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Fundamentals of Nursing

15.4 Nursing Standards of Delegation

Fundamentals of Nursing15.4 Nursing Standards of Delegation

Learning Objectives

By the end of this section, you will be able to:

  • Identify nursing standards for delegation
  • Recognize nursing principles for delegation

The act of requesting staff members to perform tasks or procedures that are outside of their normal job but within the limits of their job description is called delegation. Nurses delegate tasks and procedures to other staff members daily to cope with the constantly changing needs of patients in an active healthcare setting. Per the National Guidelines for Nursing Delegation, delegation happens when a registered nurse (RN) asks either a licensed practical nurse (LPN)/licensed vocational nurse (LVN) or assistive personnel (AP)—such as nursing assistants, certified nursing assistants, patient care technicians, or surgical technicians—to perform a task on the nurse’s behalf. RNs do not delegate to other RNs. If an RN asks another RN to perform tasks for them, it is considered a transfer of care, and the new RN becomes responsible for the patient (American Nurses Association [ANA]-National Council of State Boards of Nursing [NCSBN], 2019). While charge nurses, managers, and supervisors give assignments to other RNs, this is not considered delegating but rather assigning job tasks.

Delegation is a critical nursing skill that reflects directly on the nurse doing the delegating (NCSBN, 2016). Inappropriate delegation can cause harm to a patient and result in disciplinary action for the nurse who sets it up. Delegation is governed by nursing practice standards from the ANA, nursing practice guidelines from the ANA and the NCSBN, local and state laws regarding delegation, and individual agencies or facilities (NCSBN, 2016). All nurses must understand what they can and cannot do per the relevant guidelines and laws.

Nursing Standards for Delegation

The ANA offers basic delegation competencies in two nursing standards:

Standard 5: Implementation

  • RNs can delegate based on the needs of the healthcare consumer.
  • RNs can delegate “after 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 the care” (ANA, 2021, p. 82).

Standard 12: Leadership

  • RNs demonstrate “authority, ownership, accountability, and responsibility for appropriate delegation of nursing care” (ANA, 2021, p. 97).

Consider those statements for a moment. They emphasize the idea of accountability: an RN who delegates a task to another staff member is responsible for that choice and answerable for its consequences.

Five Rights of Nursing Delegation

When an RN designates a job to another staff member (the delegatee), that RN is still responsible for ensuring the job is performed appropriately (ANA-NCSBN, 2019). The five “rights” of nursing delegation specify when and how to delegate nursing duties (ANA-NCSBN, 2019): right task, right circumstance, right person, right communication, and right supervision. Each of these rights should be considered when delegating a task to another staff member.

Right Task

Any activity delegated to a delegatee must be included in their job description or established through the written policies and procedures of the given setting (ANA-NCSBN, 2019). However, delegated tasks can fall outside of the delegatee’s normal duties. Agencies must ensure that written policies or procedures describe the abilities and limitations of different AP (NCSBN, 2016). Facilities must provide training for any skilled competencies (such as drawing blood or using equipment) that AP may be required to perform.

Right Circumstance

Patients must be in stable condition with expected outcomes before a nurse can delegate care responsibilities (ANA-NCSBN, 2019). If the patient’s condition changes, the RN must reassess the patient to determine whether the delegation is still appropriate. For example, it is very unusual for critical-care areas to staff large numbers of AP and LPNs/LVNs because they are limited in how much assistance they can provide to unstable patients without direct, constant supervision.

Right Person

The RN is responsible for ensuring the delegatee has completed any required education and has the necessary competencies to perform the care (ANA-NCSBN, 2019). For example, a staff member must be educated in how to use patient transfer equipment, such as ceiling lifts for moving patients between surfaces, before they can be delegated tasks involving that equipment. An RN asking an AP to transfer a patient to a stretcher would have to be sure the AP had received the necessary education and was competent to perform the transfer when making the request.

Real RN Stories

Delegating Care

Nurse: Mai C., RN
Clinical setting: Inpatient psychiatric unit
Years in practice: 30
Facility location: Urban psychiatric facility in Tennessee

I remember one time when I was working the night shift. We did not often have blood draws ordered on the night shift, but that night, two of them had to be completed in the early morning. I was the charge nurse and was making patient care assignments for the unit. I delegated the blood draws to one of our AP. The AP was fairly new but had been with us long enough that I thought he had completed all his competencies.

At about 2 a.m., he came to me to tell me that he could not do the blood draws because he had not been checked off on them by our lab. All staff members had to receive education and perform three successful lab draws in our outpatient lab before they could draw blood on the unit. Since he had started on night shift and never worked on days, he had not done his blood draws for check-offs.

