Transition from Nursing Student to a Newly Qualified Nurse

Abstract

The transition from being a nursing student to a newly qualified nurse was evaluated in this work with the author focusing on the delegation aspect in regard to emerging themes of accountability, confidence, communication, enablers and barriers to effective delegation.  Also, the author discussed personal and professional development needs which are identified in an action plan.

Findings from this research points out that the transition process is challenging due to various factors such as physical, intellectual, emotional, developmental and socio-cultural changes. Nevertheless, continuous development is paramount to achieving desired goals to building a career.  As wellbeing and lives of people are at stake, health practitioners like nurses cannot afford to make mistakes as its impact can be very damaging.  Delegation being an important aspect of every teamwork should therefore be taken seriously and got right in order to avoid its damaging consequences if got wrong.

Contents

Click to expand Contents

Chapter 1: Introduction: ……………………………………………………………….5

Area of Academic Endeavour…………………………………………………..6

Author’s role……………………………………………………………………….6

Background………………………………………………………………………..6

Aims and Objectives……………………………………………………………..10

Rationale of Choice…………………………………………………………………11

Conclusion……………………………………………………………………..….13

Chapter 2: Research Approach: …………………………………………………..…14

Introduction………………………………………………………………………… 14

Research Philosophy……………………………………………………………. 14

Philosophical Assumption………………………………………………………. 15

Research Approach……………………………………………………………… 15

Research Method………………………………………………………………… 16

Data Collection Method…………………………………………………………. 16

Research Question………………………………………………………………. 16

Search Strategy……………………………………………………………………17

Inclusion and Exclusion Criteria…………………………………………………18

Data Analysis………………………………………………………………………18

Ethics………………………………………………………………………………..19

Conclusion………………………………………………………………………….19

Chapter 3: Literature Review: …………………………………………………………20

Introduction……………………………………………………………….…….20

Literature related to Delegation…………………………………………………20

Literature related to Accountability…………………………………………….23

Literature related to Communication…………………………………………..24

Literature related to Confidence……………………………………………….27

Literature related to Enablers and Barriers of Effective Delegation………29

Conclusion………………………………………………………………………..34

Chapter 4: Results and Discussion: ………………………………………………..35

Introduction……………………………………………………………………….35

Results and Discussion………………………………………………………….35

Chapter 5: Conclusion and Recommendation: …………………………………..38

Introduction………………………………………………………………………..38

Conclusion…………………………………………………………………………38

Recommendation………………………………………………………………….39

Bibliography: ……………………………………………………………………………..40

Appendix 1: ……………………………………………………………………………….43

Appendix 2: ……………………………………………………………………………….45

Appendix 3: ……………………………………………………………………………….46

Chapter 1: Introduction

International and local evidence submit that transiting from being a nursing student to a newly qualified nurse can be challenging, demanding and stressful. This is as a result of students being inadequately prepared or unable to cope, and thus discouraging developmental skills and ineffectiveness in their service as practitioners (Kaihlanen et al., 2013).  Conversely, there is some support strategies in clinical placements that should enable students to confront the many challenges and issues associated with the profession (Jokelainen et al., 2011). However, there is insufficient evidence to support the efficacy of the strategies (Killam and Heerschap, 2013).

Considering the above, this work aims to critically analyse the transition from being a nursing student to a newly qualified nurse (NQN).   The ‘SWOT’ analysis which allows a description to be expounded will be used in an attempt to explore the delegation theme, followed by an analysis of strength, weakness, opportunities and threats.

Area of academic endeavour

This study derives from the area of Registered Nurse RN/B.Sc. (Hons) Nursing Practice (Adult) Programme.  Its main focus is on acquiring necessary knowledge and skills to guide and support nursing students in the delivery of quality care as per Nursing and Midwifery Council (2010) standards.  Accordingly, nurses are expected to uphold high levels of professionalism as they delegate, lead and supervise other nurses and healthcare professionals. As stipulated by the Nursing and Midwifery Council (2010), it is therefore crucial to gain and develop analytical, problem-solving and decision making skills during training and throughout the nursing career.

Author’s role

As an awaiting newly qualified nurse, the author is very keen in acquiring knowledge, skills and abilities which are the cornerstone of the profession. The core values and roles of the profession are to be upheld, even while trying to advance practice (Holtman et al., 2011). It is argued that the transition from being a nursing student to a newly qualified nurse is a common rite of passage that marks the end of initial nursing education and the beginning of a professional nursing journey (Nash et al., 2009). Arguably, the transitional process enables nurses to build their clinical confidence and consolidate their clinical skills in addition to developing a positive professional image and become ‘competent’,(Council, 2015).

Background

Transition from being a nursing student to a newly qualified nurse: The delegation aspect – a detailed description of its context is outlined.

Transition is defined as paths or movements from one state, situation, or place to another, “capable of producing profound alterations in the lives of individuals, their significant others having important implications on well-being and health” (Duchscher, 2009). There are different types of transitions: developmental, situational, health-illness and organisational transitions (Al-Yateem and Docherty, 2015) all of which can be affected by several factors such as the level of preparation,  planning and the individual’s knowledge (Al-Yateem and Docherty, 2015).

Apparently, transition from being a nursing student to a registered nurse is a process punctuated by excitement but the road is not smooth as challenges are encountered (Deasy et al., 2011). Morrow (2009) affirms by stating that graduates eagerly anticipate their first position in the ‘real world’ as they experience challenges in their first year of practice. This is because the transition process is filled with a stressful experience; moreover, the phenomenon is not only confined to the United Kingdom but a global concern. The graduates are ‘living the nest and joining the flight’ (Morrow, 2009)  and ‘thrown in the deep end’ (Whitehead and Holmes, 2010).

Despite developments, a radical transformation is required in nursing education (Benner et al., 2010, Spector and Odom, 2012). Nurses in the 21st-century arrive into their new role of profession with insufficient skills and knowledge required for them to practice confidently and competently (Benner et al., 2010). Without a doubt the transition is a “complex and multidimensional” concept with many factors such as physical, intellectual, emotional, developmental and socio-cultural changes to be taken into consideration (Duchscher, 2009).  Regardless of the stressful nature, progressing requires the feelings of preparedness, decision making and confidence in clinical skills. There is also need for support and socialisation as a newly qualified nurse (Duchscher, 2009) in order to embed the NHS ethos of the 6 Cs of care. Therefore, there is need to demonstrate competence and courage to act with confidence, alongside communication, collaboration and continuity in order to practice effectively (England, 2016).

