Global nursing and healthcare workforce shortages

Nursing Inquiry. 2021;00:e12413.  | 1 of 10

© 2021 John Wiley & Sons Ltd


Global nursing and healthcare workforce shortages, increased de- mands on healthcare systems and growing healthcare expenditure have resulted in a focus on the development of strategies to pro- vide cost- effective health care (All- Party Parliamentary Group on Global Health (APPG), 2016; National Health and Hospital Reform Commission (NHHRC), 2009). As part of these strategies, skill mix and nurse staffing are manipulated to reduce costs and provide qual- ity care to patients (Aiken et al., 2013; Jacob et al., 2015; NHHRC, 2009). Adding to this, the COVID 19 pandemic has placed further strain on the healthcare system resulting in the need to build surge workforce capacity to meet the needs of patients (Al Mutair et al., 2020; Marshall et al., 2020). Healthcare organisations have been required to reframe the delivery of patient care examining options to augment and extend the nursing and healthcare workforce. A

common strategy is a tiered healthcare team approach to patient care delivery based on the idea of experienced staff supervising less experienced or lower trained staff members working together to meet the patients’ needs (Al Mutair et al., 2020; Marshall et al., 2020). This may occur in situations where tasks traditionally per- formed by one worker are shifted to another worker (APPG, 2016).

Prior to the pandemic, pressures on healthcare systems interna- tionally had increased the reliance on the use of unregulated nursing assistant (NA) roles in the acute hospital setting (Aiken et al., 2016; Blay & Roche, 2020; Duffield et al., 2014; Kalisch, 2011). To meet pandemic surge workforce demands, healthcare teams may be addi- tionally augmented with reassigned or redeployed staff with trans- ferable skills, healthcare staff re- entering the hospital workforce, final year students in nursing, medical and allied health courses and NA roles (Al Mutair et al., 2020). It is imperative when working in the multi- skilled/ multi- tiered nursing workforce environment that

Received: 8 April 2020  | Revised: 3 March 2021  | Accepted: 12 March 2021 DOI: 10.1111/nin.12413


Transparent teamwork: The practice of supervision and delegation within the multi- tiered nursing team

Felicity Ann Walker1,2  | Madeleine Ball2,3 | Sonja Cleary2 | Heather Pisani2

1Faculty of Health, Southern Cross University, Bilinga, QLD, Australia 2School of Health & Biomedical Sciences, RMIT University, Melbourne, Vic., Australia 3School of Health Sciences, University of Tasmania, Melbourne, Vic., Australia

Correspondence Felicity Walker, Faculty of Health, Southern Cross University, Gold Coast Campus, Southern Cross Drive, Bilinga, Queensland 4225, Australia Email:

Funding information Australian Government Research Training Program Scholarship

Abstract Supervision and delegation are important leadership skills that nurses require when practising within the multi- tiered nursing team. In response to increasing demands globally on healthcare systems, Nursing Assistants are becoming more prevalent mem- bers of the nursing workforce in the acute care setting. An exploratory descriptive re- search design was used to examine supervision and delegation of Nursing Assistants in an acute hospital setting in Victoria, Australia. It was found that supervision and delegation in the context of a multi- tier nursing team required a complex assessment and decision- making process which was influenced by multiple factors. This research promotes developing transparent nursing practices and mutual understanding in the multi- tier nursing team to facilitate effective supervision and delegation based on in- formed decision- making and culture of openness and trust. Pre- registration education and continuing education and support for nurses are important to build transparent supervision and delegation practices and teamwork, empowering the nursing team to practice to their full scope of practice to provide high- quality patient care.

K E Y W O R D S accountability, delegation, leadership, nurse, nursing assistant, supervision, transparency



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each team member is cognisant of their roles, responsibilities and capabilities and that appropriate delegation and supervision prac- tices are in place to ensure the quality and safety of patient care. This research aims to contribute to nursing practice through exam- ining supervision and delegation practices occurring in a multi- tiered nursing team consisting of Registered Nurses (RNs), Enrolled Nurses (ENs) and NA in an acute care setting in Victoria, Australia.

This research focuses on the question of how supervision and delegation of a NA position are practised in a multi- tier nursing team. In the situation, researched NAs were introduced to the acute hospi- tal setting, to enhance the patient experience, assist with the nurses’ workload allowing them to work up to their full scope and improve retention of nursing staff at the research setting. The NA position was additional to the mandated 1:4 nurse/ patient ratios and was used to supplement the nursing workforce. NA attended to basic care duties including patient hygiene, mobilisation, specialling at- risk patients and general duties including restocking of cupboards and checking of equipment. The NA was required to practice under the supervision and delegation of the RN at all times.

