Table 3.

Major themes and sub-themes from the included studies, with summative finding.

Major themes	Sub themes	Summative finding
Regulatory and contextual factors
	Governance and financing at the national, state, and organisational level	Legislation and policy was found to facilitate or impede delegation of medication administration. A lack of clear governance and communication of policy lead to confusion over what medication related tasks could be delegated and who held responsibility for delegating. Monitoring procedures and adherence to policy also varied. Fewer problems were reported where clear policies, governance and monitoring procedures were in place
	Educational standards and policy	Standards varied for the level of training required by non-registered support workers, including how training was designed, delivered, and assessed. The adequacy of training for medicines administration was a concern for many nurses, non-registered support workers and senior stakeholders
	Geography and staff turnover	Managing delegation over large geographical areas and without adequate staffing levels were reported as barriers at an organisational level
Individual and team level factors
	Supervision, follow up and feedback	Delegation is a complex phenomenon, central to which is the relationship at the micro level between the nurse, non-registered support workers and patient. Adequate supervision, including assessment and monitoring of competencies, is key to developing confidence in the delegation process
	Acceptance of delegation	non-registered support workers, nurses, service managers and patients were largely accepting of delegation
	Concerns about delegation	Despite general acceptance, there were numerous concerns about delegation, including, coercion, safety, cost cutting and job erosion
Outcomes of delegation
	Service efficiency	Delegation of medication administration was widely reported by nurses, non-registered support workers and service managers, to improve service efficiency and free time for registered nurse to focus on more complex nursing care or assessments of patients
	Improved patient care and error rates	Mixed findings are in contrast with anecdotal reports of positive impact of delegation on patient safety and error rates across a range of medication. No studies report on change in medication error rate directly attributable to non-registered support workers undertaking delegated medication administration
	Staff cohesion	The delegation process enhanced trust and helps to develop supportive and collaborative relationships between staff
Process of implementation and evaluation
	Communication	Clear communication at all levels facilitated the delegation process, including communication of legislative and regulatory issues at national or state level; existence and communication of local delegation policy and procedures; communication within teams
	Stakeholder engagement	Evaluations of bespoke delegation programmes reported that the success of delegation hinged on stakeholder engagement from the start of implementation and strong leadership
	Service champions	Greater acceptance of delegation was reported to be influenced by the presence of a senior nurse or non-registered support worker ‘champions’, often those were already well known to staff
	Ability to evaluate and modify	Positively evaluated delegation programmes emphasised the importance of dedicating time for service evaluation, reflection, and flexibility to modify policy and practice