What 2 tasks Cannot be delegated by the RN?

Snapshot: This article reviews the scope of practice for different types of nurses and nursing assistants, and tasks that may and may not be delegated to different types of personnel. Delegation is a central feature of contemporary nursing practice, and a key component of professional academic nursing knowledge.

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Delegation Overview RN’s (Registered Nurses) LPN’s (Licensed Practical Nurses) UAP’s (Unlicensed Assistive Personnel)  

Delegation Overview

• Delegation is the act of transferring responsibility and accountability to another person to carry out a task while maintaining accountability for the action and the outcome.
• RN’s must delegate numerous tasks, and delegation is a core nursing responsibility. Nurses most frequently delegate tasks to LPN’s (Licensed Practical Nurses) and to unlicensed assistive personnel (UAP).
• In deciding when and what to delegate, RN’s must take a number of factors into account, including the scope of practice required for the task, the complexity and predictability of the task, the potential for harm, and level of critical thinking required to perform the task.
• Delegation is important for both practical and academic reasons. It is a core “real world” nursing skill, and it is also a major focus of the NCLEX-RN exam.

RN’s (Registered Nurses)

It is within an RN’s scope of practice to:

• Independently assess, monitor and revise the nursing plan of care for patients of any kind
• Initiate, administer, and titrate both routine and complex medications
• Perform education with patients about the plan of care
• Admit, discharge and refer patients to other providers
• Delegate appropriate tasks to both LVN’s and UAP’s

Tasks that an RN may, therefore, perform include the ability to:

• Initiate and administer blood to a patient
• Administer high risk medications, including heparin and chemotherapeutic agents
• Give IV medications and medications administered via IV push
• Independently monitor and titrate medications
• Perform any tasks that may be performed by LVN’s or UAP’s

LPN’s (Licensed Practical Nurses)

It is within an LPN’s scope of practice to:

• Assist the RN by performing routine tasks with predictable outcomes
• Assist the RN with collecting data and monitoring client findings
• Reinforce an RN’s patient teaching, but not perform independent patient education or assessments
• Perform any of the tasks that UAP’s (Unlicensed Assistive Personnel) are permitted to perform (see below)
• Delegate tasks to UAP’s (Unlicensed Assistive Personnel)

Tasks that an LPN may, therefore, perform include the ability to:

• Administer medications that are not high-risk
  • For example, LPN’s may administer standard oral medications, but not medications such as heparin or chemotherapeutic agents
  • Note: some states do not permit LVN’s to administer intravenous medications of any kind
• Administer a nasogastric (NG) tube feeding
• Perform wound dressing changes
• Monitor blood products
  • LPN’s may not, however, initiate the infusion of blood products; only an RN may initiate the infusion
• Do tracheostomy care
• Perform suctioning
• Check nasogastric tube patency
• Administer enteral feedings
• Insert a urinary catheter

With further education and certification only, LPN’s may administer:

• Maintenance IV fluids
• IV medications via piggy-back
• Monitor infusions of IV fluids

It is not within an LPN’s scope of practice to: 

• Administer high risk medications of any kind (such as Heparin and chemotherapeutic medications)
• Administer IV push medications of any kind
• Titrate medications of any kind
• Independently provide patient education (about medications, disease processes, etc.)
• Perform or chart admissions of patients, or to discharge patients

UAP’s (Unlicensed Assistive Personnel)

It is within a UAP’s scope of practice to:

• Assist patients with activities of daily living (ADL’s), including:
  • Eating
  • Bathing
  • Toileting
  • Ambulating
• Perform routine procedures that do not require clinical assessment or critical thinking, such as:
  • Phlebotomy (except for arterial punctures)
  • Take vital signs
  • Monitor intake and output (of food and drink, urine, etc.)

