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Moradi et al. BMC Health Services Research (2024) 24:592 https://doi.org/10.1186/s12913-024-11054-4

BMC Health Services Research

*Correspondence: Mahboubeh Rezaei [email protected] 1Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, Iran

Abstract Background Considering the significance of care delegation in enhancing the quality of nursing care and ensuring patient safety, it is imperative to explore nurses’ experiences in this domain. As such, this study aimed to explore the experiences of Iranian nurses regarding the delegation of care.

Methods This qualitative study was conducted between 2022 and 2023, employing the content analysis method with a conventional approach. The study utilized purposeful sampling method to select qualified participants. Data collection was carried out through in-depth and semi-structured interviews utilizing open-ended questions. The data analysis process followed the steps proposed by Graneheim and Lundman (2004) and involved the use of MAXQDA version 12 software. To ensure the trustworthiness of the data, the study employed the four rigor indices outlined by Lincoln and Guba (1985).

Results In the present study, a total of 15 interviews were conducted with 12 participants, the majority of whom were women. The age range of the participants fell between 25 and 40 years. Through qualitative data analysis, eight subcategories and three main categories of “insourcing of care”, “outsourcing of care” and “delegating of care to non- professionals” were identified. Additionally, the overarching theme that emerged from the analysis was “delegation of care, a double-edged sword”.

Conclusions The results of the study revealed that the delegation of care occurred through three distinct avenues: to colleagues within the same unit, to colleagues in other units, and to non-professionals. Delegating care was found to have potential benefits, such as reducing the nursing workload and fostering teamwork. However, it was also observed that in certain instances, delegation was not only unhelpful but also led to missed nursing care. Therefore, it is crucial to adhere to standardized principles when delegating care to ensure the maintenance of high-quality nursing care.

Keywords Delegation of care, Insourcing, Outsourcing, Quality of nursing care

Delegating care as a double-edged sword for quality of nursing care: a qualitative study Tayebeh Moradi1, Mahboubeh Rezaei1* and Negin Masoudi Alavi1

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Introduction Nurses play a crucial role in delivering healthcare ser- vices on the frontline. They serve as planners, coordina- tors, providers, and evaluators of care, performing a wide range of nursing tasks from the moment of admission to discharge to enhance patients’ health and facilitate their recovery [1–3]. Given that nurses constitute the major- ity of healthcare personnel worldwide, the quality of care they deliver holds significant importance [4]. Hence, any disruptions in the flow of care provided by nurses can lead to a decline in the quality of care [2].

The delegating care or delegation of authority is rec- ognized as one of the factors that impact the quality of nursing care [5]. Various definitions of delegation of authority can be found in the related literature, but they all share a common theme: the transfer of responsibility for an activity from one person to another who accepts the responsibility to carry out the activity in an appropri- ate manner [6]. Nurses possess the authority to safeguard the health and well-being of each patient, allowing them to assign certain care activities to other qualified and competent individuals [7]. In the 21st century, nurses are expected to possess the ability to delegate care services while also supervising the delegated care. Delegation of care enables nurses to allocate more time to patient care, support, and education [8]. The process of delegating care involves complex decision-making, where nurses must demonstrate leadership and change management skills to establish team cohesion, support patients, and ensure the effective implementation of nursing activities [9]. In essence, delegation is viewed as a leadership skill that can significantly impact the quality of care and patient satisfaction [5]. Campbell et al. (2020) demonstrated that effective delegation of care and proper communica- tion between nurses and nursing assistants can enhance cooperation, job satisfaction, and ultimately reduce nega- tive outcomes for patients [10]. Delegation improves accountability, productivity, and facilitates the develop- ment of teamwork [11]. Proper and principled delegation of authority enhances nurses’ knowledge, decision-mak- ing abilities, and competence. It also improves communi- cation skills, reduces missed care, and minimizes delays in care [12, 13]. However, the effectiveness of teamwork and delegation between nurses and healthcare assistants varies across different unit cultures and work styles. In some settings, delegation of care may not be executed properly, leading to inefficiencies and decreased effec- tiveness [14]. Providing safe care is contingent upon safe delegation, and this necessitates that nurses appropriately plan, delegate, and monitor assigned tasks. Failure to del- egate care activities safely and appropriately can result in adverse outcomes for patients and contribute to missed nursing care and nursing care rationing [15]. In certain instances, due to high workload, nurses may delegate

