Nurse Delegation

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Quality problems in America's nursing
homes tied to turnover
Date:
February 7, 2014
Source:
University of Maryland, Baltimore
Summary:
Nursing researchers find adverse outcomes are linked to turnover in studies of a sample representing more
than 16,000 nursing homes in the United States, suggesting that preventing staff turnover should be given
greater emphasis.

Two studies examining the relationship between turnover of nursing staff and quality
problems in nursing homes have found adverse outcomes. This comes at a time of greater
demand for care by the growing numbers of elderly Americans.
The studies, both published in December, were based on data from the 2004 National Nursing Home
Survey, which generated a sample of 1,174 nursing homes representing more than 16,000 nursing homes
in the United States. These data were linked by facility to quality outcomes from contemporaneous
databases used to monitor standards of nursing home care. The linkages were to Quality Indicators from
Nursing Home Compare and to data on deficiencies of care from the Online Survey, Certification and
Reporting (OSCAR).
Staff turnover is of concern for nursing homes, as high turnover has been associated with increased
adverse outcomes. These studies suggest that preventing staff turnover should be given greater emphasis.
In the first study, "Are Nursing Home Survey Deficiencies Higher in Facilities with Greater Staff
Turnover," published in the Journal of the American Medical Directors Association, Nancy B. Lerner,
DNP '10, RN, BSN '66, an assistant professor at the University of Maryland School of Nursing
(UMSON), and colleagues including UMSON Professor Alison M. Trinkoff, ScD, MPH, RN, FAAN,
found that turnover for both licensed nurses and certified nursing assistants (CNAs) was associated with
quality problems as measured by deficiencies considered to be closely related to nursing care (qualify of
care, qualify of life, and resident behavior deficiencies reported by OSCAR).
In the second study, "Turnover Staffing, Skill Mix, and Resident Outcomes in a National Sample of U.S.
Nursing Homes," published in the Journal of Nursing Administration, Trinkoff and colleagues found that
adverse resident outcomes such as pressure ulcers and pain are related to high turnover among CNAs. The
study, even after controlling for factors including skill mix, bed size, and ownership, found nursing homes
with high CNA turnover had significantly higher odds of pressure ulcers, pain, and urinary tract
infections.
"Changes are needed to improve the retention of care providers and reduce staff vacancies in nursing
homes to ensure high quality of care for older Americans," Lerner states. Further the study by Lerner and

colleagues suggests the need for continued research using deficiencies as a measure of quality in addition
to the quality indicators used by others.

Story Source:
The above story is based on materials provided by University of Maryland, Baltimore. Note:
Materials may be edited for content and length.

Journal References:
1. Nancy B. Lerner, Meg Johantgen, Alison M. Trinkoff, Carla L. Storr, Kihye Han. Are
Nursing Home Survey Deficiencies Higher in Facilities With Greater Staff Turnover.
Journal of the American Medical Directors Association, 2014; 15 (2): 102 DOI:
10.1016/j.jamda.2013.09.003
2. Alison M. Trinkoff, Kihye Han, Carla L. Storr, Nancy Lerner, Meg Johantgen,
Kyungsook Gartrell. Turnover, Staffing, Skill Mix, and Resident Outcomes in a
National Sample of US Nursing Homes. JONA: The Journal of Nursing Administration,
2013; 43 (12): 630 DOI: 10.1097/NNA.0000000000000004
http://www.sciencedaily.com/releases/2014/02/140207083613.htm

Developing Delegation Skills
^md
Alice Weydt, RN, MS
ANA online CE contact hours are available for this article.
Abstract
One of the most complex nursing skills is that of delegation. It requires sophisticated clinical
judgment and final accountability for patient care. Effective delegation is based on one’s state
nurse practice act and an understanding of the concepts of responsibility, authority, and
accountability. Work Complexity Assessment, a program that defines and quantifies various
levels of care complexity based on the knowledge and skill required to perform the work, has
demonstrated that methods of patient assignment and staff scheduling that support consistency
increase what could be delegated to ancillary personnel by using the more effective assignment
patterns. The author begins this article by discussing delegation and the related concepts of

responsibility, accountability, and authority. Next factors to consider in the delegation process,
namely nursing judgment, interpersonal relationships, and assignment patterns are
presented. The author concludes by sharing how to develop delegation skills.
Citation: Weydt, A., (May 31, 2010) "Developing Delegation Skills" OJIN: The Online Journal
of Issues in Nursing Vol. 15, No. 2, Manuscript 1.
DOI: 10.3912/OJIN.Vol15No02Man01
Key words: accountability, authority, delegation, delegation potential, pairing and partnering
scenarios, patient assignments, professional practice, relationship management, responsibility,
simulation, staff schedule, state nurse practice act, unit-based, Work Complexity Assessment
Registered Nurses (RNs) are brokers of patient care resources. RNs synthesize data collected by
nurses and other healthcare professionals so as to coordinate the patient’s safe, individualized
care and to best address patient and family needs in a way that maximizes available resources.
RNs decide what patient care interventions are necessary and how, when, and by whom these
interventions need to be provided. These decisions are made in a clinical environment in which
shrinking resources and increased demands for services heighten the need for nurses to delegate
care based on professional guidelines and their state nurse practice acts. The author begins this
article by discussing delegation and the related concepts of responsibility, accountability, and
authority. Next factors to consider in the delegation process, namely nursing judgment,
interpersonal relationships, and assignment patterns are presented. The author concludes by
sharing how delegation skills can be taught and strengthened.
Delegation and Related Concepts

Delegation is an important skill that influences clinical and financial outcomes...Perhaps one of
the most difficult responsibilities an RN has is that of effective delegation. RNs are required to
understand what patients and families need and then engage the appropriate care givers in the
plan of care in order to achieve desired patient outcomes while maximizing the available
resources on the patient’s behalf. Delegation is an important skill that influences clinical and
financial outcomes; yet, an RN’s delegation skills often are not evaluated in the same manner as
other clinical skills, even though a number of nurses continue to need help in delegating
appropriately.
The following scenario is a typical situation that RNs frequently describe when sharing their
need for more staff:
...the RN performed work that others could have completed.Near the end of her shift, the RN
finds that the LPN and nursing assistant have all their work completed and are sitting in the
nursing station waiting for the next shift to arrive. The RN has been running all evening trying to
juggle competing patient needs, such as administering blood and initiating IV antibiotics for
patients assigned to the LPN and nursing assistant, in addition to answering a pharmacist’s
questions about a patient’s lab results and performing requests made by team members from
other services, all while trying to complete the care needed for her patients. The RN is struck by
how overwhelmed she feels and questions the LPN and nursing assistant about why they did not

help her. The LPN and nursing assistant respond that had the RN asked them to help, they would
have, adding, “but we can’t read your mind.” The RN responded, “I didn’t have time ask.
Couldn’t you see I was busy?”
There is no doubt that this RN needed help. The RN’s challenge, however, was not related to a
lack of available personnel. Rather the situation developed because the RN performed work that
others could have completed. Almost all RNs can benefit from strengthening their delegation
skills so as to maximize the available resources.
Delegation and Related Concepts