It is not within a UAP’s scope of practice to:

• Perform assessments
• Delegate tasks
• Perform patient education
• Perform tasks that require clinical expertise, including ‘routine’ tasks such as:
  • Administering medications
  • Administering tube feedings
  • Performing wound care or dressing changes

Many definitions for delegation exist in professional literature. One of the most commonly cited definitions of the word was jointly established by the American Nurses Association and the National Council of State Boards of Nursing. These groups describe delegation as the process for a nurse to direct another person to perform nursing tasks and activities. Delegation involves at least two individuals: the delegator, and the delegatee. The delegator is a registered nurse who distributes a portion of patient care to the delegatee.

Essential Components of Delegation

Responsibility

Based on individual states’ nurse practice acts, registered nurses have a professional duty to perform patient care tasks dependably and reliably.

Authority

Authority refers to an individual’s ability to complete duties within a specific role. This authority derives from nurse practice acts and organizational policies and job descriptions.

Accountability

Accountability within the nursing context refers to nursing professionals’ legal liability for their actions related to patient care. During delegation, delegators transfer responsibility and authority for completing a task to the delegatee; however, the delegator always maintains accountability for the task's completion. The registered nurse is always accountable for the overall outcome of delegated tasks based on each state's nurse practice act provisions.

Possible legal and ethical constraints arise regarding delegation in nursing. Therefore, the American Nurses Association developed the five rights of delegation to assist nurses in making safe decisions.

Five Rights of Delegation

• Right task

• Right circumstance

• Right person

• Right supervision

• Right direction and communication[1]

Five Rights of Delegation Case Study Approach

Mark is a new graduate registered nurse who has recently completed nursing orientation. He is now on his second week of non-precepted practice on a busy medical-surgical unit. During the middle of his busy night shift, Mark has several tasks that need to be completed quickly. These tasks include a linen change for a patient who just vomited, an assessment of a possibly infiltrated intravenous line, and the administration of intravenous pain medication for a patient who rates her pain 10 out of 10. Mark also needs to make hourly rounds within the next few minutes, and he is very behind on his charting. He knows he must delegate some of the tasks to his coworkers. However, Mark is unsure what he can delegate and to whom. He decides to use the five rights of delegation to help with his delegation decisions.

Right tasks

First, Mark needs to determine which tasks are right to delegate. Some questions he may ask at this time would include (1) which tasks are legally appropriate to delegate and (2) can I delegate these tasks based on this organization’s policies and procedures? Correctly answering these questions will require familiarity with institutional and nurse practice act guidance. Generally, registered nurses are responsible for assessment, planning, and evaluation within the nursing process. These actions should not be delegated to someone who is not a registered nurse.[2]

Right circumstances

After determining the right tasks for delegation, Mark considers the right circumstances of delegation. In so doing, Mark may ask the following questions: (1) are appropriate equipment and resources available to perform the task, (2) does the delegatee have the right supervision to accomplish the task, and (3) is the environment favorable for delegation in this situation? To appropriately answer these questions, it is imperative that Mark completes an assessment on each client. Patients who are or may become unstable and cases with unpredictable outcomes are not good candidates for delegation. For example, it may be appropriate for unlicensed assistive personnel to feed patients requiring assistance with the activities of daily living. However, if a patient has a high risk for aspiration and a complicated specialty diet, delegation of feeding to unlicensed assistive personnel may not be safe.

Right person

If a task and circumstance are right for delegation, the next “right” of delegation is the right person. Mark needs to consider if the potential delegatees have the requisite knowledge and experience to complete delegated tasks safely, especially concerning the assessed patient acuity. Before delegating a task, the registered nurse must know the delegatee’s job description and previous training. Mark may be unsure about his potential delegatee’s qualifications. Therefore, he might ask the following questions before delegating a task: (1) have you received training to perform this task, (2) have you ever performed this task with a patient, (3) have you ever completed this task without supervision, and (4) what problems have you encountered in performing this task in the past?

Right supervision              

The right supervision must be available in all delegation situations. Nurse practice acts require the registered nurse to provide appropriate supervision for all delegated tasks. In the case study, Mark must be sure that the delegatee will provide feedback after the task is complete. Following task completion, Mark is responsible for evaluating the outcome of the task with the patient. Registered nurses are accountable for evaluation and the overall patient outcomes.

