital signs for clients who are stable, thus providing the nurse more time to closely monitor the effectiveness of interventions in maintaining complex clients’ hemodynamics, thermoregulation, and oxygenation. Collaboration among the nursing care team members allows for the delivery of optimal care as various skill sets are implemented to care for the client.

Properly assigning and delegating tasks to nursing team members can promote efficient client care. However, inappropriate assignments or delegation can compromise client safety and produce unsatisfactory client outcomes that may result in legal issues. How does the RN know what tasks can be assigned or delegated to nursing team members and assistive personnel? What steps should the RN follow when determining if care can be delegated? After assignments and delegations are established, what is the role and responsibility of the RN in supervising client care? This chapter will explore and define the fundamental concepts involved in assigning, delegating, and supervising client care according to the most recent joint national delegation guidelines published by the National Council of State Boards of Nursing (NCSBN) and the American Nurses Association (ANA). [3]

• American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation.   https://www.ncsbn.org/public-files/NGND-PosPaper_06.pdf ↵
• American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www.ncsbn.org/NGND-PosPaper_06.pdf ↵

Advanced practice registered nurses (APRN), registered nurses (RN), licensed practical/vocational nurses (LPN/VN), and assistive personnel (AP).

Certified nursing assistants (CNA), client care technicians (PCT), certified medical assistants (CMA), certified medication aides, and home health aides.

Nursing Management and Professional Concepts 2e Copyright © by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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3.4 Delegation

There has been significant national debate over the difference between assignment and delegation over the past few decades. In 2019 the National Council of State Boards of Nursing (NCSBN) and the American Nurses Association (ANA) published updated joint National Guidelines on Nursing Delegation (NGND). [1] These guidelines apply to all levels of nursing licensure (advanced practice registered nurses [APRN], registered nurses [RN], and licensed practical/vocational nurses [LPN/VN]) when delegating, and there is no specific guidance provided by the state’s Nurse Practice Act (NPA). [2] It is important to note that states have different laws and rules/regulations regarding delegation, so it is the responsibility of all licensed nurses to know what is permitted in their jurisdiction.

The NGND defines a delegatee  as an RN, LPN/VN, or AP who is delegated a nursing responsibility by either an APRN, RN, or LPN/VN (where the state’s Nurse Practice Act allows), is competent to perform the task, and verbally accepts the responsibility. [3] When performing a fundamental skill on the job, the delegatee is considered to be carrying out an “assignment.” Routine care, activities, and procedures are assigned based on what is included in the delegatee’s basic educational program. A licensed nurse is still responsible for ensuring an assignment is carried out completely and correctly. Delegation is defined as allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and not routinely performed. This definition of delegation applies to licensed nurses as well as to assistive personnel. [4]

Delegation is summarized in the NGND as the following: [5]

• A delegatee is allowed to perform a specific nursing activity, skill, or procedure that is outside the traditional role and basic responsibilities of the delegatee’s current job.
• The delegatee has obtained the additional education and training and validated competence to perform the care/delegated responsibility. The context and processes associated with competency validation will be different for each activity, skill, or procedure being delegated. Competency validation should be specific to the knowledge and skill needed to safely perform the delegated responsibility, as well as to the level of the practitioner (e.g., RN, LPN/VN, AP) to whom the activity, skill, or procedure has been delegated. The licensed nurse who delegates the “responsibility” maintains overall accountability for the client. However, the delegatee bears the responsibility for the delegated activity, skill, or procedure.
• The licensed nurse cannot delegate nursing judgment or any activity that will involve nursing judgment or critical decision-making.
• Nursing responsibilities are delegated by someone who has the authority to delegate.
• The delegated responsibility is within the delegator’s scope of practice.
• When delegating to a licensed nurse, the delegated responsibility must be within the parameters of the delegatee’s authorized scope of practice under the NPA. Regardless of how the state/jurisdiction defines delegation, as compared to assignment, appropriate delegation allows for transition of a responsibility in a safe and consistent manner. Clinical reasoning, nursing judgment, and critical decision-making cannot be delegated.

For example, in some agencies, medication administration is delegated to specially trained CNAs. This task is outside the traditional role of a CNA, but the delegatee has received additional training for this delegated responsibility. They have received competency validation in completing this task accurately, but the licensed nurse still maintains accountability for the client. Accountability is defined as being answerable to oneself and others for one’s own choices, decisions, and actions as measured against a standard. If, under the circumstances, a nurse does not feel it is appropriate to delegate a certain responsibility to a delegatee, the delegating nurse should perform the activity themselves. [6]

Another example illustrating the difference between assignment and delegation is evidenced when considering patient assistance with eating. Feeding patients is typically part of the role of assistive personnel. However, if a client has recently experienced a stroke (i.e., cerebrovascular accident) or is otherwise experiencing swallowing difficulties (i.e., dysphagia), this task cannot be assigned to assistive personnel because it is not considered routine care. Instead, the RN should perform this task themselves or delegate it to a specially trained team member.