Delegation is a complex process in professional practice requiring sophisticated clinical
judgment and final accountability for patients’ care (National Council of State Boards of Nursing
[NCSBN], 2005). The variability and complexity of each patient situation requires RN
assessment to determine what is appropriate for the LPN, nursing assistant, and/or other assistive
personnel, or even another RN, to perform. In the delegation process, RNs need to match the
skills of the staff with the needs of the patient and family. Matching staff skill to patient and
family needs highlights the difference between delegation and assignment. The NCSBN defines
delegation as “giving someone a task from the delegator’s practice” (NCSBN, 1995, p.1). This
task, however, needs to be one that the person accepting the assignment is qualified to perform.
Assignment is defined as “giving someone else a task within his/her own practice and is based on
job descriptions and policies” (NCSBN, 1995, p.1). Clarifying the difference between delegation
and assignment helps staff members understand why one cannot develop a simple laundry list of
what can be delegated to others.
Perhaps one of the most difficult responsibilities an RN has is that of effective delegation.
Delegation belongs to the practice of registered nurses, but often it is not well understood or
practiced. Ebright, Patterson, Chalko, & Render (2003) have stated that innovations, such as
work redesign, have contributed to increased complexity affecting how delegation occurs. Work
redesign has relied heavily on assistive personnel, sometimes called nurse extenders; however,
many tasks cannot be delegated to these assistants because they exceed the scope of practice of
these personnel (Ebright, et al.)
In the scenario provided above, the RN was the person directing the work of others. However,
the RN did not communicated with the LPN and nursing assistant about what needed to be done.
In addition, the RN accepted the responsibility to perform additional activities requested by other
departments rather than redirecting some of them. This behavior is not uncommon. A study of
170,000 healthcare workers found that RNs often performed inappropriate work or work that
others could have done, thus contributing to a loss of the professional components of nursing
(Murphy, Ruch, Pepicello, & Murphy, 1997).
Nurses are stewards of healthcare resources. They promote cost containment for healthcare
organizations (NCSBN & American Nurses Association [ANA], 2006). Delegation is a skill that
maximizes the available resources in the interest of patient care. Professional nurses need to
work effectively with assistive personnel because of the escalating shortage of RNs, rising
patient acuity, and increased therapy complexity (NCSBN & ANA). RNs are responsible for the
care they provide and for determining what care can be appropriately delegated to others. LPNs

and assistive personnel have technical expertise that can be maximized when RNs become
skilled delegators who understand the concepts of responsibility, accountability, and authority,
and grasp how these concepts influence what activities RNs can delegate to others (Forte,
Forstrum, & Lindquist, 1998).
Responsibility
Frequently when discussing delegation, RNs will comment: If I am responsible for someone
else’s work, I would rather do it myself. This statement infers that one is liable or has to answer
for the actions of another. The ANA has stated that responsibility involves liability with the
performance of duties in a specific role (ANA Code of Ethics, 2001). Responsibility is a twoway process that is both allocated and accepted (Creative Health Care Management, 2008).
Assistive personnel accept responsibility when they agree to perform an activity delegated to
them.
Accountability
Accountability involves a retrospective review which includes critical thinking to determine if
the action was appropriate and giving an answer for what has occurred. RNs demonstrate
accountability when they answer both for themselves and for others regarding their actions
(ANA Code of Ethics, 2001). RNs assure appropriate accountability by verifying that the
receiving person accepts the delegation and accompanying responsibility (NCSBN and ANA,
2006).
Authority
RNs, by virtue of their professional licensure, have the authority to transfer a selected nursing
activity in a specific situation to a competent individual (NCSBN, 1995). Authority is the right to
act in areas where one is given and accepts responsibility (Creative Health Care Management,
2008). RNs have authority, or legitimate power, to analyze assessments, plan nursing care,
evaluate nursing care, and exercise nursing judgment (NCSBN) which includes delegation. In the
scenario at the beginning of the article, the RN had the authority, but did not exercise this
authority, to delegate to the LPN and/or nursing assistant.
Summary
LPNs are accountable for the quality of their performance... In the delegation process
accountability rests within the decision to delegate, while responsibility rests within the
performance of the task. LPNs are accountable for the quality of their performance and
responsible for caring out the activities assigned to them. When a RN delegates an activity, such
as medication administration, to an LPN, the LPN is accountable for safely performing this
medication administration according to established regulations and standards, and responsible for
completing this activity. The RN is then accountable to follow up with the LPN to review the
outcome. This intentional reflection on the delegated activity directs future efforts and promotes
learning (Creative Health Care Management, 2008). Understanding the difference between

responsibility and accountability helps to clarify how RNs can delegate work to another without
being held responsible for their actions.
Delegation and Nursing Judgment

The ANA Code of Ethics (2001) notes that delegation is based on the RN’s judgment concerning
a patient’s condition, the competence of all members of the nursing team, and the degree of
supervision required. This statement coincides with the Five Rights of Delegation developed by
the NCSBN (1995). These Rights of Delegation include: (a) the right task, (b) the right
circumstance, (c) the right person, (d) the right direction/communication, and (e) the right
supervision.
Additionally, four guidelines for effective delegation have been identified by Koloroutis (2004,
p. 136). They include the following:
1. Delegation requires RNs to make decisions based on patient needs, complexity of the
work, competency of the individual accepting the delegation, and the time that the work
is done.
2. Delegation requires that timely information regarding the individual patient be shared,
defines specific expectations, clarifies any adaptation of the work in the context of the
individual patient situation, and provides needed guidance and support by the RN.
3. Ultimate accountability for process and outcomes of care – even those he or she has
delegated - is retained by the RN.
4. RNs make assignments and the care provider accepts responsibility, authority, and
accountability for the work assigned.
Delegation decisions are sometimes made based on a list of tasks found in a job description, such
as taking vital signs, bathing, or ambulating patients. In these cases the RN is really assigning
tasks rather than using professional judgment to match the staff member’s skills to patient needs.
Assigning nursing assistants to perform all the baths or take all the vital signs for a group of
patients indicates that the delegation is task based rather than judgment based. Making
assignments based on a list of tasks in a job description short-circuits the critical thinking skills
of the RN because the RN’s judgment is not utilized. Matching the staff member’s expertise to
patient needs is essential for sound delegation decisions.
An example of this matching would be an RN’s decision that an LPN with five years of long
term care experience prior to working in orthopedics is a more qualified care giver for a 91 year
old post operative arthroplasty patient than an LPN who is also available but who has less
background in caring for geriatric patients. It is the understanding of the geriatric patient’s needs
at this point in time that would lead the RN to intentionally select the LPN with long term care
experience. In this situation, the RN would still assume the responsibility of first assessing the
patient before delegating the care to the LPN, and the responsibility of clarifying expectations of
the care to be given in order to meet the desired outcomes. The RN would periodically assess the

patient’s status and not hesitate to instruct the LPN about what to monitor and direct specific
interventions. In this example, the matching of patient need to the nurse skills would be very
intentional, relying on the RN’s professional judgment.
Although delegation is a skill that requires knowledge and practice, delegation is not commonly
identified as an RN competency. Understanding and applying the delegation guidelines presented
above provides a foundation for effective delegation.
Delegation and Interpersonal Relationships