I found another AP who could do the blood draws that night. Then I spoke with our nurse manager to be sure that the AP had the opportunity to do his check-offs in the outpatient lab one morning before he left work. The next time I asked him to draw blood labs, he could without difficulty.

Right Communication

When RNs delegate to other employees, they must provide appropriate instructions, and the delegatee must have the opportunity to ask questions (ANA-NCSBN, 2019). Clear communication must be provided to ensure the delegatee understands the specifics of the assignment. The delegatee must also agree to perform the assignment. The delegatee cannot make any decisions regarding care changes without consulting the delegating RN (NCSBN, 2016).

Right Supervision

The RN must provide supervision to ensure the activity is performed correctly and evaluate patient outcomes. The delegatee must communicate patient information accurately to the RN. If the performance of the task is inadequate, the RN must intervene as necessary. Consider this example. An RN has asked an AP to take a patient’s vital signs. When the AP gives the information to the RN, the patient’s blood pressure is substantially higher than expected, representing a considerable alteration over previous readings. The RN then returns to the patient’s room to verify the elevated blood pressure by taking it themself.

Delegation versus Assignment

There is a difference between being delegated a task and being given a patient assignment. An assignment consists of the routine activities and procedures that are part of a staff member’s normal job and taught in either a degree or certificate program or as part of on-the-job training (ANA-NCSBN, 2019). RNs may still be responsible for supervising other staff as they complete their assignments, but not to the same degree as with delegation. For example, an LPN/LVN with a patient assignment who gives their patients medication, takes their vitals, draws their labs, and documents their responses to care is functioning within the capacity of their degree and scope of practice; they should be able to complete these tasks with limited to no supervision. In contrast, an LPN/LVN whose patient goes into respiratory arrest would reasonably expect a code team to manage the patient’s care when they arrive. With the proper supervision, however, the code team could delegate a task to the LPN/LVN, such as providing bag-mouth ventilation—that is, helping the patient breathe by squeezing a bag connected to an oxygen supply and the patient.

Principles for Delegation

The ANA and NCSBN have developed principles for delegation. These fundamental principles are strategies to protect the patient’s well-being, health, and safety, and they must be considered along with the five rights of delegation discussed previously (ANA, 2013). They include the following:

  • While elements of nursing care may be delegated, the nursing process cannot.
  • Decisions to delegate must be based on the nurse’s judgment and consideration of the patient’s complexity and care needs and the ability of the RN to provide appropriate supervision to the AP.
  • Delegation should always be respectful of both the delegate and patient.

Authority

Facilities use the nursing scope and standards of the ANA and the state’s nurse practice acts to determine the authority and practice capacity of RNs within their agencies (ANA-NCSBN, 2019; Barrow & Sharma, 2022). Under this authority, nurses are expected to complete their job duties. These duties include delegating tasks to AP and LPN/LVNs based on the needs of the patient population, the stability of training, the training of delegatees, and the nurse’s ability to provide appropriate supervision.

Accountability

Nurses are legally and ethically liable for their patient care actions, known as accountability, including decisions to delegate activities to APs and LPN/LVNs. Even when care is delegated to other personnel, the RN remains accountable for the care provided. If nurses are concerned about delegating a task, they should perform it themselves (ANA-NCSBN, 2019). Once a delegate has accepted the responsibility of a delegation, they are accountable for completing that activity correctly, timely, and per facility protocol (ANA-NCSBN, 2019).

Responsibility

All RNs are responsible for acting within their states’ nursing practice acts and performing reliable and dependable patient care tasks (Barrow & Sharma, 2022). When delegating tasks, RNs are responsible for providing high-quality communication and clearly explaining the delegated responsibility. Further, they are responsible for ensuring that delegated tasks are completed appropriately (ANA-NSCBN, 2019).

Delegatees are responsible for delegated activities they accept and should only accept activities for which they have been appropriately trained (ANA-NSCBN, 2019). They are also responsible for maintaining their competencies—reviewing and renewing educational modules or skill check-offs on an ongoing basis—for activities they may be required to perform if delegated. Figure 15.12 outlines the responsibilities of all parties involved in the delegation of nursing tasks.

Venn diagram showing how responsibilities of employer/nurse manager, registered nurse (RN), and delagatee overlap in safeguarding patients.
Figure 15.12 This Venn diagram shows how the responsibilities of the employer, nurse, and delegatee are different and where they overlap (ANA-NCSBN, 2019). (credit: attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
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