Delegation and supervision are important leadership skills for effective nursing care and teamwork. When delegating to and su- pervising another worker, nurses need to use their critical thinking skills to make an informed decision on the appropriate course of action to maintain safe and quality patient care (Bittner & Gravlin, 2009; Quallich, 2005; Standing & Anthony, 2008; Weydt, 2010). The nurse must use their assessment skills and determine whether a task is appropriate for delegation and the required level of supervision by examining the patient, the context and environment, as well as the skill level/ qualification level needed for the task. They also need to consider the competency and skill level of the person they are delegating to, as individuals have different capabilities and supervi- sion needs independent of role title. Second to this, the nurse must establish whether the person also has the capacity and resources to be able to attend to the task, taking into consideration the wider context and ward needs (All- Party Parliamentary Group on Global Health (APPG), 2016; Quallich, 2005; Weydt, 2010).

Nurses need to be aware of their accountability and responsi- bilities when delegating and supervising others, remembering that they retain accountability for their decision to delegate and for monitoring outcomes (Nurisng & Midwifery Council, 2018; Nursing and Midwifery Board of Australia (NMBA), 2007). The delegating nurse is responsible for making sure the delegated task is completed successfully and within a reasonable time frame, with feedback provided to the delegate for learning and development purposes (NMBA, 2007; Nursing & Midwifery Council, 2015; Quallich, 2005). When delegating to another worker, it is important for the RN to practice the appropriate level of supervision, which incorporates education, guidance, direction, and monitoring and evaluating out- comes (NMBA, 2007, p. 19; Nursing & Midwifery Council, 2015).

Efficient delegation and supervision in nursing practice is a com- plex process that requires the nurse to use critical thinking, rational decision- making, risk assessment processes and positive interper- sonal skills (Bittner & Gravlin, 2009; NMBA, 2007; Weydt, 2010).

Supervision and delegation are an inherent part of the nurses’ role, and therefore, it is important to examine the understanding and ac- ceptance of these practices and factors influencing them in the nurs- ing team. Evidence in the literature demonstrates the importance of the relationship between successful delegation to teamwork and quality patient care (Bittner & Gravlin, 2009; Potter et al., 2010).

1.1  |  Literature review

Internationally, nursing care is commonly delivered by a team of workers of differing levels of experience and qualifications (Kalisch & Lee, 2013; Kalisch et al., 2013). Delegation and supervision are an in- trinsic component of working as part of an effective multi- tier/multi- skilled healthcare team to deliver high- quality patient care (Potter et al., 2010). As the scope of practice of nurses and NA positions evolve to meet the pressures on the healthcare systems globally, it is important that each member of the nursing team understands and operates their role and responsibilities in the delegation and supervi- sion process. The importance of effective supervision and delegation practices in the nursing team has been recognised internationally.

Delegation is described as a process of mutual understanding of specific results expected and how those results are achieved (Potter et al., 2010). Standing and Anthony (2008) found that nurses viewed delegation as either the explicit act of instructing the NA to perform a task, or implicit delegation, whereby the NA attends to duties as part of the routine practice of their role. Magnusson et al. (2017, p. 46) reported five styles of delegation; (a) the do- it- all nurse, who completes most of the work themselves, (b) the justifier, who over- explains the reasons for decisions and is sometimes defensive, (c) the buddy, who wants to be everybody’s friend and avoids assuming authority, (d) the role model, who hopes others will copy their best practice but have no way of ensuring how, and (e) the inspector, who is acutely aware of their accountability and constantly checks the work of others. Each of these styles was shown to potentially have a negative outcome and be poorly received by the NA thus impacting teamwork. The authors argue that nurses need to exercise personal authority and assertiveness for effective delegation practice and re- quire support and a safe space to enhance these skills (Magnusson et al., 2017).

Successful delegation between nurses and NAs depends on multiple factors including communication, teamwork, initiative, system support, nursing leadership, positive interpersonal rela- tionships and attitudes, work environment, ward culture, work- load and characteristics and the NA’s competence and knowledge (Bittner & Gravlin, 2009; Gravlin & Bittner, 2010; Johnson et al., 2015; Potter et al., 2010). It is important for nurses to learn skills to delegate effectively, such as critical thinking, negotiation and assertiveness to ensure patient safety and quality of patient care (Bittner & Gravlin, 2009; Magnusson et al., 2017; Potter et al., 2010; Schluter et al., 2011). Bittner and Gravlin (2009) report seven factors relevant to critical thinking and delegation between the nurse and NA which are knowledge, expectation,



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relationships, role uncertainty, communication barriers, system support and omitted care. These findings are supported in the lit- erature (Hasson et al., 2013; Magnusson et al., 2017; Potter et al., 2010; Standing & Anthony, 2008).