The manner in which a team member is asked to perform care by the delegating RN influences
the team member’s willingness to respond. Another important factor in delegation is the
relationship between the RN and the LPN, nursing assistant, and/or other team member(s). Each
member of the healthcare team has a valuable contribution to make to patient care (Creative
Health Care Management, 2006). This contribution is magnified when the RN has a healthy
interpersonal relationship with the team providing care. Delegation is the invitation for
participation. The manner in which a team member is asked to perform care by the delegating
RN influences the team member’s willingness to respond. Communication style influences
teamwork and relationships. Engaging in direct, open, and honest communication is a
characteristic of good teamwork. Thus the ability to delegate and the quality of the delegation is
influenced by healthy interpersonal relationships, the manner in which the activity is delegated,
and the openness of the communication.
In contrast, in the scenario at the beginning of this article, comments made by various team
members set the stage for blaming. The LPN and nursing assistant stated that they would have
helped, had the RN asked them to do so, thus blaming the RN. One can wonder why the LPN
and nursing assistant did not offer help or take initiative on their own to do more. Had the RN,
LPN, and nursing assistant had a better relationship, the LPN and/or assistant might have had a
greater desire to see their team provide the best care possible and have taken the initiative to
perform the care that was within their scope of practice. Then the RN could have better managed
what needed to be done and better patient care could have been provided.
In the ideal situation, the RN, LPN, and nursing assistant would have been active partners in care
and shared the work. The RN, anticipating what would need to be done while she was busy with
other activities, would have discussed openly, directly, and honestly with the LPN and assistant
the additional care she needed to ask them to manage. Healthy interpersonal relationships among
all personnel on the shift promote a synergy between team members, enabling them to work
together more effectively. Although there is a connection between healthy relationships among
team member and quality care, positive interactions among all staff members on a given shift are
not always demonstrated in practice.
Healthy interpersonal relationships among all personnel on the shift promote a synergy between
team members, enabling them to work together more effectively. Trust is an important element in
developing healthy team relationships. Kolorouits (2004) has noted that effective delegation is
based on both trust and an understanding of professional practice. When RNs state that they are
reluctant to delegate care when they do not know their team member’s skill level, they are likely
saying that they avoid delegation because they don’t trust their other team members. Trust, a

critical factor in relationships, is based on knowledge of one another’s capabilities and
confidence in these abilities. Caregiver consistency, which builds trust, is achieved by staffing
schedules and methods of patient assignment which directly impact how work is delegated. The
staffing schedule and patient assignment methods that promote consistency among caregivers
and between caregivers and their patients become the foundation for enhancing the quality of
work relationships (Koloroutis, 2004) as described below.
Delegation and Assignment Patterns

The correlation between consistency of care givers and delegation potential (the amount of
nursing care that can legally and safely be assigned to a non-professional staff member) is
explored in the Work Complexity Assessment (WCA) Program. WCA is a consultant-led
process, developed by Tom Ingalls and licensed through Creative Health Care Management; it
helps define and quantify various levels of care complexity based on the knowledge and skill
required to perform the work. The delegation potential is based on what could be delegated
rather than on traditional delegation practices that are often task based. WCA uses the three
scenarios (three different ways of assigning personnel) to determine the delegation potential and
examine the impact of staffing schedules and methods of patient assignment on delegation. The
three scenarios, namely unit based, pairing, and partnering, vary in the amount of time in which
nurses and other personnel work the same shifts and care for the same patients (Koloroutis,
2004). Each scenario is described below.
Unit-Based Scenarios
In the unit-based scenario, assistive personnel, such as the ward secretary and nursing assistant,
serve the unit. The nursing assistant works off a task list usually found in the job description, and
has minimal direction from, or interaction with the RNs. The nursing assistant is often left to
prioritize the multiple tasks given by differing RNs who are unaware of one another’s requests of
the assistant. This lack of communication can cause conflicts. The RNs do not know what their
fellow RNs have also asked the assistant to do and the assistant has no way of knowing to which
RN they are ultimately accountable. Nursing assistants express frustration with conflicts and
work expectations that cannot be negotiated. RNs express frustration about not knowing the
nursing assistants whereabouts or what they are doing.
An example of the unit based scenario is assigning a nursing assistant to take all the vitals signs
or bathe all the patients. The nursing assistant understands what is expected, but may be
interrupted in completing the vital signs and baths and asked to ambulate a patient by one RN,
who does not know that another RN has just requested the nursing assistant to help with a
dressing change. Meanwhile, the nursing assistant is trying to complete the bathes and take all
patients’ vital signs, while the RNs are questioning why the nursing assistant hasn’t responded to
their requests for help. In these scenarios the emphasis is on completing tasks of care, rather than
focusing on the care process. It is difficult to develop healthy relationships and trust under these
conditions.
Pairing

Pairing is the second scenario in which one RN works with an LPN and/or a nursing assistant for
the shift (Koloroutis, Felgen, Person, & Wessel, 2007). However, the RN and LPN and/or
assistant are not intentionally scheduled to work the same shift each day. Although they may all
work the same shift on the next day, they may not be paired on the next day to care for the same
patients. For a given shift, however, they work together, or are paired, and care for the same
group of patients. Delegation usually increases with pairing. In this scenario, the RN and the
LPN or nursing assistant discuss how care is to be prioritized and how it is to be done, and
identify expected individualized outcomes for the shift. For instance, a patient’s therapeutic goal
for the shift might be for the patient to ambulate the length of the hall 30 minutes after the pain
medication has been administered, with a pain rating no greater than 2 on a scale of 1 to 10 at the
end of the walk. The nursing assistant would report observations and the pain scale rating to the
RN who would then determine if the plan for pain control is adequate. Pairing increases the
delegation potential and promotes healthy relationships.
Partnering
The third scenario is partnering (Koloroutis, Felgen, Person, & Wessel, 2007). In partnering, one
RN and one LPN and/or nursing assistant are consistently scheduled to work together, making a
commitment to maintain healthy interpersonal relationships, trust each other, and advance each
other’s knowledge. It is recognized that the RN has the authority to make the delegation
decisions. In this model, the LPN, nursing assistant, and RN know one another well enough to
anticipate what is going to be needed for patient care. The LPN or nursing assistant who works in
a partnership with the RN knows that the RN will want a specific patient to ambulate and to
achieve pain control by a certain time within a eight hour shift and/or will need a particular piece
of equipment or certain supplies at a certain time. This knowledge enables the assistant to have
the information or equipment available even before the RN asks for it. Compared to the assistant
in the paired assignment, the assistant who is partnered could anticipate that the RN will want the
patient walked within a given timeframe after a pain medication has been administered, and
could plan to be available to walk the patient at the appropriate time. Together the RN and the
LPN or nursing assistant care for “our patients” rather than “your patients” and “my patients.”
This reflects a major shift in thinking and in the method assignments are made. Had partnering
been used in the scenario at the beginning of the article, the staff involved would have known
each other’s needs and expectations and would have been able to coordinate their efforts more
effectively.
Partnering is supported by a staffing schedule that is developed so as to consistently have care
givers working together and by the method of patient assignments that ensures the same staff
cares for the same group of patients for their length of stay. Partnering reflects a philosophy of
care that values continuity and relationships, with management and staff honoring the
partnership. The delegation potential is generally highest when staff partner with each other
because consistent relationships over time enhance knowledge about capabilities and help to
foster trust between members of the nursing staff.
Thus staffing schedules and patient assignments impact the delegation potential. When this
connection is understood and valued, staff members see how work can be done differently. This
becomes especially effective when staff at the point of care take ownership of a staffing schedule

that promotes continuity of care and when the patient assignment matches the talents of the
caregivers to the needs of the patient and family.
...the amount of work delegated can be expanded when direct care givers work together
consistently. Because the depth of expertise varies within roles, including the RN role, delegation
is more difficult when the assistant is not known by the RN. Pairing and partnering increase
delegation because trust is developed, relationships are fostered, and growth is supported. In
partnering, there is increased commitment to one another and confidence that complex situations
can be managed. The partnership enables RNs to perfect their delegation skills more fully.
Some staff members have shared with me that having limited nursing assistants or LPNs
available with whom they can partner poses a challenge to implementing this partnering
scenario. Creativity is needed to make this scenario work using existing resources. For example,
in situations with predominately RN staff, more experienced RNs could mentor new RNs using
pairing or partnering, thus enhancing care and helping the new RNs to grow professionally.
Work Complexity Assessment consultants have demonstrated that the amount of work delegated
can be expanded when direct care givers work together consistently. Delegation potentials are
significantly higher when caregivers are paired or partnered, with the partnered scenario
generally having the highest delegation potential. In analyzing the findings from delegation
potential studies, RNs frequently cite trust with their co-workers as a key factor when delegating.
They state that delegation requires an understanding of one another’s knowledge and skills.
Direct care givers who work together consistently have been found to experience the following
gains in the work setting: (a) more knowledge about each other’s competence and continued
growth in competence; (b) increased commitment to each other and ability to deal with more
complex situations; and (c) increased efficiency in getting the work done through natural synergy
(Weydt, 2009, p. 11). The Table compares the description, outcomes, and challenges of the unitbased, pairing, and partnering assignment patterns.
Developing Delegation Skills