The delegation process is multifaceted. See Figure 3.2 [7] for an illustration of the intersecting responsibilities of the employer/nurse leader, licensed nurse, and delegatee with two-way communication that protects the safety of the public. “Delegation begins at the administrative/nurse leader level of the organization and includes determining nursing responsibilities that can be delegated, to whom, and under what circumstances; developing delegation policies and procedures; periodically evaluating delegation processes; and promoting a positive culture/work environment. The licensed nurse is responsible for determining client needs and when to delegate, ensuring availability to the delegatee, evaluating outcomes, and maintaining accountability for delegated responsibility. Finally, the delegatee must accept activities based on their competency level, maintain competence for delegated responsibility, and maintain accountability for delegated activity.” [8]

Five Rights of Delegation

How does the RN determine what tasks can be delegated, when, and to whom? According to the National Council of State Boards of Nursing (NCSBN), RNs should use five rights of delegation to ensure proper and appropriate delegation: right task, right circumstance, right person, right directions and communication, and right supervision and evaluation: [9]

• Right task: The activity falls within the delegatee’s job description or is included as part of the established policies and procedures of the nursing practice setting. The facility needs to ensure the policies and procedures describe the expectations and limits of the activity and provide any necessary competency training.
• Right circumstance: The health condition of the client must be stable. If the client’s condition changes, the delegatee must communicate this to the licensed nurse, and the licensed nurse must reassess the situation and the appropriateness of the delegation. [10]
• Right person: The licensed nurse, along with the employer and the delegatee, is responsible for ensuring that the delegatee possesses the appropriate skills and knowledge to perform the activity. [11]
• Right directions and communication: Each delegation situation should be specific to the client, the nurse, and the delegatee. The licensed nurse is expected to communicate specific instructions for the delegated activity to the delegatee; the delegatee, as part of two-way communication, should ask any clarifying questions. This communication includes any data that need to be collected, the method for collecting the data, the time frame for reporting the results to the licensed nurse, and additional information pertinent to the situation. The delegatee must understand the terms of the delegation and must agree to accept the delegated activity. The licensed nurse should ensure the delegatee understands they cannot make any decisions or modifications in carrying out the activity without first consulting the licensed nurse. [12]
• Right supervision and evaluation: The licensed nurse is responsible for monitoring the delegated activity, following up with the delegatee at the completion of the activity, and evaluating client outcomes. The delegatee is responsible for communicating client information to the licensed nurse during the delegation situation. The licensed nurse should be ready and available to intervene as necessary. The licensed nurse should ensure appropriate documentation of the activity is completed. [13]

Simply stated, the licensed nurse determines the right person is assigned the right tasks for the right clients under the right circumstances. When determining what aspects of care can be delegated, the licensed nurse uses clinical judgment while considering the client’s current clinical condition, as well as the abilities of the health care team member. The RN must also consider if the circumstances are appropriate for delegation. For example, although obtaining routine vitals signs on stable clients may be appropriate to delegate to assistive personnel, obtaining vitals signs on an unstable client is not appropriate to delegate.

After the decision has been made to delegate, the nurse assigning the tasks must communicate appropriately with the delegatee and provide the right directions and supervision. Communication is key to successful delegation. Clear, concise, and closed-loop communication is essential to ensure successful completion of the delegated task in a safe manner. During the final step of delegation, also referred to as supervision , the nurse verifies and evaluates that the task was performed correctly, appropriately, safely, and competently. Read more about supervision in the following subsection on “ Supervision .” See Table 3.4 for additional questions to consider for each “right” of delegation.

Table 3.4 Rights of Delegation [14]

Keep in mind that any nursing intervention that requires specific nursing knowledge, clinical judgment, or use of the nursing process can only be delegated to another RN. Examples of these types of tasks include initial preoperative or admission assessments, client teaching, and creation and evaluation of a nursing care plan. See Figure 3.3 [15] for an algorithm based on the 2019 National Guidelines for Nursing Delegation that can be used when deciding if a nursing task can be delegated. [16]

Responsibilities of the Licensed Nurse

The licensed nurse has several responsibilities as part of the delegation process. According to the NGND, any decision to delegate a nursing responsibility must be based on the needs of the client or population, the stability and predictability of the client’s condition, the documented training and competence of the delegatee, and the ability of the licensed nurse to supervise the delegated responsibility and its outcome with consideration to the available staff mix and client acuity. Additionally, the licensed nurse must consider the state Nurse Practice Act regarding delegation and the employer’s policies and procedures prior to making a final decision to delegate. Licensed nurses must be aware that delegation is at the nurse’s discretion, with consideration of the particular situation. The licensed nurse maintains accountability for the client, while the delegatee is responsible for the delegated activity, skill, or procedure.  If, under the circumstances, a nurse does not feel it is appropriate to delegate a certain responsibility to a delegatee, the delegating nurse should perform the activity. [17]