The purpose of delegation is to gain work efficiency, which Potter et al. (2010) argue can only be achieved when nursing team members work together in partnership. Problematic delegation may have negative impacts on patient care and teamwork (Allan et al., 2016; Bittner & Gravlin, 2009; Johnson et al., 2015). Johnson et al. (2015) argue that poor delegation can lead to nurses and NAs work- ing in parallel rather than as an integrated team. They found that ward culture, personal working styles, skills and competencies, and effective communication were factors that informed collaborative nursing between newly qualified nurses and NAs. Ineffective del- egation practices and poor communication appear to be a source of conflict between nurses and NAs, thus effecting teamwork and quality of patient care (Johnson et al., 2015; Potter et al., 2010). Researchers argue this conflict is accentuated by a lack of under- standing and comprehension by NAs of the role and duties of the RN, with NA’s perceiving very little difference between their roles (Potter et al., 2010; Standing & Anthony, 2008).

Effective communication was shown to be essential to the del- egation process and the follow- up of completed duties (Anthony & Vidal, 2010; Gravlin & Bittner, 2010; Potter et al., 2010; Wagner, 2018). Communication issues, such as sharing information pertinent to the patient and patient care plan, understanding delegated du- ties, absence or lack of communication or reporting, and communi- cation styles were also consistent findings (Bittner & Gravlin, 2009; Gravlin & Bittner, 2010; Potter et al., 2010; Standing & Anthony, 2008; Wagner, 2018). There is a high expectation on NAs to report back abnormal findings and demonstrate prioritisation skills, which is beyond their knowledge and skill level (Bittner & Gravlin, 2009). Researchers argue that poor communication and ineffective com- munication styles have potentially negative outcomes for patient care and nursing teamwork (Bittner & Gravlin, 2009; Wagner, 2018).

The nurse and NA interpersonal relationship was found to influ- ence the effectiveness of the delegation process (Anthony & Vidal, 2010; Gravlin & Bittner, 2010). In situations where a positive rela- tionship was perceived between the nurse and the NA, delegation was enhanced (Gravlin & Bittner, 2010; Potter et al., 2010; Standing & Anthony, 2008). Mutual trust is a consistent finding for successful delegation (Anthony & Vidal, 2010; Bittner & Gravlin, 2009; Standing & Anthony, 2008). The perception of the importance of the recipro- cal nature of the nurse– NA relationship is also discussed (Standing & Anthony, 2008). Other influences on the delegation and supervision relationship considered in the literature are individual personality char- acteristics, work ethic, favouritism, the fear and frustration of working with poorly performing NAs, fear of reprimanding wayward NAs, the reluctance of NAs to accept duties, nursing confidence to delegate and the perception of nurses handing off the “dirty work” (Potter et al., 2010; Saccomano & Pinto- Zipp, 2011; Standing & Anthony, 2008).

The nurses’ acceptance of their accountability for the work del- egated to the NA was explored in the literature (Alcorn & Topping,

2009; Potter et al., 2010; Standing & Anthony, 2008). There was ev- idence that some nurses believe they should not be accountable for the actions of others (Alcorn & Topping, 2009; Hasson et al., 2013). A “red flag” in this space was reported by Hasson et al. (2013), where 46% (n = 204) of student nurse participants indicated they did not believe a nurse should have to supervise the NA, while 78% (n = 342) did not believe their nursing training had prepared them to work alongside NAs. Delegation and accountability are complicated by the variation in the scope of practice expected of the NA and nurses uncertainty about the role boundaries. Clarity and education on accountability and delegation and supervision practices were advo- cated (Bittner & Gravlin, 2009; Hasson et al., 2013; Wagner, 2018).

The movement towards diluting the nursing skill mix around the globe means nurses are responsible for the delegation and supervi- sion of lower trained workers within the nursing team. Evidence in the literature demonstrates the importance of the relationship be- tween successful delegation to teamwork and quality patient care (Bittner & Gravlin, 2009; Potter et al., 2010). It is important to under- stand how supervision and delegation are practised in the nursing team to enhance patient care and teamwork.


In this study, an exploratory descriptive research design was un- dertaken to examine the supervision of NAs practising in an acute hospital setting, triangulating multiple sources of evidence. Nursing leaders (policymakers, managers, supervisors and educators) (n = 20), nurses (RN/EN) (n = 74) and NAs (n = 10) from 13 medical, surgical and specialty wards of a tertiary hospital in Victoria Australia participated in this research. To be included participants had to have had direct involvement in the development or implementation of the NA model, worked directly with the NA in the acute ward environ- ment (>3 months) or worked in the role of a NA (>3 months) at the hospital organisation. Recruitment and demographic information is listed in Table 1. Ethical approval for the research was obtained from the relevant University and Hospital organisation ethical review boards, and this research was conducted according to the principles and values of ethical conduct, as specified in the National Statement on Ethical Conduct in Human Research (2007).