...role clarification becomes increasingly important as new positions develop to
address...complex patient care needs. Delegation is a multifaceted skill set that begins with
understanding one’s state nurse practice act which outlines nursing’s legal responsibility,
authority, and accountability for patient care. RNs are encouraged to conduct ongoing reviews of
their state practice act with special attention given to delegation. The review often prompts
discussion about organizational policies and procedures as well as clarifying roles, such as that of
the LPN or technical support staff. The role clarification becomes increasingly important as new
positions develop to address the variety of complex patient care needs. Understanding the role
expectations as well as knowing the expertise of the staff to whom care is delegated influences
what the RN delegates.
Delegation skills can be strengthened when:


RNs understand the nurse state practice act



Nursing education and nursing service support students and RNs as they continually
expand their knowledge about delegation



Simulation exercises using scenarios found in daily practice are used to teach and
demonstrate delegation competency



Pairing and/or partnering is utilized and supported by the staff schedule and method of
patient assignment



Delegation is viewed as competency that is based on a skill set and that requires ongoing
development

Developing delegation skills is indeed a multifaceted activity. Developing delegation skills
begins during pre-licensure nursing education. It is important that educators and organizations
provide clinical experiences for students to see delegation as a skill set that has to be practiced in
order for it to be perfected. Developing practice environments that foster students’ learning of
delegation skills reinforces the authority of all RNs to delegate to LPNs and nursing assistants
who may see the student as inexperienced. As new RNs enter professional practice, they need
ongoing support and education to perfect this skill.
Delegation skills can also be developed using simulation to create practice scenarios reflecting
daily practice. Delegation skills can also be developed using simulation to create practice
scenarios reflecting daily practice. Both clinical aspects of care and delegation skills can be
evaluated during the simulation. Simulation creates the opportunity for feedback and analysis of
how pre-licensure students and/or RNs directed the work of others during the simulation, with an
emphasis on the effect that the simulated delegation would have had on clinical and financial
outcomes. RNs can evaluate their interpersonal skills used during the simulation, as well as
review the work performed, asking how the work could have been done differently and
considering who else might have been in a position to do this work.
Simulation might be used, for example to improve both the skill of delegation and that of
administering blood for a post-operative patient. In the simulation scenario, the required
technical skills of blood administration could be evaluated as well as the RN’s ability to
appropriately delegate, during the procedure, some responsibilities for patient care to either the
LPN or nursing assistant. The post-simulation discussion (debriefing) could include an
evaluation of both the blood-administration procedure and also the quality of the delegation with
a focus on the RN’s communication skills. The LPN and nursing assistant could provide
feedback as to their perception of the RN’s delegating skills.
Conclusion

It is important that educators and organizations provide clinical experiences for students to see
delegation as a skill set that has to be practiced in order for it to be perfected. Delegation is a
complex professional skill requiring sophisticated clinical judgment and final accountability for
patients’ care. Effective delegation is based on one’s state nurse practice act; it serves to
maximize patient care resources. Concepts of responsibility, accountability, and authority are

integral to each RN’s understanding of professional nursing practice, which includes properly
assuming authority for the decisions and outcomes associated with patient care, sharing the
process of patient care with other responsible members of the nursing team, and holding all
members of the nursing team accountable for their responsibilities. Delegation requires RNs to
use critical thinking skills in order to match staff expertise with patient and family needs. Staff
relationships also influence the delegation potential and the delegation process. Three assignment
scenarios are used in Work Complexity Assessment, namely unit based, pairing, and partnering,
to determine the delegation potential for a specific patient care unit/service. Staffing schedules
and consistent patient assignments that support pairing and partnering enable staff members to
increase knowledge about each other and help to foster a strong sense of trust, thus increasing the
delegation potential.
When RNs do not effectively delegate to others, quality of care can be lessened and valuable
resources can be mismanaged. Resources will surely continue to shrink and care demands will
surely continue to rise, thus increasing the risks of inappropriate delegation. Having clarity about
what can be delegated helps to define quality professional practice not only for nurses but also
for other team members, patients, and families.
Author
Alice Weydt, RN, MS
E-mail: [email protected]
Ms. Weydt has more than thirty years of experience working in acute care settings and leading
nursing and interdisciplinary teams in a variety of acute care settings. As she has worked to
improve patient care processes and outcomes, she has focused considerable attention on
developing healthy interpersonal relationships and delivery systems that span the care
continuum. She currently serves as Director of Patient Care Services at Arcadia Medical Center,
Arcadia, WI, and adjunct faculty with Creative Health Care Management. She earned her
Master’s degree in Healthcare Administration from Cardinal Stritch University, Milwaukee, WI,
and her BSN from Montana State University. Alice is also a graduate of the University of
Minnesota Independent Study Program in Patient Care Administration.
References
American Nurses Association. (2001). Code of ethics for nurses with interpretive statements an
independent study module. Author: Washington DC.
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/
OJIN/TableofContents/Vol152010/No2May2010/Delegation-Skills.html

Nursing Delegation in the United Kingdom

^md
Patricia Gillen, PhD, RN, RM, RNT, MSc, BSc
Sean Graffin, RN, RMN, RNT, BSc
Abstract
This article describes how registered nurses in the United Kingdom (UK) delegate some nursing
activities to support workers who assist them in providing nursing care. The global shortage of
qualified nurses and the ageing nursing population has resulted in a growing dependency on nonqualified personnel to provide certain aspects of patient care within the care setting. The authors
begin this article by presenting the differing nursing staff roles in the UK along with the legal
and professional aspect of delegation. Next they discuss the benefits, facilitators, and
barriers. They conclude by describing the changes in role expectations, the variety of nursing
settings in which delegation occurs, and nursing delegation challenges within the UK.
Citation: Gillen, P., Graffin, S. (May 31, 2010) "Nursing Delegation in the United Kingdom"
OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 2, Manuscript 6.
DOI: 10.3912/OJIN.Vol15No02Man06
Key words: nursing delegation, barriers to delegation, facilitators of delegation, managing
delegation, Health Care Assistants, HCAs, legal aspects of delegation, professional aspects of
delegation
Healthcare is becoming increasingly complex in today’s world. The delegation of care forms part
of that complexity. This article describes how registered nurses in the United Kingdom (UK),
which includes England, Scotland, Wales, and Northern Ireland, delegate some nursing activities
to support workers who assist them in providing patient care.
The role of registered nurses has increased over the past decade. Nurses now carry out more
highly technical care, sometimes taking on the work of junior doctors. This has resulted in some
patient care being shifted to Health Care Assistants (HCAs) who are also know as support
workers and care assistants. While there have always been nursing auxiliaries, such as HCAs,
providing care to patients, the emphasis has now moved to the HCA as a more formal care
worker (Spilsbury & Meyer, 2004).
The global shortage of qualified nurses and the ageing nursing population has meant that there is
a growing dependency on non-qualified personnel, such as Health Care Assistants (HCAs)
within the U.K. care setting. Qualified nurses in the UK are those nurses who are registered with
the Nursing and Midwifery Council (NMC); they are the nurses who have undertaken an NMCapproved course of education. As a result of this change in skill mix, nurses need to able to
delegate tasks to HCAs so that appropriate and safe care is delivered to patients. Clear
procedures are required to clarify the roles of the registered nurse and HCAs in relation to

delegated tasks so as to ensure that patients receive a high standard of care from the most
appropriate healthcare staff member.
We will begin this article by presenting the differing nursing staff roles in the UK along with the
legal and professional aspect of this delegation. Next we will discuss the benefits, facilitators,
and barriers related to delegation. We will conclude by describing changes in role expectations,
the various settings in which delegation occurs within the UK, and nursing delegation challenges
within the UK.
Differences in Nursing Staff Roles Related to Delegation