complex and challenging care tasks to individuals with lower skill levels, and there may be a lack of adequate monitoring of the delegated activities. Consequently, care may be missed, duplicated, or administered improperly [15]. GransjönCraftman’s study highlighted that the high workload experienced by nurses and the challenges they face have led to the delegation of drug administration tasks to unlicensed personnel, potentially compromis- ing the quality of care [16]. Poor delegation practices can result in nurses and nursing assistants working in parallel and separately, rather than functioning as an integrated team. It leads to ineffective communication, inappropri- ate work dynamics, conflicts between nurses and nursing assistants, and ultimately a decrease in the quality of care [14]. Furthermore, improper delegation of authority can result in non-compliance with care standards, inadequate documentation of provided care, and poor assessment and monitoring of patient conditions [17]. Some nurses lack understanding of the concept of delegation and do not provide proper monitoring when delegating author- ity. This lack of monitoring also may lead to missed nurs- ing care and potential adverse events for patients [15, 18].

In Iran, the delegation of care is performed by nurses, though in some cases this delegation is inappropriate. The nursing structure in Iran differs from that of other countries. The majority of nurses employed in Iranian hospitals hold a bachelor’s degree and work in hospitals and health centers under the ownership and administra- tion of the Ministry of Health and Medical Education. Nurses in Iran face various challenges such as a short- age of nursing personnel, immediate employment after graduation without prior work experience, overtime work, undefined responsibilities, inadequate equipment, low wages, and a gap between theoretical knowledge and practical application [19, 20]. Consequently, the delega- tion of care in Iran appears to be distinct from that of other countries and warrants further investigation. Rood- dehghan et al. (2015) showed that Iran’s nursing care system lacks specific guidelines for delegating care. As a result, due to the nursing shortage, care is sometimes del- egated to non-professionals, including the patient’s fam- ily. Additionally, due to high nursing workload, proper monitoring of these delegated tasks is not consistently carried out. Consequently, the provision of nursing care is disrupted, posing a threat to patient safety [8].

Examining the experiences of Iranian nurses regarding the delegation of care can provide valuable insights and a more realistic understanding of their perspectives on this issue. Quantitative research methods may not offer the necessary flexibility and depth required to investigate the experiential aspects of a phenomenon. Therefore, the most suitable approach to explore the experience of care delegation is through the use of qualitative research methods. These methods are particularly effective in

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exploring questions that involve human interpretations, mentalities, and the depth and complexity of phenomena [21]. Considering the significance of care delegation in the quality of nursing care and the limited research con- ducted on this topic in Iran, the purpose of this study was to explore the experiences of Iranian nurses regarding the delegation of care.

Methods Design The main question of this research focused on under- standing the experience of Iranian nurses in delegating care. To address this question, the appropriate research method utilized was qualitative research, with conven- tional content analysis approach. Qualitative content analysis is a research method commonly used to explore individuals’ understanding of everyday life phenomena and interpret the content of qualitative data. In conven- tional content analysis categories are directly extracted from the data [22].

Participants and sampling The participants consisted of nurses working in various units of hospitals in Kashan city, located in the central region of Iran. The inclusion criteria for participating in the study included being a clinical nurse (a nurse who has at least a bachelor’s degree in nursing and is responsible for direct clinical care of the patients), having a minimum work experience of six months, and providing consent to participate. The exclusion criterion was the partici- pant’s decision to leave the research during the study. The participants were selected using purposeful sampling method, taking into account the maximum variation in terms of personal and job characteristics. Sampling con- tinued until data saturation was reached.