According to statistics, almost 60% of the nursing workforce consists of newly qualified nurses (Whitehead, 2001, Holmes and Whitehead, 2011) with 25% lacking professional skills such as delegation (Saintsing et al., 2011).  During the transition period, one begins to fully understand their responsibilities as professionals (Nash et al., 2009) and be accountable for decisions to delegate tasks and duties to other people. While delegating task, it has to be ensured that everyone a task is delegated to is adequately supported considering safety is paramount while providing compassionate care. It must also be ensured the task and duties delegated are within the other person’s scope of competence and that they fully understand instruction (Council, 2015).  From a newly qualified nurse perspective, delegation of task could be argued to be a ‘reality shock’ because one could still be holding on to the values learnt from university which could be in conflict with work world values (Kramer, 1974): bridging the gap between theory and practice which can be difficult in some situations (Hatlevik, 2012). Contradictions may arise between what graduate nurses understand from their training and the reality they face in their practice. It is argued that once in the hospital environment the newly qualified nurse is absorbed in a firmly deep-seated and ordered culture (Duchscher, 2009).

Wheeler (2007) defines delegation as when ‘one person appoints another to act as a chosen representative on his or her behalf’. In other words, delegation describes a self-motivated process that includes responsibility, accountability and authority (Saccomano and PINTO‐ZIPP, 2011). For newly qualified nurses, delegation is a skill that needs to be learnt especially because the guidance on delegation states that a qualified nurse is ‘in control for the accuracy of that delegation’ and would be answerable for the actions of the individual carrying out the delegated task (Harrison, 2007). According to Eaton (2009) delegating registered nurse is professionally accountable (NMC 2015) and is obliged to follow the NMC Code of Conduct, 2015. According to the Code, to delegate effectively, the person being delegated too must be able to perform the required task, they must be supervised and supported throughout and the result needs to meet the required standards, (Eaton, 2009). The supervision may be direct or indirect (Vaughan, 2008). The accountability remains with the person who has delegated and is not passed on to the individual who is performing the task (Cornock, 2009). An example of delegation could be when delegating the task of checking the blood glucose level of a diabetic patient to a health care assistant. The nurse delegating the task should make sure the health care assistant is competent (Royal College of Nursing, 2016), they should check to ensure the task has been completed properly and should inspect the results are in accordance with the NMC Code, 2015.

Weydt (2010) observed that one of the most difficult nursing skills is that of delegation as it needs excellence clinical judgment and final responsibility for patient care.  Furthermore, the delegated individual also takes responsibility for the task and answers to the qualified nurse. However, the issue of responsibility is different.  Anyone accepting to carry out a task that could have been delegated to someone else will be responsible for their actions in carrying out a delegated task (Cornock, 2009).

Moving on, the concept of transition in nursing is supported by government due to the fact that nurses have influence on health policy. The ‘Preceptorship Framework’ was put in place to nurture and develop new registrants wishing to develop careers in nursing. Through mentoring programmes, the transition phase aid new nurses in adjusting to the new work environment.  The framework has made recommendations for improvements to nursing education and professional development (Department of Health 2010). Similarly, ‘A High-Quality Workforce’ was implemented to improve the NHS as they drive a quality workforce of their services for their staff (Department of Health 2008).

Kramer’s (1974) transition theory entitled the “reality shock” explains the anxiety, doubt and confusion nurses experience as they advance from being a nursing student to a professional registered nurse.  Reality shock, also called ‘role transition’ is argued to be the reason that causes as many as 30% of newly qualified nurses to leave their profession or change jobs within their first year of employment (Duchscher, 2009). The transition process goes through an initial stage in which newly qualified nurses are excited and delighted, then followed by the reality of what the task entails including the expectations of the professional values (Kramer, 1974).  This stage can leave newly qualified nurses confused and disillusioned.  After the shock follows a period of recovery and resolution stage leading to a sense of balance (Duchscher, 2009).  It was observed that the transition can also be affected by the environment of the individual in transition including values and rituals of the individual or the society within which the individual is living (Al-Yateem and Docherty, 2015). Also, the emotional, physical well-being and their attitudes towards change can be a barrier to transition.  Not knowing nor understanding the process triggers stress, anxiety, and feeling unsure thus disrupting the transition process. So, research in transition emphasises on having appropriate knowledge and skills to help the individual during the transition experience (Al-Yateem and Docherty, 2015).

Aims and objectives

• Rationale for role choice, outlining personal and professional development needs in relation to delegation
• Undertake a comprehensive review of literature on the enablers and barriers to effective delegation.
• Present a detailed action plan to demonstrate how the author will address developmental needs to enhance transition to a registered nurse.

Rationale for role choice: SWOT analysis

The choice to settle for the topic on delegation during the author’s transition period into nursing was driven by: firstly, the knowledge gap identified in this important picture following the SWOT tasks. During the nurse training, the author developed several skills such as accountability, responsibility and liability, but the basic principles of delegation have been unclear.  Day et al. (2014) affirms to this statement by suggesting that registered NQNs have difficulty learning delegation, supervision and lack confidence in executing these skills.  Secondly, the author was driven by the fact that there is not enough support provided to students in regards to developing skills during graduate training. Nowell (2016) concurs by revealing that it is challenging to provide nursing students the opportunities needed to develop the leadership skills required in today’s demanding health care environment. Arguably, nursing students are undereducated for the demands of current nursing practice.  They lack opportunities to delegate care to other members of the health care team and practice the skills of prioritising, collaborating, consulting and delegating care (Benner et al., 2010). This lack of sufficient education in delegation has been attributed to a shift in care delivery models that took place in the 1980’s when nursing care delivery shifted to primary care (Powell, 2011). However, in the current era, emphasis on delegation has been aroused by the focus on collaborative and team nursing practice making delegation to become a critical competency of new graduating nurses (Powell, 2011).

The above point is evidence from literature as well as from the student’s experience as shown in the SWOT analysis table in appendix 1.  It demonstrates that there is a gap between the expected skill levels and authentic abilities of newly qualified nurses comparatively to delegation (Ruff, 2011). This is evidenced by statistics highlighted in a survey conducted by Berkow et al. (2009) which pointed out that out of the 3,265 nurses surveyed, only 10% were competent in the skill of delegation. To add to this dilemma, was the fact that out of the 36 competencies surveyed, satisfaction with delegation skills was graded the lowest.  Also, a study by Henderson et al., (2006) concluded that 59% of student nurses graduated without sufficient knowledge and understanding of the basics of delegation pointing a gap in nursing education curricular as a key reason.

Thirdly, the choice to gain more knowledge and understanding on the topic has been driven by the comments made by Sir Robert Francis in his report ‘Care failings at Mid Staffs Hospital’.  He stressed on the importance of proper support and supervision for HCAs warning they should not be ‘left to their own devices’ potentially exposing patients to risk (Keogh, 2014). This is more-so when the NMC (2015) stipulates that registered nurses have a duty of care and a legal liability towards their patients.