...only those whose name is registered with the Nursing and Midwifery Council (NMC), the
governing body for Registered Nurses in the UK, are legally permitted to call themselves
registered nurses. In order to explain the process of delegation in the UK, we will first describe
what we mean when we use the term ‘nurse’ and what we mean when we use the term ‘Health
Care Assistant.’ In 2006, the Royal College of Nursing (RCN), the major nursing professional
body in the UK, acknowledged some difficulty in defining a nurse. While a nurse may be
described “as a person qualified and authorised to practise nursing” (RCN, 2003, p. 18), in the
UK there is no legal definition of a nurse. Indeed, the term nurse is commonly used by others
who work in dental, nursery, and veterinary care environments. However, only those whose
name is registered with the Nursing and Midwifery Council (NMC), the governing body for
Registered Nurses in the UK, are legally permitted to call themselves registered nurses
(henceforth referred to as nurses) (RCN, 2003). In order to be registered as a nurse, the person
needs to have successfully completed an education programme which adheres to NMC standards
for Preregistration Nurse Education (NMC 2004, currently being updated). Health Care
Assistants (or support workers or care assistants) are less clearly defined. They are generally
accepted to be persons who work in the capacity of support workers in an area of healthcare and
who normally work under the guidance of a registered practitioner (NHS, 2009).
We want to emphasize that the term ‘non-qualified’ is used to denote the person to whom an
aspect of care is delegated. It does not mean that the person is not of paramount importance, nor
that they have not been trained to carry out that aspect of care. Rather it means that the nature of
the duty being delegated and/or the consequence(s) of delivering the care to the patient do not
carry as high a level of risk and associated responsibility for patient safety and welfare as the
duties performed by nurses who are qualified, i.e. registered.
Spilsbury and Meyer (2004) have identified three main areas of HCA work, namely direct patient
care, housekeeping duties, and clerical tasks. Direct patient care includes washing and dressing
the patient, assisting with feeding, taking observations, and assisting with toileting.
Housekeeping involves cleaning equipment and sorting laundry. The clerical aspects relate to a
range of duties, such as ordering supplies. The duties that are most often delegated by nurses to
HCAs include those of providing assistance with washing and dressing, feeding, mobilising,
toileting, and bedmaking (NHS, 2009).
Those HCAs who have received the appropriate training and who have been assessed as
competent may undertake patient observations including (but not limited to) temperature, pulse,
respirations, and weight (NHS, 2009). In order to prepare for an increased level of responsibility

within their role, HCAs may be offered the opportunity to undertake one of the National
Vocational Qualification (NVQ) programs. These are programs in which HCAs are taught the
skills and knowledge necessary to practice competently as HCAs. In these programs participants'
competency is assessed at various levels to determine the level of proficiency at which they are
able to provide patient care. The programs provide levels of skill that can be transferred from one
setting to another during the HCA’s work life. These NVQs are the most recognised form of
vocational training for HCAs (Skills for Health, 2010). An NVQ Level 2 prepares the HCA to
take on further responsibilities than they have in their current role. The NVQ Level 3 is
recognised as meeting the entry requirement to a Pre-Registration Nurse Education programme.
Legal and Professional Aspects of Delegation

A number of definitions of delegation can be found within the nursing literature. The important
emphasis within each definition is that the work is being done by another (the delegatee) who
accepts responsibility for carrying out the delegated work and is accountable as to how the work
is carried out. It is emphasized, however, that the accountability and responsibility also remain
with the delegator who needs to be sure that the work is delegated appropriately (Hansten &
Jackson 2004; Marquis & Huston 2009; McEachen & Keogh 2007; Quallich, 2005). Dimond
(2008) has described the legal responsibility of the nurse undertaking delegation by noting, “it is
the personal and professional responsibility of each practitioner who delegates activities to
ensure that the person to carry out that activity is trained, competent, and has the necessary
experience to undertake the activity safely” (p. 570).
Although the NMC does not offer a definition of delegation, it does emphasise the importance of
delegation by including within the NMC Code the following statement regarding standards for
conduct, performance, and ethics for nurses and midwives:


You must establish that anyone you delegate to is able to carry out your instructions



You must confirm that the outcome of any delegated task meets the required standards



You must make sure that everyone you are responsible for is supervised and supported
(NMC, 2008a, p.6)

It stresses the need to ensure that delegation only takes place when it is in the best interests of the
person receiving the care... In addition, the NMC (2008) has established principles which should
be adhered to by nurses when delegating to others. It stresses the need to ensure that delegation
only takes place when it is in the best interests of the person receiving the care and when a
holistic assessment of need has been undertaken by the nurse who delegates the care. It
emphasises the importance of accountability and responsibility within the process of delegation.
The nurse who delegates remains accountable for the appropriateness of the delegation and
making a judgement about the supervision required by the person carrying out the delegated task.
Overall the employer has the responsibility to ensure that the persons to whom nurses may
delegate tasks have the appropriate education, training, and skills to carry those tasks that a nurse
may be expected to delegate to them.

However, the nurse who delegates the task retains the responsibility to judge the appropriateness
of the delegation by:


Reassessing the condition of the person in the care of the nurse or midwife at appropriate
intervals and determining that it remains stable and predictable; and



Observing the competence of the caregiver(s) and determining that they remain
competent to safely perform the delegated task of care safely and effectively



Evaluating whether or not to continue delegation of the task” (NMC, 2008b, p. 3)

Thus the NMC provides considerable guidance related to delegation in nursing.
The RCN, too, does not offer a definition of delegation, although it also provides guidance and
an emphasis on the nature of delegation. It has determined that the following factors need to be
considered by the delegator when considering what to delegate and to whom:


the individual’s skills, competence, attitudes and experience;



the requirements of the patient/client/client group;



the nature of the task in the specific circumstance (RCN. 2006, p. 11).

It is important to note that in the UK, just as in other countries such as the United States (US), a
basic guideline for delegation decision making focuses on the Five Rights of Decision Making as
described by the U.S. National Council of State Boards of Nursing (1995).
The UK has developed legal definitions relating to delegation, encompassing the following
factors: (a) leadership functions and delegation, (b) management roles and delegation, (c)
information on tasks that can be delegated, including legislation, guides, job descriptions,
policies and procedures, and patient needs, and (d) guidelines on how to delegate (Dimond,
2008).
Benefits of Delegation

Delegation builds the confidence and self-esteem of HCAs by allowing them to hone their caring
skills under supervision. Delegation has many positive outcomes for both patients and staff.
Barker, Sullivan, and Emery (2006) have explained that delegation is a trust-building activity as
it allows HCAs to demonstrate that they can accomplish tasks delegated by registered nurses,
thus showing the valuable contribution they can make to patient care. As a consequence, nurses
feel more confident about delegating duties to HCAs. Delegation builds the confidence and selfesteem of HCAs by allowing them to hone their caring skills under supervision. Delegation helps
HCAs grow, learn, and become leaders as they see more of the ‘big picture.’
Delegation benefits the patient in that it can match the right person with the right expertise for
the right job. If used judiciously, delegation can ensure that HCAs can perform caring roles that

have a beneficial effect on patient health outcomes. Keeney et al. (2004) have reported that
HCAs were viewed positively by patients. However, there needs to be a concerted effort to
discover how delegation of duties to HCAs in the UK healthcare...there needs to be a concerted
effort to discover how delegation of duties to HCAs...correlates with positive patient outcomes.
setting correlates with positive patient outcomes. Unfortunately, there is a dearth of literature that
has identified specifically how delegation benefits patient care. Spilsbury and Meyer (2004) have
acknowledged this lack of literature on “the impact on care when HCAs substitute for RNs” (p.
416).
Delegation frees managers from more routine tasks, allowing them the time for relatively more
important activities relating to patient care. It is also an important tool in succession planning,
i.e., the process for developing internal personnel with the potential to fill key organisational
positions. Succession planning ensures the availability of experienced and capable employees
that are prepared to assume more advanced roles as they become available.
Facilitators of Delegation in the United Kingdom