Data were collected using semi- structured individual interviews (24), focus groups (11 focus groups with average of 6 participants) and documentary information in the period between September 2013 and March 2014. Participants were accessed and recruited via various means, including advertisement posters in the hospital, re- searcher presentations on wards, word of mouth, networking and through gatekeepers such as nurse managers and nurse educators. Recruitment was guided by the concept of data adequacy, and the accessibility and willingness of stakeholders to participate in the re- search. Interviews and focus groups were guided by semi- structured interview questions which were peer- reviewed for content valid- ity and then refined, through progressive focusing. The interview guides were developed to reflect the research aim and to collect



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information that would inform and provide a comprehensive de- scription of the topic under study.

Documentary evidence was used to augment and provide con- text to the information learned from the interview and focus group process. Both publicly and privately accessible documents were reviewed and included: organisational documents such as policies and administrative documents, academic documents such as for- mal papers and evaluations, government reports and inquiries, and government and industrial body communication and information re- leases. Interviews and focus groups were conducted by the primary researcher. They were audio- recorded and transcribed verbatim by the researcher and manually analysed. The thematic data analysis for this research consisted of data condensation, data display, and conclusion drawing and verification as outlined by Miles et al. (2014). The analytical tactics were configurational (the what), normative (the how) and field (the why) analysis as per Vincent and Wapshott (2014).

Rigour was maintained through a comprehensive description of the case and systematically following and presenting the research design as per Yin (2014). This research aimed to be relatively value neutral and free of bias, building objectivity within the research pro- cess as outlined by Miles et al. (2014) and Holloway and Wheeler (2010). Transcripts of individual interviews were sent back to

participants for verification. A sample of focus group transcripts were reviewed by the research team to verify the interpretation of the meaning expressed by participants. Triangulation of multiple sources of data was utilised to verify conclusions drawn from the data analysis. The researcher ensured that the documents collected were from a variety of sources with a variety of purposes, and in- tended audiences to maintain a balanced representation of the evi- dence available. A wide net was cast for recruitment of participants, with the aim of recruiting participants that reflected the full stake- holder population. This examination of supervision and delegation practices in the multi- tier nursing team was completed as a compo- nent of a larger research project examining a Nursing Assistant (NA) role practicing in the acute hospital setting.


3.1  |  Clarity in the framework of care delivery in the practices of supervision and delegation

The importance of building a clear framework of care delivery in the practices of supervision and delegation in the context of the multi- tiered nursing team was reported in this research. Nurse

TA B L E 1 Demographics of research participants

Embedded unit of analysis

Nurse Leader Total recruitment: 20

Nurse (RN/EN) Total Recruitment: 74

Nursing Assistant Total Recruitment: 10

Role Senior Managers/ Policy Makers— 9 NUM— 6 Nurse Educators— 5

RN— 68 EN— 6

NA— 10

Age Age Range (years) No. of Participants

Age Range (years) No. of Participants

Age Range (years) No. of Participants

35– 44 45– 54 55– 64

9 8 3

18– 24 25– 34 35– 44 45– 54 55– 64

10 34 13 13 4

18– 24 25– 34 45– 54 55– 64

3 1 5 1

Gender Male 5 Male 6 Male 2

Female 15 Female 68 Female 8

Years of Experience in Current Role

Years of Experience

No. of Participants

Years of Experience

No. of Participants

Years of Experience

No. of Participants

1– 2 years 3– 5 years 6– 10 years >10 years

6 5 7 2

RN: <1 year 1– 2 years 3– 5 years 6– 9 years 10– 15 years > 15 years EN: 6– 9 years 10– 15 years >15 years unknown

RN: 6 10 16 16 15 5 EN: 1 1 3 1

1– 2 years >2 years

3 7

Additional Information

Acting Nurse Manager (ANUM)— 9 RN participants

Clinical Nurse Specialist— 11 RN participants



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leaders promoted the importance of developing clear guide- lines and education to “ensure that the RN, EN, the NA all work within their scope of practice and all three parties are aware of their roles and responsibilities when it comes to supervision and delegation and accountability” (NL8). Despite this, there were in- consistencies in the interpretations of these guidelines and how they were operationalised in practice, which had the potential to impact teamwork and the quality of patient care. It was acknowl- edged that although nurses and NA may know what tasks a NA could perform if they “put it all into an accountability supervision delegation framework, I think you might find a bit of confusion” (NL8). This may have been complicated by pre- existing “greyness” in the scope of the RN and the EN roles in the multi- tiered nurs- ing team.