1. The licensed nurse must determine when and what to delegate based on the practice setting, the client’s needs and condition, the state’s/jurisdiction’s provisions for delegation, and the employer’s policies and procedures regarding delegating a specific responsibility. The licensed nurse must determine the needs of the client and whether those needs are matched by the knowledge, skills, and abilities of the delegatee and can be performed safely by the delegatee. The licensed nurse cannot delegate any activity that requires clinical reasoning, nursing judgment, or critical decision-making. The licensed nurse must ultimately make the final decision whether an activity is appropriate to delegate to the delegatee based on the “Five Rights of Delegation.”

• Rationale: The licensed nurse, who is present at the point of care, is in the best position to assess the needs of the client and what can or cannot be delegated in specific situations. [18]

2. The licensed nurse must communicate with the delegatee who will be assisting in providing client care. This should include reviewing the delegatee’s assignment and discussing delegated responsibilities, including information on the client’s condition/stability, any specific information pertaining to a certain client (e.g., no blood draws in the right arm), and any specific information about the client’s condition that should be communicated back to the licensed nurse by the delegatee.

• Rationale: Communication must be a two-way process involving both the licensed nurse delegating the activity and the delegatee being delegated the responsibility. Evidence shows that the better the communication between the nurse and the delegatee, the more optimal the outcome. The licensed nurse must provide information about the client and care requirements. This includes any specific issues related to any delegated responsibilities. These instructions should include any unique client requirements. The licensed nurse must instruct the delegatee to regularly communicate the status of the client. [19]

3. The licensed nurse must be available to the delegatee for guidance and questions, including assisting with the delegated responsibility, if necessary, or performing it themselves if the client’s condition or other circumstances warrant doing so.

• Rationale: Delegation calls for nursing judgment throughout the process. The final decision to delegate rests in the hands of the licensed nurse as they have overall accountability for the client. [20]

4. The licensed nurse must follow up with the delegatee and the client after the delegated responsibility has been completed.

• Rationale: The licensed nurse who delegates the “responsibility” maintains overall accountability for the client, while the delegatee is responsible for the delegated activity, skill, or procedure. [21]

5. The licensed nurse must provide feedback information about the delegation process and any issues regarding delegatee competence level to the nurse leader. Licensed nurses in the facility need to communicate to the nurse leader responsible for delegation any issues arising related to delegation and any individual that they identify as not being competent in a specific responsibility or unable to use good judgment and decision-making.

• Rationale: This will allow the nurse leader responsible for delegation to develop a plan to address the situation. [22]

The decision of whether or not to delegate or assign is based on the RN’s judgment concerning the condition of the client, the competence of the nursing team member, and the degree of supervision that will be required of the RN if a task is delegated. [23]

Responsibilities of the Delegatee

Everyone is responsible for the well-being of clients. While the nurse is ultimately accountable for the overall care provided to a client, the delegatee shares the responsibility for the client and is fully responsible for the delegated activity, skill, or procedure. [24] The delegatee has the following responsibilities:

1. The delegatee must accept only the delegated responsibilities that he or she is appropriately trained and educated to perform and feels comfortable doing given the specific circumstances in the health care setting and client’s condition. The delegatee should confirm acceptance of the responsibility to carry out the delegated activity. If the delegatee does not believe they have the appropriate competency to complete the delegated responsibility, then the delegatee should not accept the delegated responsibility. This includes informing the nursing leadership if they do not feel they have received adequate training to perform the delegated responsibility, is not performing the procedure frequently enough to do it safely, or their knowledge and skills need updating.

• Rationale: The delegatee shares the responsibility to keep clients safe, and this includes only performing activities, skills, or procedures in which they are competent and comfortable doing. [25]

2. The delegatee m ust maintain competency for the delegated responsibility.

• Rationale: Competency is an ongoing process. Even if properly taught, the delegatee may become less competent if they do not frequently perform the procedure. Given that the delegatee shares the responsibility for the client, the delegatee also has a responsibility to maintain competency. [26]

3. The delegatee must communicate with the licensed nurse in charge of the client. This includes any questions related to the delegated responsibility and follow-up on any unusual incidents that may have occurred while the delegatee was performing the delegated responsibility, any concerns about a client’s condition, and any other information important to the client’s care.