The Cambridgeshire NHS Primary Care Trust...has produced comprehensive guidelines which
include guidance on recruitment, induction, development, and training of support workers. One
important delegation facilitator is that of an organisational culture that cultivates professional
development. In recent years HCAs have been actively encouraged to undertake National
Vocational Qualifications (NVQs) (described above) to increase their knowledge and skills
needed to perform in their roles. It is also important that nurses be encouraged to continue
developing their professional skills and knowledge base.
Clear organisational and departmental policies that provide coherent guidance on the proper
utilisation of delegation also facilitate the delegation process. The publication of comprehensive,
professional-practice guidelines that equip the nurse with the fundamentals of her role vis-à-vis
delegation is a major facilitator. Some Health Trusts (these are the organisations that provide
health and in some instances social care for patient/clients) have policies in place with regard to
delegation of duties to Health Care Assistants. They take into account the training needs and
skills required to safely undertake delegated tasks. The Cambridgeshire NHS Primary Care Trust
(2006), for example, has produced comprehensive guidelines which include guidance on
recruitment, induction, development, and training of support workers (Cambridgeshire HCT
2006).
Barriers to Delegation in the United Kingdom

The three key elements in the act of delegation include the delegator, the delegatee, and the
situational context (Carr & Pearson, 2005: Swansburg & Swansburg, 2002). Any of these
elements, or a combination of any of them, can become a barrier to the delegation process.
Barriers ascribed to delegators include their preference to work alone, lack of experience,
insecurity, lack of confidence in subordinates, desire for control, lack of
organisational/managerial skills, and/or unwillingness to develop subordinates and help them
grow in their roles (Mackenzie, 2009). Barriers that may arise from the perspective of the
delegatee include lack of experience, lack of competence, avoidance of responsibility, lack of
organizational skills, and/or excessive amounts of work (Mackenzie, 2009). The barriers that

may arise as a result of the situational context include the critical nature of decisions, the urgency
of those decisions, confusion relating to responsibility and authority, and understaffing
(Mackenzie, 2009). Although barriers to effective delegation exist, many of these barriers can be
overcome through effective education and training of both the delegator and the delegatee.
Changes in Role Expectations

The provision of care in the community has evolved to meet the needs of the patients. Nurses
now have variety of job titles and roles, some of which were previously the remit of medical
staff. These roles range from the more traditional staff nurse and ward manager roles to those of
nurse practitioner, specialist nurse, and nurse consultant roles. As noted earlier, the context of
care, within which nurses in the UK are required to deliver a high standard of efficient and
effective care, has been subject to profound and enduring change (Department of Health [DH],
2006). These changes to the roles and context within which care is delivered have led to changes
in the organisation of care and an increasing need to delegate some of the more traditional
nursing roles to HCAs.
In 2007 the Health Care Assistant (HCA) toolkit was developed by the Working in Partnership
Programme (WiPP) in collaboration with Staffordshire University. This program has outlined
how HCAs can be incorporated into the primary care team by undertaking certain aspects of
patient care that previously were the remit of nurses and general practitioners (GPs). In the UK,
GPs are defined as “personal doctors, primarily responsible for the provision of comprehensive
and continuing medical care to patients irrespective of age, sex and illness” within the primary
care setting (Royal College of General Practitioners, 2010). This setting is most often that of a
health centre located in the community. The provision of care in the community has evolved to
meet the needs of the patients. Part of this evolution has included HCAs taking on a wider range
of tasks than previously was the case. The care they provide may now range from personal care
and monitoring patients’ conditions to performing venipunctures and assisting with minor
operations (RCN, 2010). These new roles require training that is focused on the specific tasks the
HCA will be expected to undertake while working in these new areas.
Variety of Nursing Settings in which Delegation Occurs

Current literature regarding the HCA role concentrates on hospital-based settings (Bach, Kessler,
& Heron 2008; Spilsbury & Meyer, 2004; Thornley, 2007). Within hospitals HCAs are employed
in medical and surgical wards, operating theatres, and also accident/emergency, maternity, and
outpatient departments. Nurses, too, now work within a wide range of settings within the hospital
and community and undertake increasingly diverse roles within the wider parameters of the
healthcare team. The tasks that are delegated to the HCA depend on the location of the care
delivery. These locations may include not only the hospital or community, but also patients’
homes, day centres, nursing and residential homes, and prisons. When the skill mix includes nonregistered healthcare workers, it is likely that nurses will be involved in the delegation of care.
Nursing Delegation Challenges in the United Kingdom

There remains ongoing confusion as to the boundaries of HCAs’ roles because there is no
standardised role for HCAs. The individual HCA’s work is dependent upon a number of factors,

including the specific clinical area, the means by which delegation occurs, and the particular
ideological thinking of the healthcare setting (Keeney et al. 2005). This lack of standardization is
reflected in the variation of job descriptions for HCAs in UK hospitals (Wakefield et al., 2009).
Such variation leads to confusion for both the registered nurses and HCAs who work together in
a clinical area. It is expected that all three of the areas identified by Spilsbury and Meyer (2004)
as being included in the HCA job responsibilities, namely direct patient care, housekeeping
duties, and clerical tasks, will be delegated and supervised by registered nursing staff. However,
in the reality of the clinical setting, there is a wide variation in how these duties are carried out,
depending on the hospital and ward. The overall findings in Spilsbury and Meyer’s study
demonstrated that HCAs often worked alone and with minimal supervision and/or delegation.
The implication was that, on the whole, they worked in a manner that did not comply with
official hospital policy (Spilsbury & Meyer, 2004).
Conclusion

Due to the changing nature and context of care, nurses need to have an ongoing, comprehensive
understanding of delegation and the role that it plays in current nursing care. The American
Nurses Association (2005) has cautioned nurses to engage in a critical-thinking process before
delegating care responsibilities to assistive personnel. As part of this critical thinking process, the
delegator must ensure the appropriate assessment, planning, implementation, and evaluation
regarding the patients’ care, so that patients receive not only safe, quality care but also that this
care is delivered by an appropriate person, i.e., one who has the requisite knowledge, skill, and
competency to carry out that care.
Authors
Patricia Gillen, PhD, RN, RM, RNT, MSc, BSc
E-mail: [email protected]
Patricia Gillen has been a Registered Nurse (RN) since 1984 and a Registered Midwife (RM)
since 1987. She has worked as a nurse, a midwife, and a midwife sister and manager in both
rural and urban hospitals. In January 2002, she began serving as a lecturer in the University of
Ulster. She completed her PhD in 2007 in the area of workplace bullying. Dr. Gillen teaches both
pre- and post-registration students across a range of areas, including nursing management.
Sean Graffin, RN, RMN, RNT, BSc
E-mail: [email protected]
Seán Graffin has been a Registered Mental Nurse (RMN) since 1984 and a Registered General
Nurse (RGN) since 1986. He has been working for a number of years in a Coronary Care Unit at
a major hospital in Belfast, Northern Ireland and has been managing Clinical Trials for several
years in the same hospital. He has served as a Registered Nurse Teacher (RNT) and has been a
lecturer in Nursing at the University of Ulster since 2001. His main teaching areas have been
cardiac nursing and nursing management.
References

