NUR 4102 Module 2 Delegation Paper: The Five Rights and the Problem of Missed Care Example

Charted as Done, Left Undone: Delegation and Missed Care on a Medical-Surgical Unit

Student Name

Bachelor of Science in Nursing, Thomas Edison State University

NUR-4102: Leadership and Management in Nursing: Scholars Track

Mentor Name

Month Day, Year

Charted as Done, Left Undone: Delegation and Missed Care on a Medical-Surgical Unit

The Problem

Our medical-surgical unit has 32 beds, and on most day shifts six registered nurses work alongside three nursing assistants. A quarterly audit last spring gave us numbers we could not explain away. Of patients flagged as at risk for pressure injuries, only 58 percent had documented repositioning every two hours. Patients with orders to walk three times a day were walking once, or not at all. Mouth care for patients who could not brush their own teeth was frequently skipped. In a single month, two patients developed pressure injuries that began on our floor. When I asked the nurses, they said they had told the assistants to do these things. When I asked the assistants, they said they were rarely told which patients needed what, and that they were often pulled away to sit with confused patients at risk of falling.

Delegation Guidelines

National guidelines for delegation were issued in 2016 by the regulatory body for nursing licensure, working jointly with the American Nurses Association (National Council of State Boards of Nursing, 2016). In their terms, delegating means letting a delegatee carry out a particular nursing activity that falls outside that person's usual role but that the person has been trained and judged competent to perform, while the registered nurse remains accountable for the patient. The guidelines spell out separate responsibilities for the employer, for the licensed nurse and for the delegatee. They condense the nurse's decision into five rights: the task must be suitable, the circumstances must allow it, the person must be competent, the instructions and communication must be clear and the delegated work must be supervised and evaluated. Communication is meant to run both ways, so that the nurse explains what is needed and the assistant can ask questions and report when something cannot be done.

Missed Nursing Care

Kalisch (2006) ran focus groups with registered nurses and assistants on medical-surgical floors in two hospitals and asked what care went undone. Participants named nine recurring areas: getting patients out of bed and walking, repositioning, feeding on time, teaching, planning for discharge, emotional support, bathing and mouth care, recording what patients took in and put out and watching for changes in condition. They gave seven reasons, ranging from too few staff and staff deployed poorly to the time tasks take, weak teamwork, poor delegation, habit and denial. Denial meant staff believing that care was getting done when it was not.

In a later concept analysis, Kalisch et al. (2009) defined missed care as required patient care that is left out entirely, only partly completed or postponed. They traced its antecedents to three groups: how much care patients need, what staff and supplies are available and how well team members relate to and communicate with each other. Their argument was that missed care is an error of omission, that it can harm patients as surely as a wrong action and that it grows out of the unit's environment as much as out of individual decisions.

Diagnosing Our Delegation

Walking through the five rights for our floor exposed gaps at almost every step. The task was right: turning, walking patients and mouth care are well within an assistant's training. The circumstances were not stable, because assistants were regularly reassigned mid-morning to sit with confused patients, and no one picked up the work they left. The person was right, but the directions were not; nurses would say "do the turns" without naming which patients or at what times. Supervision was missing, since nobody checked whether turning had happened until the audit. Communication ran in one direction, and assistants told me they did not feel free to say they were overwhelmed.

Hearing From the Assistants

Before planning anything, I met with the three day assistants and two from nights. They described starting each shift with a list of 10 or 11 patients and no sense of which ones mattered most. One said she had once turned the same patient twice because two nurses had asked her to, while a patient down the hall waited. Another said she had stopped reporting undone tasks because nothing changed. Their comments matched Kalisch's description of teamwork as an antecedent of missed care, and they shaped every part of the plan.

A Plan

Working with the unit manager and two of the assistants, I designed four changes. First, a five-minute pairing at the opening of each shift, where each nurse and assistant agree on named patients and times for turning, walking and mouth care, posted on the hallway whiteboard. Second, short check-ins at 11 a.m. and 3 p.m. in which the assistant reports what is done and what will not get done, so the nurse can step in or reassign. Third, when an assistant is pulled to sit with a patient, the charge nurse redistributes her list before she leaves. Fourth, the charge nurse spot-checks turning and mouth care for a few patients twice each shift.

Night Shift

Nights posed a different problem. With only two assistants for 32 patients, the night team could not turn every at-risk patient every two hours on their own. The night nurses agreed to share the work, so that each nurse repositions her own patients at the 2 a.m. and 4 a.m. rounds. This was a fair test of the guidelines' point that delegation must fit the circumstances: when staffing does not support handing off a task, the nurse keeps it.

Teamwork and Respect

Several assistants told me they felt invisible to the nurses. Bringing them into the design of the plan and thanking them by name at shift huddles cost nothing, and both changes mattered. Kalisch's work suggests that relationships on a unit are part of the cause of missed care and therefore part of the cure.

Evaluation

Three months later, a repeat audit showed repositioning on schedule for 84 percent of at-risk patients, and most patients with walking orders walked at least twice a day. No new pressure injuries began on our unit in the third month. Assistants reported in a short survey that they now knew which patients to prioritize.

Limits

Audits measure what is documented, which may not match what happened at the bedside. A severe staffing shortage could overwhelm any delegation system. The unit and its staff are invented.

Conclusion

The national guidelines gave our unit five rights and a clear statement that the nurse stays accountable, and Kalisch's research explained why the same few kinds of care keep falling through. Named assignments, two-way check-ins, redistribution when assistants are pulled away, a fair night plan and real respect for the assistants turned vague requests into care that actually reaches patients.

References

Kalisch, B. J. (2006). Missed nursing care: A qualitative study. Journal of Nursing Care Quality, 21(4), 306-313. https://doi.org/10.1097/00001786-200610000-00006

Kalisch, B. J., Landstrom, G. L., & Hinshaw, A. S. (2009). Missed nursing care: A concept analysis. Journal of Advanced Nursing, 65(7), 1509-1517. https://doi.org/10.1111/j.1365-2648.2009.05027.x

National Council of State Boards of Nursing. (2016). National guidelines for nursing delegation. Journal of Nursing Regulation, 7(1), 5-14. https://doi.org/10.1016/S2155-8256(16)31035-3