Variations in the interpretation of supervision and delegation guidelines existed at all stakeholder levels (nurse leaders, RN and EN, and NA) thus effecting horizontal (peer to peer) and vertical re- lationships (different stakeholders) and associated teamwork. NAs expected that they “were going to work side by side with a RN, so she would be giving us our instructions and our directions and she would work with us and we would be part of a team” (NA4). However, they expressed disappointment “that hasn’t happened … we’re very much left to ourselves” (NA4). Contrary to this, other NAs embraced the autonomy in their role and did not perceive an ab- sence of supervision and delegation by the RN “it may be unspoken but I always feel that they [nurses] are supervising me” (NA1). Where NA felt they were inappropriately supervised, they expressed frus- tration and anxiety.

Multiple factors influenced the understanding and practices of supervision and delegation within the multi- tier nursing team includ- ing the: interpretation and understanding of policy, trust, collegiality, individual work priorities, prior experience, and ward culture and ac- cepted practices. Nurse leader views on the level of supervision re- quired for a NA ranged from very conservative, one arguing “I don’t think any [NA] should ever be left alone with a patient” (NL1), to a broader perspective:

A RN might ask the [NA] to do a shower while they go to tea, so they’re not there but the assumption is that when you go to tea somebody else is kind of keeping an eye on your patients.


Addressing these variations is essential as nurse leaders confirmed the importance of appropriate supervision and delegation “because if we don’t get that right, then it dilutes the effectiveness of the [NA] role” (NL2). Nurses also held diverging views on the practice of su- pervision and delegation of the NA one nurse stating “we don’t really follow them around and put them under the microscope because we consider them part of the team” (N10). Whereas another nurse ac- knowledged “we could probably do it [supervision of the NA] better” (N1). There were some nurses that perceived supervising the NA as an additional burden one RN referred to the NA as “someone else you

have to supervise and make sure that they haven’t disappeared” (N9). They described being “slowed down” by supervision requirements of a NA trainee.

Due to the variability in the understanding and interpretation of the NA role boundaries, NAs were required to communicate clearly the duties they were allowed to assist with. Nurse leaders promoted building an inclusive team environment where the NA was empow- ered and “encouraged to speak up if they’re unsure or if they’re not able to do it” (NL4). It was recognised that “as a [NA] you have to be really strong to say “look I can’t do that” (NL2). A senior nurse leader commented that “they [NAs] actually became very much the police of their own scope of practice” (NL9). In light of this, there was a concern that “some of them [NAs] may feel they don’t have the right to say no to nurses because we are supervisors of them” (NL6), and “some of them [NAs] will just do it because they have been asked” (NL2). Further, concern was expressed that the NA may not identify: “‘I’m not a nurse’ just let it kind of slide, it just depends who the [NA] is” (NL3) which may have potential negative outcomes for patient care.

3.2  |  Confidence and understanding in supervision and delegation practices.

Supervision and delegation practices within the multi- tiered nurs- ing team involve a complex assessment and decision- making pro- cess. The nursing team require an understanding of each team member’s roles, responsibilities, skill level and competencies of individuals. Patient condition and care needs must also be consid- ered. It was recognised that “as the RNs we are legally responsible for them [NA], so it’s quite critical that our new staff and grads [New Graduate Nurses (NGN)] understand their responsibilities” (N6).

Appropriate supervision and delegation practices were identi- fied as being of such significance that it was a common understand- ing by nurse leaders that casual pool/ agency staff and NGNs were precluded from supervising and delegating to NAs, as these staff potentially had a “poorer understanding” (NL2) of requirements in a particular ward setting. In the case of the NGNs, nurse leaders argued they should not be allocated an NA to assist them as “they’re [NGNs] still struggling with their own time management and prac- tice… better for them to be looked after by the rest of the team rather than NAs” (NL4). However, this did not translate into practice, as both casual pool/ agency staff and NGNs described practising su- pervision and delegation of NAs.

New graduate nurses participants acknowledged that they were regularly assisted by the NA position but felt underprepared for the leadership responsibility suggesting that further preparation for supervising and delegating to the NA would be beneficial “I’m a grad and I don’t really know much about them [NA]… I find it hard, I don’t know all supervision stuff and what actual tasks they can do” (N11). A lack of confidence in their ability to delegate and supervise, combined with a weaker understanding of the boundaries of the NA



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role, impacted some NGN’s willingness to delegate without direct supervision “I usually use them as my extra pair of hands. So if I’m mobilising, or if I’m doing a bed wash and I need that extra pair of hands, so I am with them” (N12). The potential negative impact of this lack of confidence and understanding was demonstrated when a NA “went out of their scope of practice because she was trying to help a NGN and the graduate didn’t have the confidence to actually stop the person doing what they were doing… the problem, lack of experience with the role and lack of understanding around what the role could do lead to that issue” (NL10). This supports the need for a clear framework for supervision and delegation and ensuring that those participating have a strong understanding of each party’s roles and responsibilities.

