Expert nurse delegation is akin to summer mornings in Squamish Harbor Washington.  The Hood Canal shines like aquamarine glass.  Peaceful.  Yet unseen below, minnows flash, becoming baby seal's breakfast or the twin otters' lunches.   Vital life -- from plankton to orcas -- flourishes.  Only a few transactions surface as a splash.

When Julie RN, The Ultimate Charge Nurse, is on duty, the unit is quiet and calm.  Life blossoms as a part of the natural order.   Despite the churn of admissions, discharges, and rapid responses, competence and confidence reigns.  Smiling team members stride with capable patience and proficiency.   Family members and providers alike sense that this is a safe healing space. 

What makes the difference?  What is it about Julie RN that sheds light and warmth into an environment that could be toxic, hectic, and injurious?   The Ultimate Charge RN -- as expert delegator and supervisor -- uses herself as an instrument of healing.  Let's examine the qualities that set this leader apart from others.

SKILL

Concepts and Definitions

Actual skills are developed from the concepts in our brains. We believe the following mental constructs are necessary to generate delegation and supervision skills in nurses.

• Definitions of delegation, supervision, accountability
  

• The Five Rights of Delegation and Supervision (Under the Right Circumstances, match the Right Person with the Right Task and then deliver the Right Communication/Direction and Right Feedback or Supervision) ( www.NCSBN.org)

• State regulations and laws related to delegation and supervision of assistive personnel

• Methods to incorporate initial direction and periodic inspection into the flow of care

• Steps of effective an feedback process

Model or Map

Given this knowledge, a nurse is not yet able to magically materialize as an Ultimate Charge RN-expert delegator and supervisor-- by osmosis of concepts, no matter how well the ideas are presented.  Many nurses admit to being confounded by not being clear in their picture of how to actually implement leadership, delegation, and supervision practices, to make them real in daily work.   

A model or map is necessary for the learner to visualize the 5 Rights of Delegation coming alive.  Timid RNs often avoid generating a plan for each day, incorporating times for offering initial direction, checkpoints and follow-up, as well as the communicating essential feedback and celebration at the end of the shift or episode of care.  

Few RNs feel sufficiently confident to change the culture and norms of unit life the next shift after a short "Delegation and Supervision class."   Transformed bedside care won't arise without the unit leadership and/or council's support and coaching.  For example, the RROHC® bundle of  10 best practices combine the delegation/supervision leadership principles into daily work life and base all of the decisions on the patient/family's goals.  As elementary as these concepts may seem to the expert practitioner, culture and nursing practice development requires ongoing leadership endorsement and application.

Practice

As we know from research on critical thinking and clinical judgment, actual experiential application of skills are necessary to improve decision-making (Whiteside, 1997, Dimensions in Critical Care Nursing; Hansten, dissertation, 2001).  Coaching training we provide in the RROHC program helps participants to not only "learn how to learn" for their own future growth, but also how to coach their peers. 

Resistance and avoidance can occur when altering group norms, such as changing processes of reciprocal feedback or patient/family participation in shift handovers.  Expert RNs fear a return to novice levels when performing new skills publicly, especially in front of patients and their peers.  Delegation and supervision, and leadership of others, entails extremely complex critical thinking processes that involve clarity of intended outcomes, engagement of multiple other personnel with competing ideas and spheres of influence and knowledge, and continual prioritization in a constantly changing environment.  Practice is essential!

Leadership

To engage followers, the leader must be competent, think effectively, and use excellence in emotional and appreciative intelligence, coaxing the best performance from existing potential within each team member.    Foundational to leadership is a sense of mastery and confidence, an affirmation that "Yes! Together we can move forward in a positive direction."  The leader's intent to help set the course with patients/families and their healthcare team, and to guide or navigate toward a common purpose stems from an actual decision or act of the leader's will.   For effective leadership, this decision or choice must have occurred internally.  Too often RNs do not see themselves as leaders or worthy of followers when in fact they must not abdicate that responsibility.  The safety of their patients is at stake.

Execution

We know from preparation and past performance that through education, skill practice, feedback, coaching, and experiential application of the principles, concepts, and models, those who choose to become an Ultimate Charge RN are consistently transformed.  Additionally, our team's vital advice for organizational development assists executives and managers to individualize care models and hurdle obstacles to the best patient and family driven care.   We will coach you in the execution phase of best teamwork practices at the bedside, developing your own Ultimate Charge RNs, as building blocks for excellence.