Data collection After identifying eligible participants and obtaining their consent to participate in the study, information regard- ing personal characteristics (such as age, gender, level of education, marital status, and number of children) as well as occupational characteristics (including unit of ser- vice, work experience, and position) were collected. Data collection was conducted through in-depth and semi- structured interviews utilizing open-ended questions. The first participant was purposefully selected as a key informant among the nurses working in Kashan hospi- tals, and then subsequent sampling continued with maxi- mum variation. Before the interviews, the participants were contacted by phone to arrange the details. The first researcher introduced herself and explained the purpose of the study to the participants. If the participants agreed to take part, the time and location of the interview were determined based on their preferences and convenience.

With consent from the participants, the interviews were recorded using a MP3 Recorder and later transcribed verbatim. The interviews were guided by the following questions: (a) Please explain your experience of delegat- ing care to another person; (b) What kind of care have you delegated to others, and to whom did you delegate the care? (c) What factors influenced your decision to delegate care to others? To encourage the participants and gather more in-depth information, probing questions such as “Please explain more,” “Clarify your statement further,” or “Provide an example” were asked during the interviews. The duration of the interviews ranged from 20 to 70 min. In three cases, due to fatigue of the partici- pants during the interview, it was decided to conduct the rest of the interview in the second session.

Data analysis The data analysis commenced after the first interview and continued alongside data collection. This iterative process allowed for a back-and-forth movement between developing concepts and gathering data, enabling subse- quent data collection to acquire relevant information to address the main research question [22]. The data analy- sis procedure followed the steps proposed by Graneheim and Lundman (2004) [23]. The verbatim transcripts of the interviews were imported into MAXQDA software, version 12 for coding and analysis. The researchers thor- oughly read the interview texts multiple times to gain a comprehensive understanding. In this research, the entire text of each interview was considered as the unit of analysis. Following that, words, sentences, or paragraphs were identified as meaning units and grouped based on their content and meaning, resulting in condensed meaning units. These condensed meaning units were abstracted, labeled, and transformed into codes. Coding was performed using the participants’ language (in vivo) or based on the researcher’s general understanding of the participants’ speech (in vitro). The codes were then com- pared to identify similarities and differences and then were categorized into subcategories and main categories, forming the manifest content. Through a process of care- ful reflection and comparison among the categories, the latent content, which was the theme of this study, was revealed. An example of how data were analyzed is pro- vided in Table 1.

Rigor and trustworthiness In this research, the trustworthiness of the data was assessed using four rigor indices proposed by Lincoln and Guba (1989) [24]. Prolonged engagement with the data for several months, appropriate and long-term participa- tion and interaction with the participants, and member checking increased the credibility of the data. To increase the dependability of the data, immediate transcription of

Page 4 of 12Moradi et al. BMC Health Services Research (2024) 24:592

the interviews was performed, followed by seeking the opinions of two expert colleagues in the field of qualita- tive research (peer Checking). Moreover, the participants themselves reviewed the text of the interviews. For this purpose, several initial interviews, along with the pre- liminary codes derived from them, were provided to three participants involved in the interviews, allowing them to confirm or suggest corrections. The use of a suf- ficient and suitable sample with maximum variation in terms of demographic and occupational characteristics strengthened the confirmability of the data. Addition- ally, to ensure the transferability of the data, direct quotes from the participants were included, and comprehensive details related to the participants were described to pro- vide a rich understanding of the context.

Results In the present study, a total of 15 interviews were con- ducted with 12 eligible participants. The majority of the participants were women whose ages ranged from 25 to 40 years. Additional characteristics of the participants can be found in Table 2.

Qualitative data analysis resulted in the extraction of eight subcategories and three main categories as well as the theme of “delegation of care, a double-edged sword” (Table 3).

After analyzing the data, it was found that nurses had experienced delegation of care in three ways: “insourcing of care”, “outsourcing of care” and “delegating of care to non-professionals”.

Insourcing of care One of the categories extracted in this research was insourcing of care. Delegation of the patient’s care by the nurse to their colleagues in the same unit is called insourcing of care. In this type of delegation, the nurse delegates some of her/his patient care to other nurses in the unit for various reasons, including high workload or serious patient conditions. The insourcing of care can be accomplished through three methods: Seeking assistance from colleagues in the same shift, seeking assistance from

the head nurse, or delegating care to colleagues on the next shift.