The concept of transition can assist the author’s direction as a prospective adult nurse through the numerous stages of transition during the early months of being a registered nurse. Harmer (2010) observed that the preparation of talented graduate nurses and assisting them during the transition to the professional nursing role are essential purposes of nursing education.  Reading around the topic has now taught the author that during the transition stage, the student’s confidence can be knocked by determined requests to assist with or perform procedures such as delegation, prioritising and accountability which the author may not have the competence and experience. Josephsen (2013) affirms that the professional nursing role as delegator can be challenging to learn and teach in the nursing education setting. Likewise, Holmes and Whitehead (2011) argued that the issue of responsibility and accountability was a major stressor in the transition stages. From the author’s perspective, it is now clear that the professional development of a nurse is a process that starts during undergraduate education and continues throughout working life (Pennbrant et al., 2013). This can be achieved through evaluating and re-evaluating one’s educational experiences, developing professional self-efficacy and developing clinical competence. To facilitate this professional development, new nurses need support from their nursing-school educators and their healthcare employers (Pennbrant et al., 2013).

Conclusion

Discussed is the definition of transition and Kramer’s (1974) transition theory which was adopted by the author in SWOT task of transition from being a nursing student to a newly qualified nurse. Author concentrated on the delegation theme for reasons aforementioned.

Chapter 2: Research Approach

Introduction

This section explains and justifies the research philosophy associated with research strategy and the research design adopted. This work adopts sources of qualitative data.

Research Philosophy

Epistemology (nature of knowledge), Ontology (nature of reality) and Axiology (values about knowledge) are philosophical assumptions noted by Saunders et al. (2009). The research methods and strategy are to be supported by the afore-mentioned assumptions. It is argued that when undertaking a research study in any field, one should rely on accepted philosophies as this reasonably defends any stance taken (Johnson and Clark, 2006).

Positivism concept is advantageous as the researcher is independent (objective) and in control of the research. This is because the philosophical assumption argues that social reality is external due to rules and laws that are to be followed making it solid and concrete eliminating prejudice and opinions. In addition, positivism is highly methodical, replicable and are measurable in terms of numbers. Its flaw is the generalisation of findings (Saunders et al., 2009).

On the other hand, the philosophical assumption of interpretivism assumes that the nature of knowledge is best understood from the participant’s viewpoint. According to Mead (1920) cited in McNeill and Chapman (2005), it argued that the sense of self, of who one is in relation to others can develop a social context.   It can be argued that the assumption indeed allows an in-depth analysis as the researcher has the opportunity to observe and/or interact with what/who is being researched. But the researcher’s judgement can be prejudiced as the analysis is depended on his or her perception.  The assumption is subjective in nature because the truth is deliberated as inner product of the researcher’s mind. It uses qualitative methods in dealing with terms and definitions in discovering a phenomenon.

In its difference with the above mentioned concepts, the assumption of realism sees the nature of reality as both external (concrete) and internal (social construct); thus the researcher has to be subjective and objective. With this approach, it creates some balance because things which are not seen nor observed can be known through practical and theoretical processes in social science. Arguably, this assumption infers the truth by balancing positivism and interpretivism making it both quantitative and qualitative research methods (Saunders et al., 2009).

Philosophical Position

This work adopts the philosophical of interpretivism because the skills that are needed to transit from being a nursing student to a newly qualified nurse are known to the author as the work is written from the author’s perspective.

Research Approach

Methods of reasoning are deductive and inductive approaches to research. Deductive approach being a method of instructions is aimed at testing theory while inductive approach generates new theory emerging from collected data as it is a method of discovery (Knauff, 2002). The implementation of the most effective research approach is dependent on the conceptual framework of the research study (Bryman, 2012).  Inductive and deductive approaches are generally associated with qualitative and quantitative research respectively. Therefore, this work will adopt inductive (qualitative) approach.

Research Methods

Munhall and Munhall (2007) argue that qualitative approach is used to describe life experience and situation to give them meaning. Qualitative literature review uses a wide range of literature already researched around a specific topic area (Aveyard, 2014). That is exactly what the author intends to do, describing personal experience which ought to be faced in the author’s transition.  Moreover, qualitative research draw attention to an interpretivism view in which research of individual ‘embraces the view that as far as people’s perspective are concerned, there is one single truth’ (Hartley and Muhit, 2003). Arguably, things are being interpreted differently by different people at different times in different places making reliance on ‘interpretivism’ assumption is justifiable.

Data Collection Method

Primary (see appendix 1 and 2) and secondary data (literature review) are to be used to analyse the author’s experience. This approach purports to answer the proposed question.  Secondary data approach allows collection of large volumes of data within a short period of time (Bryman and Cramer, 2011). Advantages with secondary data is its reduction of time and cost and also ensures limited observer bias while its disadvantages are associated with the inability to check accuracy, sufficiency and the out-dated nature of data (Becker et al., 2012).

The Research Question

The research question is “What are the barriers and enablers of effective delegation encountered by newly qualified nurses?” Analysis of the research question shows that it is not too long or confusing in adherence to Parahoo (2014) suggestion that the title of a research must not be too long or too short as this can be can be confusing or misleading. The research question also fits well within the Problem/Patient/Population, Intervention/Indicator, Comparison, Outcome, (PICO) framework in figure 1 below.

Search strategy

To search for suitable, current and relevant research articles for the research question, several key words were generated from the (PICO) framework below.

Figure 1: PICO framework

P- Patient /Population	Newly qualified nurses/ nurses
I- Intervention	Delegation
C- Comparison	Assignment
O – Outcome	Effective patient care/ Barriers AND /OR facilitators of delegation,

These words used included terms like “nursing delegation”, “nursing transition and delegation”, “legal and professional aspects of delegation”, “barriers AND /OR facilitators of delegation”. These key words were used to search for literature from several electronic data bases like Medline, PubMed, AMED, CINAHL Plus with Full Text and SUMMONS as shown in appendix 2 below.

Several current and out-dated research articles were generated from the literature searches which were in the form of quantitative and qualitative research articles. Reviewing these numerous number of articles was not possible, and therefore it was important to use search controls to bring down the successes made.   According to Polit-O’Hara and Beck (2006)the use of ‘belonging search operators’ such as OR, AND, or NOT is one way of increasing or limiting the search process.  For instance, by joining search times like barriers AND/OR facilitators of delegation, it was possible to limit the search to only articles that discussed these key terms.

Inclusion and Exclusion criteria

The literature search will be restricted to research articles published between 2006 and 2016.  Moule and Hek (2011) supports this approach by suggesting that a maximum time frame of between five and ten years is typically placed on the age of the articles to be included in a research.  Also involved in the essay are peer reviewed journal articles, because peer reviewed are as well appropriate research issued in English. Current literature reviews and organised reviews were also used and are considered as important sources of data due to their ability to offer a good overview of the research that has been conducted (Ely and Scott, 2007).  Excluded are articles making references to delegation in other areas besides nursing.

Data analysis

The analysis of the articles included for review in this essay is supported using suitable Critical Appraisal Skills Programme (CASP) tools which are relevant to the type of research used (Critical Appraisal Skill Programme 2012) (see appendix 3).  According to Lee (2006), the use of CASP tools is valuable as it helps with the process of scrutinising the trustworthiness, results and the significance of the research.  In this essay the key findings from the literature reviewed will be presented in a thematic approach according to the main patterns identified within the data analysis (Sandelowski et al., 2007).

