Nine Strategies to Improve Allied Health Delegation
This article discusses what good allied health delegation looks like. We unpack 9 common allied health delegation problems and suggest a range of solutions. We show you why good allied health delegation is so important to your clients, your workforce and your organisation.
Australia is currently facing enormous health workforce shortages, particularly in a range of allied health disciplines, and in regional, rural and remote areas. Training new health practitioners is generally not a quick fix and is normally a time consuming and expensive way to meet workforce demands. Allied health delegation is an effective and efficient way to quickly respond to workforce needs.
Allied health delegation increases health workforce capacity by identifying tasks that can be delegated from a scarce (and normally highly qualified and high cost) workforce to other workers with the appropriate skills to meet specific needs. Often these workers can be trained in a set of specific competencies to meet workforce gaps, rather than spending years training new professionals.
We discuss a range of allied health workforce solutions here and provide more information in this paper.
Why should allied health professions delegate?
Delegation is used at all levels of the workforce, from the employment of certificate and vocationally qualified workers such as allied health assistants to extending and expanding the roles of doctors, nurses and allied health practitioners through advanced practice roles. Examples include the growth of non-medical prescribing in the nursing and allied health workforce, and employment of allied health practitioners to triage surgical waiting lists, such as triage, assessment and treatment on orthopaedic specialist caseloads.
However, allied health delegation is only effective if those delegating the roles do so effectively and consistently. Practitioners and managers spend a great deal of energy deciding what tasks can be delegated and to whom. However, in many cases, allied health practitioners do not delegate consistently, or to the full scope of practice of the delegate.
Why is effective allied health delegation important?
Ultimately effective allied health delegation will allow for more and better client care.
Effective allied health delegation can:
- substantially reduce the burden on healthcare workers in overstretched health services;
- improve overall organisational efficiency;
- improve the efficiency of all types of healthcare workers in any type of organisation (private or public); AND
- most importantly allow your organisation or team to effectively and efficiently organise care so that you are consistently delivering the highest quality and best value care to your clients.
Ineffective allied health delegation leads to:
- inefficient workforce practices;
- less effective treatment provision;
- strained and in some cases destructive relationships; AND
- resentment between practitioners.
Ultimately, this impacts on the quality of care that can be provided to clients.
We undertook a systematic review and re-analysed existing, unpublished data from allied health delegation from projects that explored the employment of allied health assistants and advanced practice allied health professionals. One output of this review was the identification of barriers to allied health professionals delegating efficiently.
Reasons for ineffective allied health delegation
Health practitioners fail to delegate when there are regulatory barriers where tasks are regulated and cannot be delegated for legislative reasons, or where there is a lack of clarity around professional accountability which we term discretionary barriers – where the delegating practitioner has control or discretion over what and how they delegate.
So what can you do about this? We have synthesised the findings of our research into 9 barriers you need to be aware about and some solutions you might want to consider.
9 barriers and solutions to efficient allied health delegation
PROBLEM 1: Tasks are regulated and cannot be delegated
In a small number of cases, particularly triage, assessment and treatment models, some of the tasks which would make the delegation process more straightforward were regulated, and not able to be delegated.
For example in orthopaedic screening services, allied health practitioners or general practitioners with special interests are often responsible for assessing (screening or triaging) surgical or medical waiting lists. There are examples of allied health practitioners being unable to order necessary diagnostic tests, such as Medical Resonance Imaging, without the approval of the specialist. This reduced the ability of the practitioner to perform diagnostic tests.
SOLUTION 1: The tasks need to be delegated within a tight supervisory framework, or the regulations need to be changed
If tasks are restricted by legislation, then it can be difficult to delegate them without changes to legislation. Allied health prescribing is an example of legislative changes that have been introduced to overcome delegatory boundaries between doctors and allied health professions.
Sometimes restricted tasks can be performed by others under very tight supervision. There are a number of resources that can help you to devise a supervisory framework for delegated tasks.