• Rationale: The delegatee is a partner in providing client care. They are interacting with the client/family and caring for the client. This information and two-way communication are important for successful delegation and optimal outcomes for the client. [27]

4. Once the delegatee verifies acceptance of the delegated responsibility, the delegatee is accountable for carrying out the delegated responsibility correctly and completing timely and accurate documentation per facility policy. The delegatee cannot delegate to another individual. If the delegatee is unable to complete the responsibility or feels as though they need assistance, the delegatee should inform the licensed nurse immediately so the licensed nurse can assess the situation and provide support. Only the licensed nurse can determine if it is appropriate to delegate the activity to another individual. If at any time the licensed nurse determines they need to perform the delegated responsibility, the delegatee must relinquish responsibility upon request of the licensed nurse.

• Rationale: Only a licensed nurse can delegate. In addition, because they are responsible, they need to provide direction, determine who is going to carry out the delegated responsibility, and assist or perform the responsibility themselves, if they deem that appropriate under the given circumstances. [28]

Responsibilities of the Employer/Nurse Leader

The employer and nurse leaders also have responsibilities related to safe delegation of client care:

1. The employer must identify a nurse leader responsible for oversight of delegated responsibilities for the facility. If there is only one licensed nurse within the practice setting, that licensed nurse must be responsible for oversight of delegated responsibilities for the facility.

• Rationale: The nurse leader has the ability to assess the needs of the facility, understand the type of knowledge and skill needed to perform a specific nursing responsibility, and be accountable for maintaining a safe environment for clients. They are also aware of the knowledge, skill level, and limitations of the licensed nurses and AP. Additionally, the nurse leader is positioned to develop appropriate staffing models that take into consideration the need for delegation. Therefore, the decision to delegate begins with a thorough assessment by a nurse leader designated by the institution to oversee the process. [29]

2. The designated nurse leader responsible for delegation, ideally with a committee (consisting of other nurse leaders) formed for the purposes of addressing delegation, must determine which nursing responsibilities may be delegated, to whom, and under what circumstances. The nurse leader must be aware of the state Nurse Practice Act and the laws/rules and regulations that affect the delegation process and ensure all institutional policies are in accordance with the law.

• Rationale: A systematic approach to the delegation process fosters communication and consistency of the process throughout the facility. [30]

3. Policies and procedures for delegation must be developed. The employer/nurse leader must outline specific responsibilities that can be delegated and to whom these responsibilities can be delegated. The policies and procedures should also indicate what may not be delegated. The employer must periodically review the policies and procedures for delegation to ensure they remain consistent with current nursing practice trends and that they are consistent with the state Nurse Practice Act. (Institution/employer policies can be more restrictive, but not less restrictive.)

• Rationale: Policies and procedures standardize the appropriate method of care and ensure safe practices. Having a policy and procedure specific to delegation and delegated responsibilities eliminate questions from licensed nurses and AP about what can be delegated and how they should be performed. [31]

4. The employer/nurse leader must communicate information about delegation to the licensed nurses and AP and educate them about what responsibilities can be delegated. This information should include the competencies of delegatees who can safely perform a specific nursing responsibility.

• Rationale: Licensed nurses must be aware of the competence level of staff and expectations for delegation (as described within the policies and procedures) to make informed decisions on whether or not delegation is appropriate for the given situation. Licensed nurses maintain accountability for the client. However, the delegatee has responsibility for the delegated activity, skill, or procedure.

In summary, delegation is the transfer of the nurse’s responsibility for a task while retaining professional accountability for the client’s overall outcome. The decision to delegate is based on the nurse’s judgment, the act of delegation must be clearly defined by the nurse, and the outcomes of delegation are an extension of the nurse’s guidance and supervision. Delegation, when rooted in mutual respect and trust, is a key component to an effective health care team.

• American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www.ncsbn.org/NGND-PosPaper_06.pdf ↵
• American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation . https://www.ncsbn.org/NGND-PosPaper_06.pdf ↵
• “Delegation.png” by Meredith Pomietlo for Chippewa Valley Technical College  is licensed under  CC BY 4.0 ↵
• NCSBN. (n.d.). Delegation. https://www.ncsbn.org/1625.htm ↵
• "Delegation Decision Tree.png" by Meredith Pomietlo for  Chippewa Valley Technical College  is licensed under  CC BY 4.0 ↵

An RN, LPN/VN, or AP who is delegated a nursing responsibility by either an APRN, RN, or LPN/VN (where the state’s Nurse Practice Act allows), is competent to perform the task, and verbally accepts the responsibility.

Allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and not routinely performed.

Being answerable to oneself and others for one’s own choices, decisions, and actions as measured against a standard.

Leadership and Management of Nursing Care Copyright © 2022 by Kim Belcik and Open Resources for Nursing is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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