Direction and delegation for New Zealand nurses

About the authors: Margaret Hughes, RN, PhD, is a senior lecturer in the School of Nursing, Midwifery and Allied Health, Ara Institute of Canterbury, Christchurch, New Zealand. Ray Kirk, BSc, MSc, PhD, is an adjunct senior fellow at the School of Health Sciences, University of Canterbury, Christchurch. Alison Dixon, RN, PhD, QSO, is an adjunct senior fellow at the School of Health Sciences, University of Canterbury, Christchurch.

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Aim

DIRECTION AND DELEGATION IS a professional competency required of all New Zealand nurses (NCNZ, 2011a; 2011b). Nurses attest to understanding direction and delegation on their annual competency-based practising certificate application (NCNZ, 2007; 2012). The purpose of this study into how enrolled nurses (ENs) and registered nurses (RNs) communicate during direction and delegation was to explore nurses’ perceptions about their everyday direction and delegation experiences. The study joins the discussion found in the overseas nursing literature about delegation (Bragadottir, Kalisch, Smaradottir & Jonsdottir, 2016; Kalisch, 2011; Parsons, 1997; 1998; 1999; 2004). This study adds a new perspective on how New Zealand nurses make sense of this professional obligation.

Methods

Nurses use stories on a daily basis as a vehicle to share information, when informing other nurses in handovers and progress notes, when communicating health information and education to clients and when contributing to interdisciplinary meetings. The stories told by ENs and RNs for this study, about their direction and delegation interactions, are an extension of these nursing roles and responsibilities. Clandinin and Connelly’s narrative inquiry method was used to capture the nurses’ experiences as stories (Clandinin, 2013; Clandinin & Connelly, 2000; Clandinin & Huber, 2010). The stories provided plot lines, which made visible the nurses’ beliefs, values, decision-making and motivations. The purposively selected participants included 19 ENs and 17 RNs. Ethics approval was granted in 2013 by the University of Canterbury Ethics Committee and the Ara Human Ethics Committee.

Findings

While the narrative inquiry approach privileged each of the nurse’s individual stories, some shared understandings emerged from the nurses’ experiences. Taken together, the major patterns that came into focus showed that the main concern for all the nurse participants was to keep the patient safe, and to ensure they worked within their scope of practice. However, both the ENs and RNs were confused about how to “do” direction or delegation, about the difference between direction and delegation, and about who was accountable for the EN’s practice. There was also confusion about where to obtain information about these two different roles. In addition, most of the EN and RN participants expressed concerns about a lack of nursing leadership. Nursing leadership was defined as any RN in a position of authority who could provide information, and the necessary time and guidance, to help RNs and ENs carry out direction and delegation well.

Differences which emerged from the 36 EN and RN stories were presented as eight narrative plots. ENs spoke of the need to “work together” and “communicate well”. “Working together” meant that ENs needed RNs who were famliar with the nursing specialty workplace they were working in before delegation interactions could occur. This had implications for agency and casual nurses who were unfamiliar with an area. The “communicating well” plot-line captured the perspectives of ENs who said communication between them and RNs needed to include the way an EN was welcomed into the workplace. It included the tone and the way interactions were handled, not just what was said.

Some of the EN participants described having to work hard to obtain direction or delegation input – these views were categorised as “seeking delegation”. Another EN view was that delegation was a two-way relationship – “delegation as a relationship” – that required fair and respectful input from both levels of nurse.

RN participants shared their stories about “working as a team”. Their experiences made clear the difference between working “as a team” and working “in a team”, and that nurses needed both of these models to support safe and effective delegation interactions. Their experiences related to “communicating professionally” illustrated the need for an advanced and sophisticated understanding of communication interactions, and the need for more information about the EN role. RNs also require an understanding of the EN’s need to be able to self-assess before accepting a delegated task or skill. Having the necessary “skills for delegation” – such as leadership, assessment and communication skills – contributed to “good” delegation practice. The nurses’ experiences categorised as “doing delegation” showed that sometimes neither delegation nor direction were occurring when they should have been. This meant that in these cases, both ENs and RNs were “working outside their scopes of practice”.

Conclusions

This narrative research study has provided unique and individual perspectives, related to direction, delegation and accountability, from 36 nurses working in a variety of settings. These included inpatient and outpatient services, private and public clinical workplaces, and education, leadership and management settings. There are significant implications concerning nurses’ access to in-service education. Direction and delegation is as important as falls prevention, smoking cessation and ISBAR (the mnemonic for Identify, Situation, Background, Assessment and Recommendation, used to ensure safe transfer of critical information) which are often the subject of compulsory in-service courses. RNs need to be given the same sort of learning opportunities to upgrade their skills and knowledge on delegation and the EN role within their specialty area.

Recommendations from the study included the need for health services to provide up-to-date and clear policies about the EN role and responsibilities within particular workplaces. These policies should include concise guidelines on how to direct and delegate and how to be directed and delegated to, and include a clarification and definition of “team”. Also, the content, theory, simulation and clinical practice taught in both undergraduate and post-graduate nursing programmes needs to be reviewed to ensure all emerging ENs, who will be expecting to be delegated to, and new RNs, know and understand not only what direction or delegation is, but how to do it, and the skills required.

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