Ethics

Ethical issues are not relevant in this work because the project is directed to author’s experience.

Conclusion

This chapter outlined the research approach used in the study as this makes it easier to understand the following chapter which focuses on the literature review.

Chapter 3: Literature Review

Introduction

According to Aveyard (2014), literature review is defined as a comprehensive study, analysis and evaluation of a specific area. Higgins and Green (2011) submits that the literature review helps with identifying and describing information that already exists in a specific area of study which aims to facilitate the nature and theoretical base of the research.

The literature review has been analysed in relation to ‘delegation role’ and other themes which emerged -:

• Accountability
• Communication
• Confidence
• Enablers and barriers to effective delegation

Literature related to Delegation

A qualitative study into the experiences of a newly qualified registered nurse within a leadership role within a ward-based care team was conducted by  Ekström and Idvall (2015). It was based on the belief that the leadership qualities of a nurse reflect the quality of care provided to their patients. Within this study were 12 nurses, (11 female and 1 male, all newly qualified) with ages ranging from 23 – 43years old.  They were interviewed and their responses transcribed. They were from four different wards: rheumatic, medical, surgical and neurological wards within a university teaching hospital. The results of the study showed newly qualified nurses struggled with delegating and prioritizing as a result of lack of experience.

By adopting a qualitative approach, researchers were able to have an in-depth understanding of the participants’ feelings and thoughts in regards to the transition period.  Moreover, as the participants were from different wards, various experiences could be explored therefore negating generalisation of findings (Kings College London, 2008). The researchers included participants who had different levels of experience; some had 6-12 months, others 13-18 months and the rest 9-24 months experience within a leadership role. This allowed for researchers to examine the competency of newly qualified nurses’ leadership skills from the beginning to the end of their transition period.  As the sample size was small and this can be viewed as weakness in generalising the findings. It could however be argued that using a small sample size allows the researchers to understand the phenomenon as they were aiming for in-depth interviews.  It would be difficult to conduct interviews in as much depth with a larger group of participants thereby making the analysis ineffective (Parahoo, 2014). Researchers assigned approximately 30-70 minutes for each interview to allow the researcher to ease into the interview and make the participant comfortable, before delving into their in-depth discussions (Holloway and Wheeler, 2010). Time to build up a relationship with the participant encourages openness and trustworthiness, which in turn increases the conformability and credibility of the research findings (Taylor and Francis, 2013).  As such, when the study was completed, Ekström and Idvall (2015) recommended that newly qualified nurses should be given the appropriate support required in order to advance their managerial and clinical skills. This would greatly improve their confidence in a leadership role when having to delegate tasks (Clark & Holmes, 2007).  This extra support can be provided in form of a preceptor. The themes found within these recommendations are supported by research from Dyess and Sherman (2009) as they argued that NQNs are not fully equipped or prepared for the responsibilities and tasks that come with their new role.   Delegation was identified as a particular area of weakness for NQNs for they were unaware of how or who to delegate to.

In their study, Dyess and Sherman (2009) used a focus group that contained NQNs, nursing leaders and preceptors over a 2-year period. All these participants had been involved in a one year transition programme called the ‘Novice Nurse Leadership Institute Programme’.  The study had 81 participants, thus enabling large amounts of data and information to be collected in groups (Parahoo, 2014).  Findings uncovered that support is needed during the first year of a NQNs transition.  They also showed that feedback from nurses and constant reflection on practise could be helpful in improving NQNs’ skills, especially their delegation skills.  Disadvantages of using a focus group is that all participants’ views may not be heard as participants with introvert personalities may be overshadowed by those with extrovert personalities (Pope and Mays, 2006). Notably, as per Keogh (2014) there are 5 types of delegators, namely: (i) the do-it-all nurse, which is the most common type, but often leaves the nurse feeling overwhelmed and stressed with important work left undone. In this type of delegator health care support workers feel they are mistrusted to do their jobs.  (ii) the justifier who is often defensive, feels it is compulsory to justify every decision, and explain to the HCA why they need their help.  Keogh (2014) admitted that this can be due to lack of confidence and worry, whereas they are perceived as lazy or not working hard enough.  (iii) buddy type of delegator who worries about being ‘bossy’ and pretend to be everyone’s friend, but some Support Workers disrespect those who took this method. (iv) is the role model who tries to act as a good model, hoping health care support workers will pick up skills and (v) the inspector, who is often aware of their accountability and repeatedly checking on the work of HCAs.

Accountability

The Department of Health (2010) introduced ‘preceptorship’ which embraces mentoring programmes for newly qualified nurses.  The role of a newly qualified nurse is limited and closely supervised in order to allow additional support and training from mentoring programmes.  For instance, further training will involve patient care, intravenous drug administration, medicine management skills amongst other relevant to their role. In order for the newly qualified nurse to truly benefit from preceptorship, it is recommended that they get this additional training for a minimum of four months (NMC 2015). It is crucial that newly qualified nurses feel supported during the early stages of the transition period. This allows newly qualified nurses to embed expectations required with the job role. By being a member of a multidisciplinary team, other healthcare members place just as high an expectation on the newly qualified nurse. 

Arguably, the newly qualified nurse is expected to hold same skills as the experienced nurses but it could be exceptionally hard for  to fit into the role (Malouf and West, 2011).  Problems such as time management could be a challenge to uphold due to staffing problem (Needleman and Buerhaus, 2003). Identifying and prioritising tasks which requires critical thinking during a shift is one of the most effective ways for goals to be achieved and in a timely fashion (Lipe and Beasley, 2004). Also, management skills as this allow managing, delegating and prioritising workload effectively. These skills will enable them to be able to deal with the uncontrollable events (Hartigan et al., 2010).

Furthermore, the Department of Health (2010) realised that innovative teaching should be implemented by nursing educators in order to equip newly qualified nurses during their transition period. Newly qualified nurses are to get used to documentation as this allows them to be able to communicate alongside other multidisciplinary members. Within these documents should be detailed care of patients. Their mentor/supervisors check and countersign any documents they produce meaning it can be used as evidence in a court of law (NMC, 2009a). The concept of accountability which is crucial to professionalism  consists of legal, moral and ethical aspects and this is because all nurses are required to justify the actions that they take when it comes to the patients’ care (Scrivener et al., 2011) as they, their employers and the public can be held accountable by their patient through civil law,  (Dimond, 2008).  

As such, if a nurse is shown to have acted negligently, a duty of care is thereby breached, and the patient who suffered will be awarded damages by the courts.  Negligence is an issue that is particularly common among less experienced nurses, so it is important that newly qualified nurses use their mentors for support and guidance during preceptorship to ensure they are well equipped to provide good standard of care and avoid a future lawsuit.