3.3  |  Collegiality, respect and trust in the delegation and supervision process

Nurses expressed greater comfort in delegating a range of duties and providing low- level supervision where higher levels of collegi- ality and trust existed between nurses and NAs. This was further strengthened where there was the perception that the NA displayed a strong work performance, high competency level and had recep- tive attitude. One RN noted “if you’ve asked them [NA] to do some- thing and they’ve done it well, then you know that you can ask them to do it again” (N2). Contrary to this, where there were lower levels of collegiality and more mistrust, nurses expressed less confidence in the NA abilities and work performance as reflected by the follow- ing “if they [NA] don’t seem confident then you’re not really going to leave them on their own” (N3). In these situations, nurses reported that they tended to avoid delegating tasks and provided higher levels of supervision where possible. Nurses with less confidence in the NA revealed that they preferred to use the NA “as a second pair of hands” (N4), rather than delegate duties that required the nurse to practice indirect supervision. It should be noted that there was a concern that too much trust and comfort between the nurse and NA may have a negative impact on supervision practices as “the more experienced they [NAs] become you trust them a bit more” (N5) leading to nurses becoming “quite blasé about supervision and delegation” (N6).

In the multi- tiered nursing team, nurse leaders identified the potential of nurses to inappropriately delegate tasks and take ad- vantage of the NA, expecting them to do the ‘dirty work’ or to “del- egate and forget… or a situation where the registered staff delegate off everything and then leave themselves with perhaps not much more than medication to work through (NL5). There was agreement among the nurses that “some people [nurses] rely on them [NAs] too much sometimes” (N13), “some people are NA hogs” (N14), and these nurses were inconsiderate of the needs of other nursing team members. There were further concerns that nurses will “leave those things [dirty work] because they expect the [NA] to do them” (NL11) thus potentially resulting in care being missed. The unstructured

nature of the NA workload created the potential for NA to be del- egated heavy workloads and create tension within the team should the NA refuse to accept a delegated duty.

3.4  |  Operationalising direct and indirect supervision.

Nurse leaders challenged the idea that the RNs were new to super- vision and delegation due to their responsibilities when working with ENs and student nurses “it should be similar in following the same principles as how they work with the ENs, how they work with novice and beginner nurses and nursing students as well” (NL9). One nurse leader identified that the introduction of the NA “made me understand that it did not really dawn on them [RNs] how much they were responsible for the supervision and delega- tion of ENs” (NL12).

Nurses were able to define direct and indirect supervision, but there were inconsistencies in their interpretation of when to apply the different levels of supervision. This was evident in a focus group disagreement where nurses argued whether a nurse was re- quired to remain on a ward when indirectly supervising a NA, or if this responsibility passed to the nurse covering the nurse while off the ward on break “you’ve always handed over to the nurse next door anyway so they’re indirectly responsible” (N7). In addition to this, many nurses expressed the belief that the nurse in charge was responsible for supervising and delegating to the NA, not identify- ing their role in explicit delegation and supervision responsibilities that ensue. Participants who acted as nurse in charge rebutted this assertion, arguing they were too busy to know what the NA was doing “as an in charge I never see her because she’s always out… it’s more up to the girls on the floor that are working with her and alongside her” (N8).

Some nurse leaders expressed concerns about the nurses under- standing and practice of indirect and direct supervision “they [RNs] really don’t understand concepts of supervision direct, indirect and accountability… I really don’t think that they even think about it much the NA just comes in and does the work” (NL13). The nurse leader then provided an example of a situation where the NA had been left in a vulnerable position as the RN had “propped open the door of the drug room so the health assistant can go in and restock… they aren’t thinking the NA should not be in there without a RN present” (NL13). Other nurse leaders agreed that supervision and delegation are an area that nursing could improve.

When considering how to improve supervision of NA in practice one nurse leader identified “the risk is sometimes that you can over supervise people particularly when a role is new because you’re worried that people will work outside of scope” (NL14). Further to this “because supervision is generally indirect and not direct and you would argue that if you had to give direct supervision all the time there’s no point having the role” (NL14). This nurse leader also indicated “I don’t think supervision could be improved but I think



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possibly giving people, giving people a bit more room, bit more flex- ibility in the role”(NL14); again highlighting the divergent views on supervision and delegation practice of the NA in the acute hospital setting.

