Attitudes of Nurse Managers’ Toward Effective Delegation: A Systematic Review

: Background and Aim: Effective delegation influence work fulfillment, obligation, profitability, and professional advancement of nursing career. Delegation is the key for nurse managers and future leaders keeping in mind the end goal to ensure beneficial results. The main aim of this review was to explore the nurses’ and nurse managers’ attitudes toward delegation . Methods: Studies published in years 2009 - 2019 were evaluated. International electronic databases such as Ovid MEDLINE, PuMed, Ovid OLDMEDLINE, Embase Classic + EMBASE (Ovid), The Web of Science (Thomson Reuters), The Cochrane Library (Wiley) and CINAHL Plus (EBSCOhost) were explored to find articles written in English-language using relevant keywords. All cross-sectional studies and quantitative and qualitative studies which focused on the specific topic have been searched as well. Findings: 845 articles were searched. After checking for duplicates, 815 papers were left for evaluation of titles and abstracts. This left 30 articles for reading of full texts. Of these, 18 papers did not meet the aim. Another six articles were not conducted within general practice settings. The remaining six articles were read thoroughly to appraise them according to the quality criteria. Only one of them did not meet the quality criteria. Hence, five studies were included in the present review. Conclusion: The nurse managers showed positive and good level of attitude toward delegation. Effective delegation skill should be enhanced for the nurse managers. Further research is strongly needed to cover this topic with conducting relationship with other variables. delegation, lateral delegation 2013). Most of the studies regarding attitudes toward delegation were conducted in developed countries, however, the attitude and preparedness of nurses and nurse managers towards delegation remains an under explored phenomenon among developing countries, and this issue was not systematically studied before. So, the main aim of this systematic review is to explore the nurses’ and nurse managers’ attitudes toward delegation. This study is a systematic review which is based on the step-by-step approach developed. In this approach, even steps were applied and followed, including: problem formulation, literature search, information gathering from the previous studies, quality evaluation, outcomes analysis and integration, evidence interpretation, and results presentation (Cooper, 2009).


INTRODUCTION
Nurses at all levels and in all settings are required to assign and delegate tasks to and supervise other health-care workers. To do so effectively, nurses must develop skills in delegation, prioritization, and oversight of nursing care (Murray, E., 2017). Effective delegation is considered a core skill for professional nursing practice globally (ICN., 2008). The ICN (2008) maintains that nurses are responsible for the delegation of nursing care and supervision of assistive personnel. Moreover, improper delegation can negatively impact patient care while also potentially exposing the delegator to legal action. All members of the health care team have valuable contributions to make toward safe, effective patient care (Gravlin G, Phoenix Bittner N., 2010).
The American nursing association (ANA) recognizes delegation as an important skill for nurses to deliver safe and effective care: The nurse -delegates according to the health, safety, and welfare of the healthcare consumer and considering the circumstance, person, task, direction or communication, supervision, evaluation, as well as the state nurse practice act regulations, institution, and regulatory entities while maintaining accountability for care‖ (ANA., 2015).
The nursing literature often uses the terms delegation and delegated authority to define the professional interaction between a registered nurse and unlicensed assistant personnel. Delegation is the transferring of responsibility for the performance of an activity to another, with the formal retention of accountability for the outcome (Huston, C., 2006). Delegation is now an entry-level nursing practice skill requirement. Still, novice nurses report a lack of knowledge, skills, and attitudes for the delegation decision-making process. Learning delegation skills -on the go‖ is a common pattern. The literature reports that there is a gap between the expected skill levels and the actual abilities of the nurses relative to delegation (Antony, M., Standing, T., 2008).
Effective delegation enhances work fulfillment, obligation, profitability, and professional advancement. Delegation and leadership promote participation among nursing staff (Yoon et al., 2016). Delegation is the key for nurse managers and future leaders keeping in mind the end goal to ensure beneficial results. The utilization of delegation in nursing administration can tackle numerous issues including medical attendant deficiencies . As indicated by a study led in Saudi Arabia, a large portion of the study participants were uncertain about their state of mind towards appointment and were additionally not arranged for compelling assignment (Sabah et al., 2018).
There are several criteria for delegation, in which the nursing profession determines the scope and standards of nursing practice, and the organization/agency is accountable to provide sufficient resources to enable appropriate delegation.etc. There are huge benefits for delegation, such as it enhances the patient care, the nurse's job satisfaction increases, and retention is improved. Also, the delegate gains new skills and abilities that can facilitate upward mobility (American Nurses Association, 2015) Despite high workloads, registered nurses working in different healthcare settings are reluctant to delegate. Many find delegation time-consuming and find it is easier to attend to tasks themselves (Kaernested and Bragadottir, 2012). When under pressure, the nurses tend to focus on simple tasks which could be delegated, rather than on their professional nursing activities (Sullivan, 2018). Also, the issue of delegation is considered very sensitive for the healthcare system, in which it has an effect on the patient and healthcare providers (American Nurses Association, 2015).There are several types of delegation such as general or specific delegation, formal or informal delegation, lateral delegation (Knox, 2013).
Most of the studies regarding attitudes toward delegation were conducted in developed countries, however, the attitude and preparedness of nurses and nurse managers towards delegation remains an under explored phenomenon among developing countries, and this issue was not systematically studied before. So, the main aim of this systematic review is to explore the nurses' and nurse managers' attitudes toward delegation.

METHODS
This study is a systematic review which is based on the step-by-step approach developed. In this approach, even steps were applied and followed, including: problem formulation, literature search, information gathering from the previous studies, quality evaluation, outcomes analysis and integration, evidence interpretation, and results presentation (Cooper, 2009).