American Nurses Association. (2005). Principles for delegation. Silver Spring, MD: American
Nurses Association.
Bach, S. Kessler, I., & Heron, P. (2008). Role redesign in modernised NHS: The case of health
care assistants. Human Resource Management Journal 18 (2), 171 – 187.
Barker, A.M., Sullivan, D.T., & Emery, M.J. (2006). Leadership competencies for clinical
managers: The renaissance of transformational leadership. Sudbury, MA: Jones and Bartlett.
Carr, S.M., & Pearson, P.H. (2005). Delegation: Perception and practice in community nursing.
Primary Health Care Research and Development, 6(1), 72-81
Cambridgeshire NHS Primary Care Trust (PCT). (2006). Support workers delegation and
support guidelines. Cambridgeshire PCT
Department of Health. (2006). Modernising nursing careers: Setting the direction London: DH.
Dimond, B. (2008). Legal aspects of nursing (5th ed.). Harlow: Pearson Education Ltd.
Hansten, R., & Jackson, M. (2004). Clinical delegation skills: A handbook for professional
practice (3rd ed.). Sudbury, MA: Jones and Bartlett
Keeney, S., Hasson, F., McKenna, H., & Gillen, P. (2005). Nurses’, midwives’ and patients’
perceptions of trained health care assistants. Journal of Advanced Nursing, 50 (4), 345 – 355.
Mackenzie, A. (2009). The Time Trap (4th ed.). New York: AMACOM.
Marquis, B.L., & Huston, C.J. (2009) Leadership roles and management functions in nursing:
Theory and application (6th. ed.) Philadelphia: Lippincott Williams & Wilkins.
McEachen, I., & Keogh, J. (2007). Nurse management demystified. New York: McGraw-Hill.
National Council of State Boards of Nurses. (1995). Concepts and decision-making processes.
National Council Position Paper. Retrieved March 8, 2010, from www.ncsbn.org/323.htm
NHS Careers. (2009). Healthcare assistants/Auxiliary nurses. Retrieved December 30, 2009
from www.nhscareers.nhs.uk/details/Default.aspx?Id=485
Nursing and Midwifery Council. (2008a). The code. Standards of conduct, performance and
ethics for nurses and midwives. London: NMC. Retrieved April 29, 2010 from www.nmcuk.org/aDisplayDocument.aspx?DocumentID=5982
Nursing and Midwifery Council. (2008b). Advice on delegation for registered nurses and
midwives London: NMC. Retrieved April 29, 2010 from www.nmc-uk.org/aArticle.aspx?
ArticleID=4009

Nursing and Midwifery Council. (2009). Record Keeping: Guidance for nurses and midwives.
London: NMC. Retrieved April 29, 2010 from www.nmc-uk.org/aDisplayDocument.aspx?
DocumentID=6269
Quallich, S.A. (2005). A bond of trust: Delegation. Urologic Nursing, 25(9), 120 -123.
Royal College of General Practitioners. (2010). What is general practice? Retrieved April 20,
2010 from www.rcgp.org.uk/patient_information/what_is_general_practice.aspx
Royal College of Nursing. (2003). Defining nursing. London: RCN.
Royal College of Nursing. (2006). Supervision, accountability and delegation of activities to
support workers: A guide for registered practitioners and support workers. London: RCN.
Royal College of Nursing (2010) Unit One The Development of the role of the Health Care
Assistant www.rcn.org.uk/development/hca_toolkit/unit_one (last accessed April 2010)
Skills for Health. (2010). NVQs/SNVQs. Retrieved April 25, 2010 from
www.skillsforhealth.org.uk/page/awards-and-qualifications/s-nvqs
Spilsbury, K., & Meyer, J. (2004). Use, misuse and non-use of health care assistants:
understanding the work of health care assistants in a hospital setting. Journal of Nursing
Management 12. 411 – 418.
Swansburg, R.C., & Swansburg, R.J. (2002). Introduction to management and leadership for
nurse managers (3rd ed.). Sudbury, MA: Jones and Bartlett.
Thornley, C. (2007). Efficiency and equity considerations in the employment of health care
assistants and support workers. Social Policy and Society 7(2), 147 – 158.
Wakefield, A., Spilsbury, K., Atkin, K., McKenna, H., Borglin, G., & Stuttard, L. (2009).
Assistant or substitute: Exploring the fit between national policy vision and local practice
realities of assistant practitioner job descriptions. Health Policy 90. 286 – 295.
Working in Partnership Programme (WiPP). (2007). HCA toolkit. Retrieved April 25, 2010 from
www.rcn.org.uk/development/hca_toolkit
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/
OJIN/TableofContents/Vol152010/No2May2010/Delegation-in-the-UnitedKingdom.html

rt & Science of Delegation in Nursing

The workload of the team should be considered and not be
uneven.
By Scott J. Saccomano, PhD, GNP-BC, RN
Posted on: February 25, 2013
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An essential regulatory role for RNs in long-term care is the ability to delegate tasks to licensed
practical or vocational nurses, and certified nursing assistants.1 The Board of Nursing Examiners
rules and regulations §225.4(6) defines delegation as the act of authorizing unlicensed assistive
personnel (UAP) to provide nursing services while retaining accountability for how the
unlicensed person performs the task.2
Delegation is a complex skill requiring both academic and clinical instruction. The practice
remains an underdeveloped skill among some nurses.3
The Five Rights
The National Council of State Boards of Nursing (NCSBN) has identified "Five Rights of
Delegation."4 Briefly, these are:
1. Right Task: A task that is delegable for a specific patient.
2. Right Circumstances: Appropriate patient setting, available resources and other relevant
factors considered.
3. Right Person: The right person is delegating the right task to the right person to be performed
on the right person.
4. Right Direction/Communication: Clear, concise description of the task, including its
objective, limits and expectations provided.
5. Right Supervision: Appropriate monitoring, evaluation, intervention as needed, and
feedback.
Each of the Five Rights further identifies specific principles and responsibilities for the nursing
service administrator and the staff nurse in developing a program for implementation.

Although one component of delegation is the performance of tasks, effective delegation depends
on what is being delegated and the abilities of those who are responsible for delegation.
RNs are often uncertain about whom to delegate, what to delegate and under what circumstances
delegation should occur. Williams and Cooksey describe several steps in the process of effective
delegation, including:


assessment of patient needs and the UAP's knowledge and skill level;



identification of tasks that may be safely assigned;



prioritization of tasks and a timeframe for completion;



communication with the UAP with encouragement to ask any questions that
may arise;



evaluation to review progress toward goals with appropriate feedback; and



revision of the plan as patient needs change. 5

Delegation Decisions

The NCSBN identifies several steps nurses should take in making delegation decisions.
Step 1: Assess the situation. Identify the needs of the patient, consult the plan of care, consider
the circumstances and setting of care and assure
the availability of adequate resources.
Step 2: Plan for specific tasks to be delegated.
This includes specifying the nature of each task
and the knowledge and skills required to perform
it, requiring documentation or demonstration of
delegate competence of each task required and
determining possible implications for patients and
significant others.
Step 3: Assure appropriate accountability. As
the delegator, accept accountability for
performance of the task and verify that the CNA
accepts the delegation and accountability for
carrying out the task correctly.
Step 4: Supervise the task. Provide the CNA with clear expectations of how the task or tasks
are to be performed; monitor performance of the tasks ensuring compliance with current