Communication in regards to delegation

Potter et al. (2010) conducted a qualitative descriptive study and observed that at the centre of delegation is effective communication. It was pointed out that good delegation requires clear, concise and complete communication. The study revealed that communication was facilitated by effective sharing of relevant information in a timely manner and conveying information that helps the team anticipate a busy workload. Key to successful delegation was the use of communication style which was important in fostering teamwork. In this article, five sources of conflict: age, work ethic, role, personality and management arose from delegation.  It was clearly established that conflict was common when teamwork between the nurse and delegates broke down and there was little or poor communication occurring. The issue of age was raised as a source of conflict especially when the newly qualified nurse was younger than the delegates.  It was shown that senior nursing assistances often resisted delegation from younger newly qualified nurses, this often leading to conflict. A key problem identified was the communication approach used by the newly qualified nurse. The study is valuable as it highlights key factors that can hinder delegation smoothly.

In their study Johnson et al. (2015) the issue of communication was also raised as a key element in facilitating delegation. One of the nurses admits that, “I always try with my healthcare assistant to go through my handover sheet and say ‘this and that need to be done’, ‘can we do this sometime during the shift?’, like weighing a patient who needs to be weighed”. This approach shows that the nurse has a confident and efficient delegation style, involving the HCA in the tasks for the day, sharing handover information in an organised way, and then prioritising tasks for them both. The nurse has clear communication which is critical to decisions surrounding delegation and points to the need to have clear expectations that are concise and also identifies the outcomes expected from the delegatees.  Clear communication will serve to support delegatees not only in delivering care as to the plan, but will support them in succeeding in their role (Currie, 2008).  Participants were 33 newly qualified nurses, 10 healthcare assistants and 12 ward managers. Researchers used qualitative methods as they adopted research approaches of ethnographic case studies conducted in 3 hospitals across England, using participant observations and in-depth interviews. In summary, effective communication is the key element to effective delegation even though it was found that newly qualified nurses learned to delegate to and supervise within a transitional `liminal’ space.

Potter et al. (2010) in their work stressed another communication issue related to work ethics in creating conflicts. The authors defined work ethic as a set of values based on hard work, diligence and initiative. The problem usually arose from the understanding that too much delegation was a sign of laziness while at the same time nurses were also accused of being unwilling to help. It was clear that the willingness to show initiative and follow a strong work ethic was valued by both the qualified nurse and the delegates. The results can be valid if one takes into consideration the fact that the authors used suitable methodologies and data collection methods such as the use of group interviews.  It can also be argued that the use of group interviews was good because it facilitates discussion about the questions posed by the researchers. To add to this also the fact that group interviews minimise intimidation that might arise in individual interviews and create an environment where participant responses arouse peer discussion about work practices. Furthermore, group interviews provoke information in a way that enables participants to ask questions of each other and reconsider their own understandings of an experience.

In another article by Cipriano (2010) it was observed that effective communication was central to the process of delegation as it helped to create agreement between the delegator and the delegate. The article correctly submits that delegation remains a weak skill among newly qualified nurses.  However, a key value of this article for this research is that it raises a key point that can help newly qualified nurses in attaining the skill of delegation as it pointed out that delegation depended upon personality, communication style, and cooperation. Effective delegation requires the ability to communicate clearly and directly.  It also requires knowledge of the stages involved in effective delegation.  It is argued that delegation is a basic management process that can be learned and understood by anyone who is willing to make the effort to get some practice.  This was encouraging for the student as it helped to uplift her confidence.

The ideas raised by Cipriano (2010) and Potter et al (2010) seem to agree with those raised by Weydt (2010) study as it was observed that communication is an important aspect that influences teamwork and relationships, and ultimately delegation.  Further findings suggest that engaging in direct, open, and honest communication is a common element of good teamwork. These factors are considered to be good interpersonal skills that can build a better relationship which is good for newly qualified nurses as they need to understand the concepts of responsibility, authority, and accountability. Moreover, such skills avoid in creating a blame culture at workplace.  In summary, healthy interpersonal relationships influence the manner in which the activity is delegated.  The limitation to the study is that it failed to mention the amount or resources relied upon including any evaluation framework used.  However the study is valuable as it contributes to enhancing communication skills.

Confidence

A qualitative study by Ng et al. (2014) found that postgraduate education in nursing helped to increase confidence and professional knowledge which can help newly qualified nurses to communicate with various stakeholders like other healthcare professionals, patients and patient’s family.  According to Robinson and Griffiths (2009), this helps the individual to perform well at work. Preceptorship should be available for newly qualified nurses in order to develop their confidence.  In addition, Ng et al. (2014) found out that not all nurses were supported by the preceptors and as a result, newly qualified nurses had to quit their jobs leading to shortage of staff.  Nevertheless, some preceptors are tremendously supportive to newly qualified nurses which greatly improve their confidence. This helps to retain nurses as they are unlikely to leave their jobs (Department of Health, 2010). In their study, Ng et al. (2014) conducted a literature review using various database to generate large amount of data but same articles may appear more than once and this can be time consuming (Harvard, 2007).

Bjerknes and Bjørk (2012) in their qualitative research adopted ethnographic design using observations, interviews and analysis of documents of the transition from being a nursing student to a newly qualified nurse.  Participants were 13 female Norwegian nurses in their mid-twenties interviewed, using a convenience/purposive sample. Findings suggest that the transition journey was not easy because established professionals were not always respectful towards the newly graduated nurse when leading a team. This left many graduate nurses feeling demoralised and not confidence in regards to upholding their duties.  They are also not confident to raise the matter.  They felt stressed about the situation feeling some members of the multidisciplinary team do not interact well with them as they are dismissive and uncommunicative.  This is poor practice and can impact negatively on patient care.  Limitation is that participants were chosen specifically for this study; therefore, findings cannot be generalised to another setting as it may not be transferable to a different gender/age group population (Patton, 1990). Nonetheless, the triangulation approach undertaken by the researchers in the form of observations, interviews and document analysis adds validity and trustworthiness to the study as the researchers followed Lincoln and Guber guidelines (Lincoln and Guba, 1986).

Enablers and barriers to effective delegation

Analysis of the qualitative descriptive study by Potter et al (2010) revealed several key enablers of delegation which according to the descriptions of the participants in the study were summed up as the five rights of delegation. The literature analysed also revealed a number of barriers to delegation.  These rights were namely: right task, right circumstances, right person, right direction or communication and right supervision.

For the student, this article was valuable for the study in that it helps her to understand the main elements of delegation.  For example, the article revealed that it was important to delegate the right task to the right person as doing so was a good way of avoiding role conflict associated with the tasks and activities shared between a qualified nurse and care assistances. The article clearly revealed that in nursing care delivery each member, qualified and unqualified nursing staff belongs to a role set.  In reality it is clear that qualified and unqualified nurses have different defined roles yet they share the interdependent tasks of basic patient care activities.  It has however been shown that delegation problems arose when the qualified nurse asked the unqualified nurse to do tasks that the unqualified nurse felt the qualified nurse could do themselves.