3.5  |  Understanding accountability and responsibility

The nurses’ understanding of their accountability and responsibility was intrinsically linked to their individual understanding and expec- tations of the practice of delegation. There were variations in the expectation and understanding of the nurses’ accountability when working with the NA. In theory, the nurses understood that they were accountable and responsible for the duties they delegated to the NA; however, how this was interpreted and practised in the ward environ- ment varied between individual nurses. When this issue was explored in detail in the focus groups, nurses were often divided as to what they should be held accountable for “if they’ve [the NAs have] been signed off on something in their training then they should be account- able for what they do” (N10); contrary to this, others argued “that’s not the way it is… we are accountable… you’re responsible (N11).

When the NA position was first introduced, nurses expressed concern at being accountable for another healthcare team member; however, they indicated that their experience working with the NA had dulled some of those concerns. It was argued that the NA had become embedded into the culture of the nursing team, and there- fore, the nurse was no longer mindful of their accountability and re- sponsibility, it had just become part of the daily routine as “I don’t think the RNs would consciously be thinking of it [their account- ability and responsibility] it’s just kind of now culturally embedded into how we practice on a day to day (NL6). There was concern that trust between the nurse and NA may result in nurses “abdicated that [accountability and responsibility of the delegated task] because we have so much faith in our NA” (NL7). One nurse leader noted “they’re [nurses are] very good at delegating probably less good at supervis- ing” (NL15). There were nurse leaders that expressed concern that nurses continue to ask questions about “what accountability was, their responsibility was and they’re still not clear.” (NL13). Further to this, there are some nurses that continue to have “an incredible amount of anxiety about their legal role related to supervision and delegation” (NL12).

3.6  |  Improving supervision and delegation through education and information

Nurse leaders argued that education, clarity in the supervision and delegation space, and support within the ward environment, would improve the practice and understanding of supervision and del- egation and accountability. At the ward level, the nurse managers promoted a clear support structure, further education, and clear

and consistent guidelines to ensure supervision and delegation of the NA was of a satisfactory standard. It was noted by one nurse leader that:

Being able to supervise and delegate incorporates skills such as being able to give feedback… leadership skills being able to critically appraise activities what needs to be done how to delegate those activities they’re all skills and from my experience, I don’t see many RNs having those skills.


Thus, impressing the importance of ongoing education in this space “we are going to have to do a revisit on the NA… I think that there is a real need for it” (NL13). This was supported by the NAs and many of the nursing participants. Educators recommended that ongoing education for the nursing team should involve practical examples and opportunities for open discussion, so nurses may gain a greater under- standing of the practical application of the principles of supervision, delegation and accountability. Those who rejected the need for further education believed that supervision and delegation were practised al- ready to satisfactory levels. Mutual understanding and transparent practices at the team level is important for supervision and delegation in the multi- tiered nursing team as nurses need to be “comfortable and confident with their scope of practice and their role in supervision and delegation and the framework they deliver care in” (NL8).


This research found that supervision and delegation practices in the multi- tier nursing team are complex and influenced by multiple fac- tors. It supports the importance of mutual understanding and trans- parency in the nursing team to facilitate appropriate supervision and delegation. It suggests that more transparent practices within the nursing team could build better shared expectations and per- formance of supervision and delegation with the aim of improving patient care, teamwork and role satisfaction. Palanski et al. (2011) define team transparency as “the sharing of information and expla- nations within a team to enable its members to carry out their re- sponsibilities within the team” (p. 203) and Horne (2012) argues that transparency requires openness, disclosure and the free- flowing sharing of knowledge. This research finds effective communica- tion is an essential part of this process, requiring the nursing team to feel empowered to openly and honestly communicate, sharing knowledge and feedback in a collegial way to maintain the quality of patient care.

In line with previous research on nursing supervision and del- egation, this study indicated mutual understanding, knowledge, skills, competence, collegiality, attitude, ward culture, communica- tion, interpersonal skills, workload, teamwork, support and initiative influenced delegation and supervision practices (Bittner & Gravlin,



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2009; Gravlin & Bittner, 2010; Potter et al., 2010; Weydt, 2010). The multiplicity of factors affecting nursing supervision and dele- gation practices within the multi- tiered nursing team culminates in a complex assessment and decision- making process requiring team members to be well informed and have access to appropriate information. Individual characteristics, skills and attitudes of team members and leaders add further complexity and inhibits a one size fits all approach. The multilayered complexity substantiates the im- portance of transparent practices so that the needs of the situation, environment and individual actors may be taken into consideration and informed decisions made.

A lack of understanding about delegation, and responsibilities and accountabilities in the delegation relationship, is associated with nurses fearing to delegate tasks and an increased risk of burnout (Quallich, 2005). This research supports the idea that nurses are more reluctant to delegate duties or provide indirect supervision in situations where they were not confident, had mistrust or lacked an understanding of the requirements of delegation and supervision. Conflict was present where there was a lack of mutual understanding as team members held mismatched expectations and understand- ing of roles and responsibilities, requirements for supervision, and workload and initiative which were further complicated by individual personalities. This supports Potter et al. (2010) finding that there are multiple sources of conflict within the nurse/NA relationship. A lack of understanding of practices and conflict within the nurse– NA re- lationship had the potential to inhibit fulfilment of the intentions of the role, which was to allow nurses to work to the upper end of their scope, improve the patient experience and improve staff retention. This is important as the APPG Triple Impact report (2016) identi- fies that it is important for nurses to work to their full potential and strengthening nursing will positively impact health, gender equality and economic growth.