Search strategy
Different databases were used for search strategy, and for systematic literature search, databases include: Ovid MEDLINE, PuMed, Ovid OLDMEDLINE, Embase Classic + EMBASE (Ovid), The Web of Science (Thomson Reuters), The Cochrane Library (Wiley) and CINAHL Plus (EBSCOhost).
The researchers interested to search in the international peer-reviewed scientific journals, the search was conducted in English language. Additionally, search in Google was done Also, hand search was conducted, reference lists of articles which have been included were done, as well as the relevant names of the authors were also searched to identify more relevant articles.
In this review, the studies which have been included were those which addressed the main aim of the present review, finding evidence of nurses and nurse managers' attitudes toward delegation. Quantitative and qualitative studies were eligible to be included as well, also the studies which have been eligible those which have been conducted in clinical practice settings. Keywords for search included: delegation, delegation among nurses, attitudes toward delegation, attitudes, attitudes toward delegation among nurse managers, nurses' delegation, effective delegation, and delegation in nursing.

Inclusion criteria for selected articles
Descriptive and cross-sectional studies which have been included are those which met the main aim of the present review, published with the period between 2009 -2010, studies which have been conducted in clinical practice settings, studies which have had its focus on the nurses and/or nurse managers, and those which have been published in an international and national peer-reviewed journal.

Quality evaluation of the selected articles
In the present review, a narrative approach method was conducted in order to identify the primary themes of search as well as the issues of importance. Data extraction was done by the researchers independently. Data which has been extracted in combination with the narratives were then tabulated to provide an overview of the obtained results and to explicate the interpretative process.

RESULTS
The search revealed 845 articles. After checking for duplicates, 815 papers were left for evaluation of titles and abstracts. This left 30 articles for reading of full texts. Of these, 18 papers did not meet the aim. Another six articles were not conducted within general practice settings. The remaining six articles were read thoroughly to appraise them according to the quality criteria. Only one of them did not meet the quality criteria. Hence, five studies were included in the present review (Figure 1).

DISCUSSION
The majority of the results which have been included in the present study, indicated that the nurse managers have positive attitude toward delegation, except for the study of Baddar et al. (2016) which indicated that the nurse mangers' attitude toward delegation is lacking of self-confidence and trust, especially from younger nurses and those with little experience. Previous studies conducted by Karnested and Bragadottir (2012), and Quallich (2005) stated that lack of self confidence in the manager, trust in subordinates, lacks to commitment and experience back ground of delegate to complete tasks in a satisfactory method are barriers to delegation and have impact on manager attitude toward delegation.
Conversely, the study of Cymerman (2002) revealed that, the improvement of the skills of delegation lead to increase the commitment to effective tasks performance and reduce unsuccessful results. Additionally, Wheeler (2001) added that, delegation can be used as a powerful tool to train and empower others, handing over a little responsibility to a staff member can increase their motivation and job satisfaction, enable an assessment of their strengths, and identify areas for future development (Wheeler, 2001). Saccomano & Pontozipp (2010) found that diploma nurses were less confident about delegating to nursing aides in comparison to nurses who held a Bachelor degrees and who had a higher level of confidence in delegation. Bittner and Gravlin (2009) found that new graduate nurses spoke about role uncertainty and how their lack of confidence prevented them from delegating [3]. Whereas the majority of nurse managers agreed that they would be upset if they gave a subordinate clear instructions only to find that the job was not done correctly Potter et al. (2010) support this finding, their study participants indicating that they got mad when delegatees failed to follow their exact instructions (Potter et al., 2010).
Regarding the agreement and positive attitudes toward delegation among nurse managers, previous studies revealed that a large percentage (66.7%), of the participants were not of the agreement toward delegate tasks and 64.4% of them gave an agreement to a statement, that they get upset when the delegated task is not done and is incomplete after a thorough delegation instructions .
Moreover, in a previous study, majority of the study participants stated that they don't feel that they have sufficient skill to especially to respond to the negative reactions of the delegates during delegation. This could be explained by the lack of confidence and/or low preparation, so there is a need for the development of skill and confidence among the nurse managers to influence delegation kills thus to increase their attitudes (Salem and Hakami, 2016). Moreover, the results of the study of Whitehead et al. (2010) revealed that 78.0% of the emergency nurse managers are prepared well and they have that excellent or good skills in delegation. But still there were 22% such nurse Managers who were not prepared and had low score on knowledge of delegation and basic principles of delegation Whitehead et al. (2010).
On the other hand, the findings revealed by the studies included in the present review are consistent with the results of Kaernested and Bragadottir (2012) where participants reported positive attitudes regarding delegation (Marquis and Huston, 2009). More importantly, the current review findings are supported by Marquis and Huston (2009) who suggested that nurse managers at all levels should delegate tasks to save time (Marquis and Huston, 2012).On the other hand, there are some results indicated that there were low percentage of nurse managers would delegate more if they were more confident in delegating. This result was not consistent with the results of Bystedt et al. (2011), in which participants stated that they felt insecure and lacked confidence when delegating because of the potential risk for negative outcomes (Bystedt et al., 2011).

LIMITATIONS OF THE STUDY
Several limitation were faced during the conduct of this review, very limited previous studies which have been conducted in such topic was the major limitation. Also, limited updated references were also an issue.

CONCLUSION AND RECOMMENDATIONS
The nurse managers showed positive and good level of attitude toward delegation. The studies which revealed low level of attitude require opportunities for learning in order to increase the managers' level of confidence as well as to enhance the skills in such issue. Further research is strongly needed to cover this topic with conducting relationship with other variables. Moreover, delegation skill should be enhanced for the nurse managers and all of the nurses who are working in managerial positions.