Responsibilities and accountabilities around restricted tasks need to be clearly articulated and managed because of the potential risks of another practitioner performing those. However, sometimes legislative boundaries are perceived, not real. For example King found that there was some confusion over the role boundaries of diabetes educators who were trained nurses compared with allied health professsionals, particularly in relation to insulin administration. Restrictive practices were implemented in some settings (favoring nurses over allied health professionals) even though there were no legislative restrictions to differentiate the roles in the context of diabetes care.
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PROBLEM 2: There is a lack of clarity over responsibilities and accountability
The most commonly cited reasons for inefficient or incomplete delegation were either a lack of clarity around the accountability structures, or a belief that the delegating practitioner was responsible for the outcomes of care provided by the delegate. This restricted the behaviour of the delegating practitioner who did not want to risk being responsible for adverse outcomes over which they had no control, so they were less likely to delegate.
By far the most common reason for inefficient delegation is the lack of a clear understanding of the responsibilities and accountabilities between the delegate and delegator. A common misconception, which is reinforced in several professional delegation policy documents, is that the delegator is responsible for the outcomes of care of the delegate. However, in the majority of public sector settings, which are also likely to be the setting for many of the new roles, it is likely that the employer, not the delegator, is responsible for the outcomes of care, as long as appropriate governance structures are in place.
SOLUTION 2: Assume that the delegate is responsible for the outcomes of their work if they have been deemed competent to practice to the level to which they are employed
A person who has been deemed competent to work to a level of practice should be expected to work within their scope of practice and take responsibility for the outcome of their care. In the public sector, this is where mechanisms like the new Victorian Enterprise Agreement and the Allied Health Credentialling, Competency and Capability (AH CCC) Framework can be used to drive changes.
These frameworks allow services to describe a new scope of practice and codify it with a credential around that is endorsed by the local credentialing committee. In the private sector assistant role boundaries for example are negotiated between the assistant and delegating AHP. This is often based on assistant skills, what the delegating practitioner can teach the assistant and client needs in the organisation. Some information about defining the role and scope of practice of AHAs can be found here.
PROBLEM 3: The delegating practitioner is uncertain of skills of person to whom they are delegating
In the majority of the delegation relationships, the delegate fulfils a role which is newly formed, is unique to a particular workplace or position, or is part of a new relationship to the delegating practitioner. This means that the delegate has a job description which not standard, and is likely to be unfamiliar to the delegator. An unwillingness to delegate is seen when the delegating practitioner is unclear about the skills and expertise of the person to whom they are delegating.
This happens because:
- the delegate was trained away from the workplace, and the delegator had no role in or understanding of the training received
- where the practitioner was not used to working with the delegated role, particularly with new graduates
- where the delegated role is new to the setting and an appropriate change management strategy has not been adopted to implement the role.
SOLUTION 3: Have the delegate trained on the job or trained using standardised credentials
Engage the delegator in the training and credentialing of the practitioner as much as possible.
Introduce new, delegated roles using an appropriate change management strategy that engages all relevant workers in the new approach.
PROBLEM 4: The delegating practitioner has a lack of confidence and trust in the delegate
In the case of podiatry, occupational therapy and speech therapy assistants, we observed that supervising staff were reluctant to delegate tasks to assistants because they did not understand the competencies or experience that they brought to the job and therefore did not trust or have confidence in the assistant. This results in inconsistent use of assistants, the underutilisation of their skills and abilities, and dissatisfaction with their work. We have also seen this happen with extended scope roles where orthopaedic surgeons will only delegate when they are confident in and trust the extended scope physiotherapist.
SOLUTION 4: Establish clear frameworks and expectations for roles within the workplace
A delegation framework such as the Calderdale framework can be useful. Engage delegating practitioners in the allocation of the tasks to other practitioners and in the development of competencies.
PROBLEM 5: The delegating practitioner is unwilling to give away tasks and wants to retain their own workload
In a small number of cases, the delegating practitioners are simply unwilling to give away the tasks that they see as their own ‘core business’. When the specialist or delegating professional is available, they treat the more ‘complex’ cases, however when they are not available, the assistant or advanced practitioner will fill this role.
SOLUTION 5: Increase awareness of others’ roles through joint working and structured induction periods
Engage the delegator in the training and credentialing of the practitioner as much as possible so they understand the role and the skills that the delegate brings to the role.