Conflict arose when there was little perceived role distinction between the nurse and nursing assistance and when the qualified nurse failed to show initiative to complete patient care tasks, but instead delegated them to the nursing assistant. The findings of this article are reliable if one takes into consideration the fact that the authors used suitable methods of data collection in the form of small semi-structured group interviews to explore participant’s experiences of delegation.  Meanwhile analysis show that the findings can be difficult to generalise to a wider context such as in the United Kingdom given that the study was conducted in the United States of America and the fact that the sample size of the participants was small (10 registered nurses and six care support workers). The importance of sample size in research is that it can help to determine if the findings of the research are clinically or statistically significant (Maltby et al., 2014).

The points raised by Potter et al (2010) were also echoed by Weir-Hughes (2013) who observed that the nurses should be careful and avoid delegating just because they are overwhelmed by their workload or they can’t meet a specific deadline.  It was also pointed out that it is important to plan what needed to be done and resourcing it suitably. The author also argues that it is important to delegate tasks that you think your team can manage, as delegating tasks to a team member who cannot complete a task can dent their confidence in themselves and in the nurse as a leader.

The above ideas were also raised by the Nursing and Midwifery Council’s NMC code (2015) which clearly observed in the section entitled, ‘Practise effectively’ that all registered professionals must be accountable to their own decisions to delegate tasks and duties to other people. The NMC (2015) concurs with both Weir -Hughes (2012) and Potter et al (2010) when they observed that to achieve effective delegation one must only delegate tasks and duties that the delegate is competent to perform ensuring the person has fully grasped the instructions. The NMC (2015) goes on to add that the delegating nurse must ensure that the delegate is sufficiently supervised and supported for them to be able to provide safe and compassionate care as well as also checking that the outcome of the task delegated meets the obligatory standard.

Currie (2008) argued that in delegation it is important to consider the issue of competency. The author admitted that competency is an on-going process and involves the ability to integrate knowledge, skills and judgment to practice safely and ethically in a designated role.  An important point raised was the need for nurses to also have a sound grasp of what “competency” means for health care assistance and support staff as well as understanding the skills they perform. The article is valuable as it highlights the ability to integrate knowledge and skills requires for competency.

The Royal College of Nursing (RCN, 2016a) pointed out that in delegation, nurses must be aware of the basic principles.  For example, the RCN (2016b) observed that delegation must always be in the best interest of the patient and not performed simply to save time or money. It is also important to state that the Support Worker must have been suitably trained to perform the intervention, as well as ensuring the evidence that the Support Workers’ competence has been assessed and recorded. Above all, the delegated task must be within the Support Worker’s job description and that the person who delegates the activity must ensure that an appropriate level of supervision is available with an opportunity for mentorship (RCN, 2016c).

In another journal article by Weydt (2010) entitled “Developing Delegating Skills”, the author concurs with the findings by Potter (2010) when they referred to the five rights of delegation.  The author clearly articulated that the five rights to delegation are: the right task, condition, person, direction and communication and supervision and evaluation. It also revealed that there are two main ways of delegating: simple task assignment based on job descriptions; and matching a staff member’s knowledge to a patient’s needs. Central to the article is also the stress placed on the need for the delegator to be clear on what is being delegated, the need to continuously develop one’s delegating skills as well as ensuring that the person being delegated the task qualified to perform it, and the fact that final accountability lay with the delegating nurse.

Corazzini et al. (2010) used a descriptive qualitative study design to explore delegation among 33 nurses. The article is relevant for this study because it reveals knowing the five rights to delegation is not enough for one to become an effective delegator but it is also important to have a grasp of the barriers to delegation.  In what was observed that there were several barriers to effective delegation in nursing of which the first barrier is associated with a lack of clinical leadership experience. It is argued that delegation in nursing is connected to leadership skills and its absence can create a barrier to effective delegation.  Another barrier is closely linked to leadership a skill which develops partnerships between qualified nurses and Support Workers.  This lack of a working relationship has led to nurses resisting delegating care as a way of avoiding antipathy from support staff.  Attitude has also been attributed to barriers of effective delegation and the main sources of attitudinal barriers and sources of conflict have been identified as age, work ethic, role confusion, disposition and dissent.

The issue of attitude was raised in a quantitative study by Gravlin and Bittner (2010). Findings suggest that successful delegation was affected by nursing assistant’s attitude among many other factors such as competence and knowledge. It is important to note that conflicting attitudes among members of the same nursing team can hinder delegation.   People can have different values due to diversity arising from cultural, age, social, religious and political factors.

Also lack of trust between the nurse and the care assistant can be a barrier to delegation as the nurse often hesitated to delegate until trust had been developed.  This is especially important because nurses must deal with the significances of mistakes as they are accountable for the task (NMC 2015). Another barrier to delegation was associated with a working environment in which reporting structures and job descriptions are not clear for delegation works better when there is a clear reporting structure (Corazzini et al., 2010). Closely linked to the above barrier is also the absence of clear role definitions because having clearly defined roles can expressively decrease conflicts during delegation (Corazzini et al., 2010).

This was observed by Potter et al., (2010) as he argued that main trigger of conflicts between nurses and care assistants was the understanding on the part of care assistants that their role was like that of the qualified nurse except when it came to giving out medication. It is clear that the care assistants were not familiar with the nurses’ clinical decision-making and patient care management responsibilities. Nonetheless, the strength of Gravlin and Bittner (2010) study is the data collection methods used which were in the form of semi-structured interviews conducted after seeking consent from the participants as well as ensuring that the interviews were conducted in a secluded area like a private conference room.  As a weakness, the sample size of 13 is small as it cannot generalise findings (Hackshaw, 2008).

In another qualitative study using an ethnographic methodology by Johnson et al (2015), the importance of team working and collaboration was raised as a key facilitator of delegation. The authors raised the point that newly qualified nurses found delegation easier due to a strong collaborative element to team working in some wards as team members knew and understood their respective roles. According to Johnson et al (2015), the tension between newly qualified nurses and support workers can be resolved by effective communication.

For example, it has been pointed out that newly qualified nurses spend time doing their records and this can then also limit their ability to supervise and delegate appropriately.  However, if there is a lack of communication, tensions between nurses and health care support workers can arise at times as support staff may feel that the nurse is not working equally hard.

The above point was also observed by Cipriano (2010) who pointed out that the delegation depended upon a constructive two-way relationship of mutual respect and trust between the nurse and care support worker and that this relation also required continuous evaluation. The article by Johnson et al (2015) also pointed to the issue of lack of confidence as a key factor that limited professionals to use their initiatives in providing health care. The author pointed out that newly qualified nurses often feel unprepared to delegate upon graduation, mainly because of lack of self-confidence, lack of knowledge, or lack of understanding of how delegation can contribute to quality employee, patient, and organizational outcomes (Johnson et al 2015).

It has been shown that the delegation process requires good judgment and communication on the part of the qualified nurse and the willingness on the part of the delegates to respond in a timely and appropriate manner. The success of delegation also depends on the creation of a working environment that supports and improves staff relationships, facilitates the work of patient care and potentially reduces patient risks for adverse events or missed care.

