NR 504 Week 6 Delegation Accountability Case Paper Example

Delegation Case: The Monthly Infant Feeding Report I Did Well for Four Years, a Handover of Two Sentences, a September Figure of 71% That Should Have Been 57%, and the Correction I Did Not Make Alone at Eleven at Night

Student Name

College of Nursing, Chamberlain University

NR 504: Leadership and Nursing Practice: Role Development

Instructor Name

Month Day, Year

Delegation Case: The Monthly Infant Feeding Report I Did Well for Four Years, a Handover of Two Sentences, a September Figure of 71% That Should Have Been 57%, and the Correction I Did Not Make Alone at Eleven at Night

I Was Good at This

For four years before I became clinical coordinator, I prepared our mother-baby unit's monthly infant feeding report. Each month I reviewed the charts of every baby discharged from the unit and recorded whether the baby had received only breast milk for the whole stay, which the hospital uses to track its breastfeeding support. It took me about six hours a month. I was good at it, and the quality department had never sent a report back.

When I moved into the coordinator role nine weeks ago, the report was one of the first things I delegated. That history is the heart of the case. The difficulty was not handing over something I did badly; it was handing over something I did so well that I no longer noticed the judgments I was making.

The Handover, as Given

I gave the report to a day nurse with four years on the unit, careful, organized and interested in quality work. I remember the handover as thorough. My notes and her memory agree that it was two sentences, given at the desk in about three minutes: "Pull the discharge list from the EHR report on the first of the month, check each chart, and mark whether the baby was exclusively breastfed. Send the spreadsheet to quality by the fifth."

She asked one question, where to find the report in the EHR, and I showed her. I did not show her a single chart.

The Standard I Never Said

Here is the standard I had been applying for four years, written down for the first time, late, in this paper.

A baby counts as exclusively breast-milk-fed only if the baby received no formula at any point in the stay, including a single supplement given at night, and received only breast milk, whether at the breast or expressed. The source is the nursing feeding flowsheet, reviewed shift by shift, not the "feeding method at discharge" field in the discharge summary, because that field records how the baby is feeding on the day of discharge, not over the whole stay. Babies admitted to the neonatal intensive care unit at any point are excluded, because the report is meant to measure care on our unit.

Every part of that standard was in my head. None of it was in the handover. I had stopped thinking of it as a set of rules and started thinking of it as simply how the report was done.

What Came Back

Her first report, for September, showed 71% of babies exclusively breast-milk-fed. My reports had ranged from 54% to 60% for two years. Before I looked at a single chart, I knew what had happened: she had used the discharge summary field. A baby who had formula on the first night and was fully breastfeeding by discharge would be counted as exclusively breastfed under that field, and on our unit, first-night supplementation is common. When I rechecked a sample of her charts against the flowsheets, the true figure was about 57%.

It is important to be clear about whose error this was. She did exactly what I told her. "Mark whether the baby was exclusively breastfed" is a reasonable instruction, and the discharge summary field is the obvious place to find the answer. The error was in the handover.

Eleven at Night

The report reached me on October 4, the day before it was due to quality. At about 2300 that night, I opened the spreadsheet at home and began redoing it myself. I had checked eight charts before I stopped.

Redoing it alone would have produced a correct report by the morning. It would also have taught her nothing, left her believing her report was right, and put the report back on my desk every month, because I would not have trusted her with it again. Heifetz and Linsky (2002) describe the temptation for leaders to solve problems themselves because it relieves the immediate pressure, while the people who need to learn never do. The private correction at eleven at night is exactly that.

I closed the laptop. The next morning, I asked quality for a two-day extension, which they gave. I sat down with her for 40 minutes, went through six charts together, told her the standard I had never given her, and explained that the error was in my handover, not her work. She rechecked the full list herself and sent the corrected report two days late.

Not Wrong, Just Different

One thing she did differently turned out to be better. I had always organized the spreadsheet by date of discharge. She organized it by the day of the week the baby was born. Once the figures were corrected, her layout showed something I had never seen in four years: babies born on Friday and Saturday nights were supplemented with formula much more often than babies born on weekdays. That points to a staffing or support pattern on weekend nights that is worth looking into.

It would have been easy to correct her layout along with her error, and I nearly did. Separating what was wrong from what was merely different from my way is part of delegating well, and here the different way was an improvement.

Accountability, and the Answer Upward

The national guidelines on nursing delegation are written for delegating patient care, not administrative work, and they state that they do not cover handoffs between licensed nurses (National Council of State Boards of Nursing & American Nurses Association, 2019). But one principle from them transfers directly: the nurse who delegates keeps overall accountability, while the person who receives the work is responsible for doing it. In this case, I kept accountability for the report's accuracy even after handing it over, which means the error was mine to answer for.

My answer upward was a short email to my manager and the quality coordinator: the September report was delayed two days because my handover did not include the standard for counting exclusive breast milk feeding; the error has been corrected; the standard is now written down and attached to the report template; and the corrected data show a weekend pattern worth reviewing. I did not name the staff nurse as the source of the error, because she was not.

References

Heifetz, R. A., & Linsky, M. (2002). Leadership on the line: Staying alive through the dangers of leading. Harvard Business School Press.

National Council of State Boards of Nursing & American Nurses Association. (2019). National guidelines for nursing delegation. https://www.ncsbn.org/public-files/NGND-PosPaper_06.pdf