Right direction and communication                

Finally, the delegator must give the right direction and communication to the delegatee. All delegators must communicate performance expectations precisely and directly.[3] Mark should not assume that his delegatee knows what to do and how to do it, even for routine tasks. Mark must consider whether the delegatee understood the assigned task, directions, patient limitations, and expected outcomes before the delegatee assumes responsibility for it. The delegatee also must comprehend what, how, and when to report back after the delegated task is complete. Delegatees also need a deadline for task completion for time-sensitive tasks.[4]

Using the five rights of delegation, Mark appropriately took care of his patients’ needs. Mark delegated the linen change to trained unlicensed assistive personnel, and he entrusted his hourly rounds to his shift charge nurse. Mark opted to assess the patient with a possibly infiltrated intravenous site first. Upon finding the site infiltrated, he assessed his patient, removed the intravenous line, and placed a warm compress on the patient’s elevated extremity. He then administered another patient’s requested pain medications after delegating new intravenous catheter placement to an intravenous-certified coworker for the patient with the infiltration. Mark was able to complete all his documentation requirements by the end of his shift.

Reasons Delegation is Necessary for the Modern Health Care Environment

If delegation decisions are so challenging and legally charged, why should nurses delegate? Fiscal constraints, nursing shortages, and increases in patient care complexity have cultivated an environment in which delegation is necessary. If appropriately used, delegation can significantly improve patient care outcomes.

Improper Delegation

Improper delegation can negatively impact patient care while also potentially exposing the delegator to legal action.[5] All members of the health care team have valuable contributions to make toward safe, effective patient care.

Essentials of Communication

While employing the five rights of delegation in nursing practice, it is important to remember that the way the delegator asks the delegatee to perform a task can make a big difference. The delegator must use direct, honest, open, closed-loop communication to encourage teamwork and safe task performance.[6] Of the five rights of delegation, the right communication and direction are arguably the most important in ensuring good quality and safety outcomes.[7] Common delegation deficiencies for registered nurses occur when delegating tasks to unlicensed assistive personnel. These include unclear delegation directions from the registered nurse, a lack of retained accountability and follow-through, and the failure of the registered nurse to obtain the agreement of the unlicensed assistive personnel.[8]

Review Questions

1.

Neumann TA. Delegation-better safe than sorry. AAOHN J. 2010 Aug;58(8):321-2. [PubMed: 20704120]

McMullen TL, Resnick B, Chin-Hansen J, Geiger-Brown JM, Miller N, Rubenstein R. Certified Nurse Aide scope of practice: state-by-state differences in allowable delegated activities. J Am Med Dir Assoc. 2015 Jan;16(1):20-4. [PubMed: 25239017]

Siegel EO, Young HM. Communication between nurses and unlicensed assistive personnel in nursing homes: explicit expectations. J Gerontol Nurs. 2010 Dec;36(12):32-7. [PubMed: 20669856]

Bittner NP, Gravlin G. Critical thinking, delegation, and missed care in nursing practice. J Nurs Adm. 2009 Mar;39(3):142-6. [PubMed: 19590471]

Gravlin G, Phoenix Bittner N. Nurses' and nursing assistants' reports of missed care and delegation. J Nurs Adm. 2010 Jul-Aug;40(7-8):329-35. [PubMed: 20661063]

Weydt AP. Defining, analyzing, and quantifying work complexity. Creat Nurs. 2009;15(1):7-13. [PubMed: 19343844]

Hopkins U, Itty AS, Nazario H, Pinon M, Slyer J, Singleton J. The effectiveness of delegation interventions by the registered nurse to the unlicensed assistive personnel and their impact on quality of care, patient satisfaction, and RN staff satisfaction: a systematic review. JBI Libr Syst Rev. 2012;10(15):895-934. [PubMed: 27820462]

Kalisch BJ. The impact of RN-UAP relationships on quality and safety. Nurs Manage. 2011 Sep;42(9):16-22. [PubMed: 21873843]