Further findings suggest that nurses need to have an on-going, comprehensive understanding of delegation and the role that it plays in current nursing care. Nurses have been challenged to adopt an approach that is underpinned by critical-thinking before delegating care responsibilities to care support workers. The strength of this article is in its ability to show that delegation must be a patient-focused and centred approach driven by appropriate assessment, planning, implementation, and evaluation regarding the patients’ care.

Conclusion

Discussed is the literature review of delegation and themes of accountability, communication, confidence, enablers and barriers to effective delegation.

Chapter 4: Results and Discussion

Introduction

This chapter presents the results and discuss delegation. An ‘Action Plan’ was adopted as this helps to improve the author’s delegation skills.

Results and Discussion

Following the literature, transition process is punctuated by physical, intellectual, emotional, developmental and socio-cultural changes. It is important to develop evidence driven action plan to overcome these challenges (Duchscher, 2009). The action plan works in hand with the SWOT analysis attached in appendix.

So, to improve on the author’s delegation skills, the author will take advantage of the opportunities available to gain more knowledge and understanding of the skill as a short term goal in final clinical placement. The author will alsotake advantage of the number of strengths like the ability to communicate effectively, having good interpersonal skills, compassion and respect for others.  As argued by Potter et al (2010), effective communication helps to facilitate nursing delegation because sharing and transmitting information in an appropriate manner enhances collaborative practice and helps others to forestall a busy workload.

In addition, the author is able to carry out accurate assessment using appropriate diagnostic and decision-making skills.  This can help to assess the task, deciding on the skills of the care assistant in relation to the task at hand.  Other abilities are time management, which is important in planning the tasks at hand as well as making sure that they are allocated enough time. Working alongside peers and mentors is evidence of being part of a team and this will help to overcome barriers associated with inters and intrapersonal issues associated with collaborative practice. To be effective at delegating, the author will take advantage of the opportunities available such as clinical placement to develop delegation skills.

This approach is supported by Pennbrant et al. (2013) who observed that the professional development of a nurse is a process that starts during undergraduate education and continues throughout working life.  The author will also learn by observing the Unit Manager and mentor as they organise and manage their duties.  Need for further development are in the areas of: weaknesses of delegation; ability to respond confidently to planned and uncertain situations; ability to identify priorities and manage  resources effectively while ensuring the quality of care is maintained and organisational skills and  staff management.

Consulting with lecturers, talking to friends on the same course, reading around the topic of delegation, leadership and management of resources can help. Taking this approach is supported by (Duchscher, 2009) who observed that the transition process was stressful due to the feelings of unpreparedness, lack of confidence in clinical skills and decision making, the need for support and stabilisation into the role.  Furthermore, the Royal College of Nursing (2016) supports the need for continuous personal development.

In the long term, especially during the first year in nursing practice, the author intends to take advantage of continuous development programmes such as mentorship provided by employers.  Success in developing delegation skills will also depend on the ability to work on the current threats such as work and family commitments; however, the work-life-balance policy tends to be supportive. The author needs to overcome the threats arising from fear of the consequences of mistakes made by delegates including overcoming personal and family issues that may be acting as threats to developing delegation skills.  Al-Yateem and Docherty (2015) supports this by observing that transition is affected by the environment of the individual in transition including values and rituals of the individual or the society within which the individual is living.  In future practice, the author intends to check and understand the job description of the healthcare assistants as this helps to know the extent to which one can delegate responsibility to them.  This will provide the delegator an insight of what they can and cannot do (Hansten and Jackson, 2010).

To build on confidence in delegation, the author intends to attend seminars, training sessions and workshops on delegation and leadership skills available as part of continuous education. According to Kleinman and Saccomano (2006) attending workshops and partaking continuous professional development in areas such as delegation can help nurses to be proficient in delegating skills.  In support, Gillen and Graffin (2010)pointed out that an important delegation enabler is that of an organisational culture that promotes professional development.

In the long run, the author will reflect continuously on practice and seek to develop skills in this area. This is especially important when there is evidence showing that   the transition from being a newly qualified nurse to a graduate nurse is a process that requires one to evaluate and re-evaluate their own educational experiences, developing professional self-efficacy and developing clinical competence (Pennbrant et al., 2013)

Conclusion

Discussed are results as they are mirrored with the author’s experience with SWOT analysis being adopted (see appendix).

Chapter 5: Conclusion and Recommendation

Introduction

This Chapter summarises the study and provide recommendation.

Conclusion

This work had demonstrated a systematic understanding of the key aspects of current professional nursing practice by looking at nursing delegation as an issue affecting newly qualified nurses.  It also demonstrated the student’s limitation in terms of knowledge and understanding in this area and has presented this information using a SWOT analysis table.  A detailed discussion around transition from being a student to a registered nurse has been presented using relevant transition theory and how the concept of transition can assist the student in developing her skill in delegation during initial months of qualifying as a registered nurse.   A critical analysis of literature has been conducted with three main themes being presented.  These three themes are: “effective communication and delegation; five rights of delegation and barriers to effective delegation, stressing a person-centred care led by interpersonal relationship and initiative”.

An action plan has been presented showing how the student will develop the skill of delegation in the short and long term.  A key lesson learnt by the student during the process of writing this extended essay is that nursing delegation is an important professional role for newly qualified and registered nurses to fully grasp because it enhances collaborative practice.  It is now clear to the student that when delegating a task, it is important to ensure that everyone’s role has been defined clearly so that conflict can significantly reduce during delegation.

Recommendations

• Develop skills requires making use of preceptorship available.
• Experienced nurses are to exercise patience when mentoring newly qualified nurses.
• Respect for others is paramount regardless of age, culture or their background.
• Newly qualified nurses should never be discouraged but hold on because ‘Rome was not built in a day’.

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Appendices

Appendix 1

Strength Able to practice autonomously providing safe, compassionate, person-centred care. Communication and interpersonal skills. Other people including my mentor see my strengths as the ability to use evidence-based nursing that respects and maintains dignity and human rights.  Am also good at time management  Good to work as part of a team

Weakness Other people think I need to develop the ability to respond confidently to planned and uncertain situations. I consider delegation as my area of weakness I am inexperienced in the ability to identify priorities and manage resources effectively to ensure the quality of care is maintained. Need to develop in organisational skills and  staff management

Opportunity I need to take advantage of the opportunity provided during clinical placement to develop my delegation skills I can also observe other professionals such as my mentor as well as the unity manager on how they organise and manage their staff. I will also develop my weaknesses by talking to my friends /Peers. I will also utilise my lecturers as well as reading around the topic of delegation, leadership and management of resources. I will also take advantage of  continuous development programmes  provided by my employers such as mentorship

Threat Work and family commitments can be a threat Working on my own Work load Differences in culture, values and beliefs. The consequences of mistakes made by delegatees is another reason for inadequate delegation