standards of practice, policies and procedures of the institution; intervene if necessary and ensure
proper documentation of the task.
Step 5: Evaluation. During evaluation, the delegation process is re-examined, including patient
outcome, status, the staff performance and obtaining and providing feedback to the CNA.
Step 6: Reassessment. During reassessment outcomes are re-evaluated and the overall plan of
care may need to be readjusted based on findings.6
Although RNs are responsible for the planning, supervision and evaluation of the CNA's work,
some are not comfortable with this responsibility. RNs are often younger and less experienced in
a health care setting than the CNAs to whom they must delegate. Some nurses, embarrassed by
their discomfort and inability to act in the role of supervisor or manager, choose instead to do the
task themselves.7
RN duties that should not be delegated is anything involving ongoing or initial assessments.
These require nursing diagnoses, professional judgment and interventions that require the
application of professional skill and knowledge, e.g., the administration of medication, admission
assessments and the development of care plans.
The workload of the team should also be considered and not be uneven through delegation of
duties and tasks.
Growing Nursing Knowledge
The scope of nursing practice and nursing knowledge that has enriched the profession has led to
changes in nursing roles and nursing practice.
Nurses now function in a wide variety of roles, including leadership, which will continue to
proliferate in the next century.8 RNs need a range of skills to function effectively in today's
healthcare environment.
Nurses now must work in collaboration with many different levels of staff, residents and
families, physicians and third party stakeholders, and effectively integrate the needs of these
groups in their care plan.
Nurses must be able to make decisions in a rapidly changing health care environment and
understand the mission and future of the organization to motivate and empower others through a
system of shared leadership, which integrate into the day-to-day operations to contribute to team
objectives.9
Therefore, educational programs that build on basic RN professional education can help nurses

improve and integrate leadership knowledge and skill into their practice base so that they can
confidently delegate to CNAs in a safe manner.
Useful educational strategies can include patient case study simulations and role-playing to runthrough delegation skills in the classroom. Expert preceptors who are skilled in delegation can be
partnered with inexperienced staff to guide them in learning to delegate confidently and
supervise CNAs safely and effectively.10
It is imperative nursing home administrators and educators include appropriate content on
supervision and delegation in orientation programs, as these skills are requisite in nursing
practice settings, particularly in long-term care. It is equally imperative that nursing service
administrators provide nurses with the continuing education necessary to develop delegation and
supervision strategies if they have not had this content in their basic academic programs.11
https://nursing.advanceweb.com/Features/Articles/Art-Science-of-Delegation-inNursing.aspx

Nurse Delegation

By Regina G. Goldwire, MSN, RN
Last updated on: October 5, 2010 | Posted on: October 4, 2010
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For nurses to be successful they must be able to
address the many challenges they face every day,
both clinical and administrative.
An important aspect of nursing is delegation.
Delegating is a major element of directing the
everyday function of nursing workflow. It is a
competency by which RNs encourage and
motivate others to get the job done.
Effective delegates must be knowledgeable in the
leadership process. They should be a role model
to others - and an inspiration.

Personnel Journey
I began my career as a CNA. As a result, the issue of delegation was something I found great
difficulty in performing once I became an RN. I transitioned from being unlicensed personnel to
a professional, but not only failed to recognize my role as a delegator, I also had no experience in
delegation.
As a novice delegator, I was often unable to let go of a task. Therefore, I micromanaged,
duplicated duties and did not plan ahead. In this new leadership role I lacked the skills necessary
to effectively guide patient care, accomplish goals and lead staff.
One of my first struggles as a delegator was a terrible sense of guilt I felt when it came to
delegating to CNAs. I identified with the difficulty of their job, feared being disliked and was
very insecure. This caused me to take back delegated tasks and undermine my own leadership
capabilities.
As a new charge nurse, I found myself feeling overwhelmed, alone and guilty. I was unable to
coordinate tasks, identify goals, encourage staff, problem solve, implement plans, use staff
appropriately or simply run the unit. My attempts to relate to unlicensed staff caused me to
misuse clinical staff, alienate nurses and overwork myself. Because of this, employees assumed I
was incompetent and unable to handle the duties of a charge nurse.
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Eventually, it became evident to me that I was not an island and that I should implement the
delegation process.
I recognized delegation is the act of empowering others and ensuring safe and efficient care is
delivered to patients; not the negative act I thought it was. I realized that as a delegator, leader
and charge nurse, I needed to earn the respect of my coworkers to be successful. I understood, as

with any skill, delegation would take practice.
Today I don't have the issues with delegation I had as a new RN, but my experience is not unique
and helps me to recognize delegation as an important issue.
Significance of Delegating
The significance of delegation in the nursing profession should not be taken lightly.
The legal and ethical implications that go along with delegation are immense. When delegation
occurs, responsibility for the care is transferred to the delegate but accountability for the care
remains with the delegator. This is an important point because the individual delegating an
assignment must be sure they are delegating to people who are competent in the skills needed to
complete the assignment.
Delegation can be seen as a teaching method for experienced to novice nurses. The skilled nurse
usually delegates to the novice nurse, and recognizes the novice as one who may process
information using not fully developed critical thinking skills, knowledge or planning.
In a situation where one delegates to experienced nurses, their skills and abilities must be
respected and assessed. Delegation here increases their job satisfaction and develops a sense of
responsibility, thereby promoting a work environment that bolsters cohesiveness and trust.
Reasons for Delegating
Delegation may take place when the manager does not have time to handle a certain task or when
passing on the task solves a problem, enhances efficiency or is better use of skills. Delegation
can also enhance nurses' self-esteem by allowing them to participate in decision making and
taking personal responsibility. Within the delegates' role, one must decide when delegation would
benefit the situation and the patient.
In the end, the delegator must make sure several important questions are addressed, to include:


Does the state practice acts allow for this type of delegation?



Would delegation benefit the patient?



Does the delegate have the knowledge and skills to perform the delegated
task?

Techniques & Barriers
The delegator must know the ability of the person to whom a task is being delegated. Jobs that
are too technical or out of staffs' scope of practice or skill range should not be delegated.
For example, if delegating to an RN, be sure it's not a task that should or could be done by
unlicensed personnel if they are available. As well, just because one holds the designation of RN
does not mean they have the skills to complete the task.
When delegating, specify goals and objectives, and give staff reasons for the duty being
delegated. Follow up to ensure duties are being done and that the delegate is able to complete the
task and encourage staff to solve their own problems.
Barriers to delegating can present per the delegator, delegate or circumstances. For instance,
barriers to the delegator may include uncertainty, fear of being disliked and lack of confidence in
staff. From the delegate's point of view, the barrier could include lack of experience, knowledge,
ability and organization.
Nursing Implications
Delegation of nursing care is a crucial skill in delivering quality patient care.
It is recognized that RNs are responsible for the supervision of others to whom they have
delegated tasks. The Five Rights of Delegation provide an additional resource to facilitate
decisions about delegation: "right circumstances, right person, right direction/communication,
and right supervision."1
Knowledge is key for an RN trying to achieve proper delegation is knowledge. The foundation of
nursing is not simply what one does with her hands; but also it is what one does with her head.
Delegation is best learned through actual work with colleagues; "effective delegation requires
experience as a practicing nurse."2
RNs are experts in many areas based on their clinical practice and education, which prepares
them for the complexities of delegation and healthcare delivery. They have diverse educational
backgrounds which ensure them the ability to assign care in a variety of settings. They streamline
patient care processes by providing holistic assessment and management of the patient's health in
partnership with a multidisciplinary team.
What's more, delegation plays a major role in controlling healthcare costs through optimizing
patient health and safety, coordination of care to reduce duplication, use of expedient processes

of care, along with appropriate facilitation and efficient use of resources in alternate levels of
care.
Delegation is a leadership tool needed for professional nurses to survive in their career. It enables
RNs to attend to more complex patient care needs, develop the skills of others, and promote cost
containment for an organization.
http://nursing.advanceweb.com/features/articles/nurse-delegation.aspx?CP=2

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