The inclusion of the NA to the nursing team requires the RN to embrace their role as a leader and to be more cognisant of their re- sponsibility and accountability as a professional nurse. The Nursing Now campaign draws attention to the need to nurture nurses’ lead- ership skills and allow nurses to work to their full scope of practice to strengthen the nursing workforce (World Health Organisation. et al., 2020). This is even more important as the demands on nurses surge from the pressures of the COVID 19 pandemic. In this research, nurses accepted their accountability when delegating to others; however, how this was conceptualised differed between individuals, which was consistent with the literature (Alcorn & Topping, 2009; Hasson et al., 2013; Potter et al., 2010; Standing & Anthony, 2008). Nurses need a clear understanding of their accountability and re- sponsibility when delegating to others to ensure that appropriate supervision is provided reducing the potential for errors and neg- ative patient outcomes (Standing & Anthony, 2008). This should be supported by clear and consistent policies and guidelines.

As a leader, the nurse should role model professional behaviour acting respectfully and delegating a fair and balanced workload to the NA position. This should be supported by organisational structures and policy. The Nursing Now campaign recognises the

importance of healthcare organisations providing an “enabling en- vironment” for nurses, to promote retention and motivation in the nursing workforce (World Health Organisation. et al., 2020). Collegiality, trust and a willingness to collaborate within the nursing team are important to enhancing teamwork, role satisfaction, the quality of patient care and professionalism in the healthcare envi- ronment (Gravlin & Bittner, 2010; Padgett, 2013; Potter et al., 2010; Standing & Anthony, 2008). There was concern in this research of a potential tipping point where overconfidence, comfort and trust in collegial relationships may result in inappropriate delegation and supervision practices as camaraderies may overshadow responsibil- ities and accountabilities. It is important that there is transparency in delegation process and that team members are empowered to communicate openly and honestly ensuring the NA practices within their role boundaries and competency level with appropriate level of supervision.

Education on the roles and responsibilities of team members and the practices of supervision and delegation within the multi- tiered nursing team is important in building transparent practices and in- formed decision- making processes. Practical examples and scenar- ios were recommended in this research to assist nurses gain a deeper grasp of this. Focus should also be placed on the importance of inter- personal relationships within the nursing team and effective leader- ship skills for nursing staff (Anthony & Vidal, 2010; Gravlin & Bittner, 2010; Magnusson et al., 2017). Similar to previous research, there was concern that newly qualified nurses and nursing students were ill prepared for the demands of delegation and supervision within the clinical setting and that there was a presumption that nurses learnt these skills “on the job”(Allan et al., 2016; Hasson et al., 2013). As the Nursing Now campaign encourages nurses to embrace their role as a leader, optimising their scope of practice and maximising their impact, it is important that nurses are provided the foundation on which to build these skills and abilities through introducing these concepts at an undergraduate level and empowering continual life- long learning and practice (World Health Organisation. et al., 2020).


Supervision and delegation in the multi- tier nursing team involve a complex assessment and decision- making processes that are in- fluenced by multiple factors. Members of the nursing team need to have a strong understanding of their roles and responsibilities and the practices of supervision and delegation. This research promotes the need for developing transparency in the team environment through sharing information and explanations in decision- making processes, building a culture of openness and trust, growing aware- ness in the roles, capabilities and responsibilities of individuals, and making practices clear and evident. Transparency in the nursing team will help inform and enhance supervision and delegation practices, thus empowering the team to practice confidently within their scope of practice in providing quality patient care. This is important as poor delegation and supervision may result in negative patient outcomes



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(Potter et al., 2010; Ray & Overman, 2014; Standing & Anthony, 2008). Education is important in supporting nurses in the practice of supervision and delegation. As the prevalence of the multi- tiered nursing team increases, a greater focus should be placed on these and other leadership skills within the undergraduate education of the professional nurse.

ACKNOWLEDG EMENTS The researchers acknowledge the support of an Australian Government Research Training Program Scholarship for this re- search. We also thank the hospital setting for their support of this research.

ORCID Felicity Ann Walker

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How to cite this article: Walker FA, Ball M, Cleary S, Pisani H. Transparent teamwork: The practice of supervision and delegation within the multi- tiered nursing team. Nurs Inq. 2021;00:e12413.


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