Appendix 2: Literature search process Table

	Key words and search terms used	Key words and search terms used	Key words and search terms used	Search limiters /   inclusion and exclusion
Databases used	nursing delegation	Nursing   transition and delegation	Barriers AND /OR facilitators of delegation, ,	Full Text, Date of Publication: 2006-2016 , Academic   Journals, Full Text References Available Abstract Available
CINAHL Plus with Full Text	16	132	79	as above
Summons	24	2,551	1	as above
MEDLINE	6	130	1	as above
Academic Search Complete	26	189	2	as above

 

Appendix 3: Assessment of the quality of papers using CASP tool

Author	Tittle	Aims	Participants	Methods	Key Findings
Ekström and Idvall (2015)	Being a team leader: newly registered nurses relate their experiences	Explored how newly qualified registered nurses experience their leadership role in the ward-based nursing care team	12 Newly experienced nurses	Interviews were transcribed using qualitative content analysis to assess both manifest and latent content.	Results indicate that the nurses felt stranded as they were forming to functioning well in their teams. They did learn to lead as they summoned courage, strength and had the desire to lead. Nevertheless, findings indicate that many factors limit nurses leadership but some circumstances are supportive. The basic leadership skills for for newly registered nurses need to improve, giving emphasis to different ways that create a supportive atmosphere that promotes professional development and job satisfaction.
Dyess and Sherman (2009)	The first year of practice: New graduate nurses’ transition and learning needs.	Exploring on new graduate nurse transition and learning needs through the eyes of new graduates and the nursing leaders and preceptors who work with them.	81 Newly qualified nurses	Interviews on a focus group	Key findings, importance of preceptorship for newly graduate nurses.
The Department of Health (2010)	Preceptorship Framework for Newly Registered Nurses, Midwives and Allied Health Professionals	Implementation of preceptorship for newly registered professionals	—	–	Advocating for preceptorship for newly registered professionals in order to benefit the public, develop careers for those involved and be able to retain staff in the organisations
Potter et al. (2010)	Delegation practices between registered nurses and nursing assistive personnel	To understand registered nurses’ and nursing assistive personnel’s perceptions of delegation practices.	Registered nurses and nursing assistive personnel	Qualitative descriptive study	Results suggest conflict was central during delegation. Sources of conflict varied between RNs and NAP. In conclusion, successful delegation is considered by effective communication, teamwork and initiative.
Currie (2008)	Delegation Considerations for Nursing Practice	Delegation tasks to non-nursing care providers.	N/A	Qualitative	One of the key findings was competency as it is key the job role.
Johnson et al. (2015)	Doing the writing’ and ‘working in parallel’: How ‘distal nursing’ affects delegation and supervision in the emerging role of the newly qualified nurse.	Exploring how newly qualified nurses recontextualise knowledge into practice, and develop and apply effective delegation and supervision skills.	33 newly qualified nurses, 10 healthcare assistants and 12 ward managers.	Qualitative method was used. Research approaches adopted were Ethnographic case studies conducted in 3 hospitals across England, using participant observations and in-depth interviews.	Findings suggest communication is they key element to effective delegation. This was because newly qualified nurses learned to delegate to and supervise within a transitional (`liminal’) space.
Cipriano (2010)	Overview and summary: delegation dilemmas: standards and skills for practice.	Considerations that are important in successful delegation.	6 articles used	Qualitative studies	Findings suggest that effective delegation requires the ability to communicate clearly and directly, it also requires knowledge of the stages involved in effective delegation.  It
Weydt (2010)	Developing Delegation Skills	Effective delegation practices	N/A	Qualitative	Results suggest that effective delegation is based on one’s state nurse practice act and an understanding of the concepts of responsibility, authority, and accountability.   Delegation to ancillary personnel by can be simplified by adopting assignment patterns that are the more effective such as pairing and partnering. Delegation is an important skill that influences clinical and financial outcomes.
Keogh (2014)	Lecturer says delegation should be a part of pre-registration courses	Exploring on the experiences of the newly qualified nurses	N/A	Qualitative	Findings – that delegation requires right skills. Also, it was found out that there were 5 types of delegators.
Ng et al. (2014)	Exploring registered nurses’ attitudes towards postgraduate education in Australia: An overview of the literature.	Exploring on the new ways of thinking and practice for nurses.	59 papers used	Qualitative study	One of the key findings is that postgraduate education in nursing helped to increase confidence and professional knowledge
Bjerknes and Bjørk (2012)	Entry into nursing: an ethnographic study of newly qualified nurses taking on the nursing role in a hospital setting	Assessing the opportunities and limitations faced by   newly qualified nurses when taking on the nursing role	13 Females	Qualitative research, which adopted ethnographic design, using observations, interviews and analysis of documents.	Findings, suggest that the transition journey was challenging and when the newly graduated nurse, when trying to lead a team they felt demoralised and not confidence regarding upholding their duties including loss of confidence to raise the matter.
Corazzini et al. (2010)	Delegation in Long-term Care: Scope of practice or job description	Exploring on delegation including strategies and processes for delegating care, and perceptions of barriers to effective delegation and potential benefits of delegation.	33 participants	Qualitative, descriptive study	Findings – stud reveals that knowing the five rights to delegation is not enough for one to become an effective delegator but it is also important to have a grasp of the barriers to delegation such as clinical leadership skills.
Gravlin and Bittner (2010)	Nurses’ and nursing assistants’ reports of missed care and delegation	Understanding reasons for missed nursing care and identify factors related to successful delegation.	13	Quantitative study – semi structured interviews	Findings suggest that successful delegation was affected by nursing assistant’s attitude among many other factors such as competence and knowledge.

CASP appraisal tool criteria for qualitative studies

Author	Clear   Aims	Appropriate   Methodology	Research   Design	Appropriate   Recruitment Strategy	Appropriate   Data Collection	Researcher   Influence Considered	Ethical issues considered	Rigour of data analyses	Clarify of findings	Valuable Research
Ekström and Idvall (2015)	✔	✔	✔	✔	✔	X	✔	✔	✔	✔
Dyess and Sherman (2009)	✔	✔	✔	✔	✔	x	✔	✔	✔	✔
The Department of Health (2010)	✔	✔	✔	x	X	x	x	x	✔	✔
Potter et al. (2010)	✔	✔	✔	✔	✔	✔	✔	✔	✔	✔
Currie (2008)	✔	✔	✔	✔	✔	✔	✔	✔	✔	✔
Johnson et al. (2015)	✔	✔	✔	✔	✔	x	✔	✔	✔	✔
Cipriano (2010)	✔	✔	✔	✔	✔	x			✔	✔
Weydt (2010)	✔	✔	✔	✔	✔	x	x	x	✔	✔
Keogh (2014)	✔	✔	✔	✔	✔	x	x		✔	✔
Ng et al. (2014)	✔	✔	✔	✔	✔	x	✔	✔	✔	✔
Bjerknes and Bjørk (2012)	✔	✔	✔	✔	✔	x	✔	✔	✔	✔
Gravlin and Bittner (2010)	✔	✔	✔	✔	✔	x	✔	✔	✔	✔
Corazzini et al. (2010)	✔	✔	✔	✔	✔	x	✔	✔	✔	✔