Confidence in delegation and leadership of registered nurses in long-term-care hospitals


1Master Graduate, 2Associate Professor, 3Assistant Professor, Division of Nursing, College of Nursing, Ewha Womans University, Seoul, Korea


Miyoung Kim

Division of Nursing,

College of Nursing,

Ewha Womans University,

52 Ewhayeodae-gil,


Seoul 03760,



YOON J., KIM M. & SHIN J. (2016) Journal of Nursing Management Confidence in delegation and leadership of registered nurses in

long-term-care hospitals

Background and aims Effective delegation improves job satisfaction, responsibility, productivity and development. The ageing population demands more nurses in long-term-care hospitals. Delegation and leadership promote

cooperation among nursing staff. However, little research describes nursing

delegation and leadership style. We investigated the relationship between registered nurses’ delegation confidence and leadership in Korean long-term-care


Methods Our descriptive correlational design sampled 199 registered nurses from 13 long-term-care hospitals in Korea. Instruments were the Confidence and Intent

to Delegate Scale and Multifactor Leadership Questionnaire.

Results Confidence in delegation significantly aligned with current-unit clinical experience, length of total clinical-nursing experience, delegation-training

experience and leadership. Transformational leadership was the most statistically

significant factor influencing delegation confidence. Implications for Nursing Management When effective delegation integrates with efficient leadership, staff can deliver optimal care to long-term-care patients.

Keywords: delegation, leadership, long-term-care hospital, registered nurses

Accepted for publication: 28 January 2016


Health-care providers must furnish safe, efficient,

patient-tailored care (Institute of Medicine, as cited in

Kohn et al. 2000). Successful, efficient delegation is

essential to optimal health care (Standing & Anthony

2008), intensifying the limited resources under pressure

from rising health-care costs (Gillen & Graffin 2010).

Effective delegation contributes to job satisfaction,

empowerment, responsibility, productivity, profes-

sional growth, and effective patient care (Kærnested &

Bragad�ottir 2012), whereas inappropriate delegation

relates to poor core caring, repetition of caring or

unbalanced workload (Anthony & Vidal 2010).

Leaders delegate to unlicensed nursing personnel

(UAP, also nursing assistants, nursing auxiliaries, care

assistants, care aides, health aides and support work-

ers; Johnson et al. 2015) to use their skills and compe-

tencies (Bystedt et al. 2011). Through successful

delegation, registered nurses (RNs) concentrate on

complicated nursing tasks (Stonehouse 2015) and

focus on reviewing charts, monitoring significant med-

ical changes, and teaching patients (Standing &

Anthony 2008). Registered nurses identify nursing

diagnoses, organise care plans, communicate with

patients and evaluate patients’ overall outcomes: skills

requiring critical thinking and professional knowledge

(Paquay et al. 2007, Kim & Jeong 2014). Unlicensed

DOI: 10.1111/jonm.12372

ª 2016 John Wiley & Sons Ltd 1

Journal of Nursing Management, 2016



nursing personnel mostly assist in direct nursing care,

such as vital signs, range of mobility, feeding and

bathing (Kleinman & Saccomano 2006). However,

inadequate supervision can engender health-care

errors, which has an impact on patients’ outcomes

(Anthony et al. 2000). Failure to delegate is an error

in nursing-task planning and execution (Standing &

Anthony 2008), generating staffing complications and

omissions (Standing & Anthony 2008, Bittner &

Gravlin 2009, Thompson 2012). Many RNs are

unsure which tasks are right for different roles and are

unaware they are responsible for their patients’ nurs-

ing care, even when they delegate to others (Hansten


The proportion of elders in Korea has rapidly

increased (7.2% in 2000 and 11.8% in 2012; Statistics

Korea 2014). Long-term-care hospitals, with the high-

est growth rate of health-care organisations (111.6%,

2005–2015; Statistics Korea 2015), are using a nursing-

staff skill mix, including UAPs, to meet elders’ diverse

needs (Kim & Lee 2014). The number of certified nurs-

ing assistants (CNAs) in long-term-care hospitals has

burgeoned (from 1436 in 2006 to 8921 in 2011),

whereas the percentage of nursing assistants in total

nursing staff was increased from 31.0% in 2006 to

49.0% in 2011, while that of Registered nurses

decreased from 69.0% to 51.0% of total nursing staff

during the same period(Ministry of Health and Welfare,

2013). The RN shortages in long-term-care settings

has increased the need to maintain RNs in leadership

positions (Fleming & Kayser-Jones 2008). Unlicensed

nursing personnel perform nursing tasks in Korean

long-term-care hospitals, but there is a lack of clear

legal standards (Kim & Jeong 2014).

Efficient leadership includes successful delegation

(Bittner & Gravlin 2009). Relationship-oriented lead-

ership emphasises people and relationships, whereas

task-oriented leadership focuses on structures and

tasks (Cummings et al. 2010). Relationship-oriented

transformational leaders encourage members to

accomplish more (Northouse 2010) by inspiring self-

esteem through positive feedback (Riahi 2011). Task-

oriented transactional leaders highlight the economic

exchange between leaders and members to achieve

work (Bass & Avolio 1993). Leaders are aware of

members’ needs and supervise their task performance

(Bono & Judge 2004).

Hutchinson and Jackson (2013) proposed a new

vision of nursing leadership emphasising realistic,

moral, shared governance, energetic involvement in

the organisation and self-determination (Hannah et al.

2014, Wong 2015). Despite the growing significance

of leadership and delegation in long-term-care hospi-

tals’ quality, little research exists on the delegation–

leadership relationship (Corazzini et al. 2010). This

study examined correlations between delegation confi-

dence and RN leadership in Korean long-term-care


Literature review


To maintain the reciprocal process of mobilising peo-

ple with various economic, political, and other

resources to realise goals independently or mutually

(Burns 1978), leadership is vital for RNs to effectively

supervise UAPs and delegate successfully (Saccomano

& Pinto-Zipp 2011). A RN’s leadership style affects

successful relationships among nursing staff (Corazzini

et al. 2010, Saccomano & Pinto-Zipp 2011) because

intellectual leadership traits include delegation, knowl-

edge and skills (Denehy 2008).

Whereas transactional leaders are task-oriented,

advocating for the current situation (Burke 2008),

transformational leaders focus on higher ideals

(Doody & Doody 2012), acknowledging members’

contributions and enhancing empowerment (Kim et al.

2012). Transformational leaders effectively resolve

challenges in long-term-care hospitals such as staff

turnover (Utley et al. 2011), vacancy rates, growing

demands for care (Grove et al. 2010), and improved

quality of care (Wong et al. 2010). In studies explor-

ing nursing leadership practices and patient outcomes,

transformational leadership aligned significantly with

fewer medication errors, patient falls and hospital

infections (Houser 2003, Capuano et al. 2005). Trans-

actional leaders contributed to enhanced patient satis-

faction by effectively managing patient care through

clear direction and work expectations (Doran et al.

2004). However, little research exists relating leader-

ship and patient outcomes (Wong 2015).


Accelerating changes in health care, an ageing popula-

tion, rising health-care costs and worldwide nursing

shortages have increased attention on delegation in

nursing (Gillen & Graffin 2010). Delegation is ‘the

transfer of responsibility for the performance of (but

not the accountability for) an activity from one indi-

vidual to another’ (American Nurses Association

1992). The American Nurses Association (ANA)

(2005) defined terms related to delegation, principles,

ª 2016 John Wiley & Sons Ltd 2 Journal of Nursing Management

J. Yoon et al.



and roles of RNs and certified nursing assistants

(CNAs). However, most US states make their own

definitions of delegation, which are different from the

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