Seeking assistance from colleagues in the same shift One form of the insourcing of care was seeking assistance from colleagues in the same shift. In the interviews, the nurses mentioned that sometimes due to the crowded unit, they asked for help from other nurses in their unit to provide care to their patients. In this regard, one of the participants said:

“When the unit is crowded, if I have a colleague whose work is less, or whose patients are more sta- ble, or my colleague is more experienced, I get help from them, and they usually help me.” (Participant No. 2).

Another participant said:

“Colleagues usually cooperate with me. For instance, a few days ago, the unit was extremely busy, and I had a patient with appendicitis. I asked my col- league to assist by providing the patient with clothes and completing a pre-operative form for them before going to the operating room. Also, she helped me by sending the patient’s test results.”(Participant No. 8).

Indeed, in delegating care to other nurses, the partici- pants pointed out that nursing care is delegated to a col- league who has less workload, otherwise, the delegated care may be missed or overlooked. Two participants commented on this issue as follows:

“Since other colleagues may also have their own tasks to complete, we typically seek help from a col- league who less busy. This ensures that we can col- lectively finish all the work while allowing that col- league to assist us as well. Otherwise, our colleague may not be able to accommodate our requests or can inadvertently forget them.” (Participant No. 4). “Sometimes my colleagues delegate care to me, but I forget. For example, I was given an urgent care to

Table 1 Examples of meaning unit, condensed meaning unit, and codes Meaning unit Condensed meaning unit Codes There is a problem with the demand for nurses from other units. There is no control over the work of these nurses and usually, the care by the temporary workforce isn’t done properly.

Lack of control over the work of nurses coming from other units and consequently the reduced quality of nursing care.

– Lack of control over the work of temporary nurses – Doing lower quality of care by temporary nursing staff

Sometimes the unit is so crowded that we’ve to delegate some work to the nurses of the next shift. If a lot of care is left to them, their workload will be increased.

An overcrowded unit forces the nurse to delegate care to the nurses of the next shift. Increased workload of the next shift nurses be- cause of assigning a large number of cares to them.

– Mandatory delegation of care to the next shift nurses due to the overcrowded unit – High workload of the shift due to the number of cares delegated by the previous shift

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do, or to notify sonography; I was so busy or involved in my own tasks that I forgot to do it or follow it up.” (Participant No. 10).

Seeking assistance from the head nurse Another subcategory of care insourcing was seeking assistance from the head nurse. Some nurses mentioned that when they face a high workload, lack of skill in car- ing for a specific situation, or when it is not possible to provide care due to moral or religious reasons, and other nurses are unable to help, they turn to the head nurse for assistance in performing the necessary care:

“Here, the head nurse is a man. If we’re on an all- female shift, we ask him to lend a hand with the urology patient, and he gladly pitches in. Sometimes, he assists us in changing the dressing of orthopedic patients which are big and heavy. We appreciate his help because it allows us to handle the patient’s care more efficiently.” (Participant No. 6). “Sometimes, nurses don’t know how to handle cer- tain care, so they call the head nurse to come and do it, hoping to learn from them. Tasks like changing the colostomy bag, taking care of the port, removing the sheet after angiography, washing the chest bottle, and so on.” (Participant No. 12).

Delegating care to colleagues on the next shift In certain situations, such as overcrowding of units, patients with serious conditions and prolonged diag- nostic and treatment procedures, nurses are compelled to delegate some of the patient care responsibilities for the current shift to the next shift. This practice can lead to delayed care during the next shift, or sometimes an increased workload for the nurses on the next shift. The following are the statements of some of the participants:

“For example, when a patient goes for dialysis, ultrasound, or needs a simple x-ray, it takes a while for them to return to the unit, and you won’t have enough time to fully take care of them. So, you end up leaving some of the patient’s care for the next shift.”(Participant No. 2). “Sometimes, the unit gets super hectic, and the patient is very ill; so that you end up having to pass on some of the tasks to the next shift. But the care gets delayed, and that puts extra pressure on the next shift.”(Participant No. 4). “It’s just unfortunate when a very sick patient trans- fers to your unit and you find out that some of his/ her nursing cares weren’t done or were done incom- pletely, and they’re delegated to your shift. You

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