Student clinical training and placements are an important way to increase role awareness and delegation practices of allied health practitioners.
PROBLEM 6: The delegating practitioner lacks the skills to delegate
Often delegating practitioners lack the skills and training to delegate because the delegated role was newly introduced without support and training of the existing workforce. It can happen also when the delegating practitioner is newly introduced to the workplace particularly when they are newly qualified.
In many cases, the delegating practitioners had not been trained to delegate tasks or work within a supervisory relationship. This is particularly evident in the introduction of allied health assistants. There is little evidence that allied health training provides students with the skills or knowledge to work with or delegate to an assistant workforce.
SOLUTION 6: Provide training in supervision and delegation for all staff involved in a supervisory role
We know of some organisations that use a dedicated Learning Management System (LMS) to ensure all allied health staff have undertaken training in how to supervise and delegate. That way allied health delegation and supervision training can be tracked and systemised. Again there are multiple tools available that can assist this.
PROBLEM 7: The delegating practitioner has a lack of understanding of role boundaries and perceives a threat to their professionalism
Professional resistance and ultimately lack of full adoption of a new delegatory role is highly associated with role clarity issues and perceived role boundary threat. In the example of a newly created Occupational Therapy Assistant Practitioner role in the UK, a lack of access to appropriate training; ambiguous supervision and accountability relationships; and a lack of a clear career direction for qualified occupational therapists, created uncertainty about which aspects of their job they should be ‘giving away’ and as such led to threats to their professionalism, mistrust and workforce inefficiency.
SOLUTION 7: Ensure there is sufficient engagement, education and appropriate change management when introducing the new role
Ensure your workforce is prepared and engaged in the process of introducing a new (delegatory) role. Key to this is focusing on client needs and the benefit the new role will provide in meeting specific client needs rather than focussing on how the role will affect the profession.
PROBLEM 8: The delegating practitioner does not value the potential of allied health delegation
This problem is often seen when assistant or delegatory roles are driven by addressing organisational or managerial problems e.g. lowering workforce costs. When this is the case the reasoning behind introducing the new role is not seen as beneficial to the professional. When new roles are designed from a client perspective, with client needs in mind, they are much more likely to be successful.
SOLUTION 8: Use a formal task analysis process to examine the most effective way to use staff time and resources, focused on client needs
An increasing number of task analysis tools are being used in allied health practice, including the Calderdale Framework and the AHCCC mentioned above.
PROBLEM 9: There are too many or too few delegating practitioners so allied health delegation is inconsistent
Delegation practice often changes when staff numbers and the mix of staff changes. For example the roles of the assistants and advanced practitioners often change when the delegating practitioner is available or not. Delegation is also affected when there are either more delegating practitioners (less delegation to assistants or advanced practitioners) or less delegating practitioners (more delegation to assistants or advanced practitioners). This is often related to dynamics around the supply and demand of the health workforce.
When qualified staff are available, they often treat the more ‘complex’ cases, however when they are not available, the assistant or advanced practitioner will fill this role.
This creates issues for the delegate who see their roles expand and contract according to the availability of qualified / specialist staff.
SOLUTION 9: Ensure consistent staffing and workflow management as much as possible
If a worker is deemed competent to deliver roles when the specialist or qualified staff are not available, then they should be able to continue that role when the qualified / specialist staff member is present.
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Conclusion
In the included studies, when delegates were asked about their confidence and their role boundaries, without exception, they said that they knew their boundaries and knew when to delegate. There were no documented examples in these studies where delegate practitioners worked beyond their scope of practice thus presenting a risk to a patient.
Workforce efficiency is optimised when the workplace environment enables staff to work to their full scope of practice. Inefficient delegation arises when practitioners practice ‘discretionary’ delegation, that is, the delegating practitioner effectively determines the scope of practice of the delegate.
All of these issues can be resolved by identifying clear accountability structures, and creating clear workplace policies and structures that remove the potential for discretionary delegation. We suggest a number of solutions to address the issues identified above to enhance efficiency of delegation practice, and ultimately, increase workforce efficiency.
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Watch this space. Coming next … our delegation diagnostic tool to help to optimise the effectiveness of your Allied Health Workforce!
