The skill and art of delegation for effective use of nursing assistive personnel (NAP)/unlicensed assistive personnel (UAP) is a critical nursing competency for the profession in the 21st century, the American Nurses Association
(ANA) and National Council of State Boards of Nursing
(NCSBN) have concluded.1
Encompassing more than 50 job titles, UAP are healthcare workers who assist in patient care activities under the delegation and supervision of a licensed practical nurse (LPN), licensed vocational nurse (LVN) or registered nurse (RN). Although professional organizations endorse this role,1-6
no universal hiring, training or job descriptions exist. Nursing policies and guidelines determine what can be safely delegated, and The Joint Commission requires all staff be properly trained and supervised for activities they are required to perform.7
State nurse practice acts define which level of licensed nurse is authorized to delegate to NAP and UAP.8
After reviewing the nurse practice act in the state in which the nurse is practicing, strategies can help discern how to safely and effectively delegate to UAP.
The use of UAP evolved in the late 1980s in response to emerging nursing shortages, as well as to rising healthcare costs.7 Therefore, many nurses practicing today entered nursing with little or no experience with the art of delegation. Additionally, the average age of nurses is increasing while the work remains physically demanding.9 These factors together help explain why many organizations now use less-expensive, less-skilled workers who still must be supervised by professional nurses, although the effectiveness of these workers has yet to be fully demonstrated.7
Supervision and delegation are interlocking concepts essential to the appropriate use of the UAP. The NCSBN and ANA have issued a joint position paper
on delegation and supervision, providing operational definitions for the two terms that provide a baseline standard for legal language. Supervision is defined as the provision of guidance and oversight of the delegated nursing task by assistive personnel. It is further described as the active process of directing, guiding and influencing the outcomes of an individual’s performance of a task. A nurse who makes patient care rounds to oversee the care delivered by staff members is performing an act of supervision. The ANA and NCSBN’s joint statement on delegation notes that individuals engaging in the supervision of patient care should not be construed to be managerial supervisors on behalf of the employer under federal labor law.1
The NCSBN and the ANA define delegation as the process for a nurse to direct another person to perform nursing tasks and activities. The decision to delegate is of utmost importance in terms of nursing accountability. Assignment shifts an activity from one person to another, including the responsibility and the accountability. Activities can be assigned only to someone who has the requisite skill, knowledge and judgment as well as legal authority for that scope of practice. A charge nurse who designates total responsibility for a group of patients to another RN is an example of assignment. The charge nurse is accountable for the assignment decision, whereupon the caregiver assumes responsibility and accountability for actual care of the patient. In this sense, nurses can never assign patient care activities to UAP; they can only delegate activities or tasks. The nursing process itself cannot be delegated. The nursing duties of assessment, planning and evaluation, as well as the use of nursing judgment, remain solely within the scope of practice of the professional registered nurse.1
Quality and Safety Education for Nurses: Teamwork and Collaboration
One of the primary goals of quality and safety education for nurses, or QSEN, is to prepare future nurses with the knowledge, skills and attitudes, or KSA, required to continuously improve the quality and safety of healthcare systems where nurses and other health caregivers are employed. In the prelicensure KSAs, one of the six competencies is teamwork and collaboration.
According to the Quality and Safety Education for Nurses website, QSEN.org, the definition of teamwork and collaboration is “Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.” Under this competency a nurse must be able to identify and manage team member roles and accountabilities, to describe the impact of the team functions on patient safety and quality of care, and to clarify how authority gradients impact teamwork and patient safety.
A nurse should function under his or her own scope of practice and be prepared to accept the role of team leader as well as team member. Other skills noted are to clarify and integrate other team members’ roles and to respect the distinctive characteristics that all members bring to a team, including variations in professional scope and accountabilities. These statements all directly relate to the role that thoughtful, appropriate delegation plays in the definition of a high-functioning team.10
Responsibility and Risk
Only RNs have the formal authority to practice nursing and to delegate nursing acts. The legal definition of nursing practice is ultimately determined by each state’s nurse practice act. These practice acts are state laws that protect the health and safety of the public by regulating practice and establishing the educational preparation and legal qualifications for who can practice nursing. These acts define expectations for which nurses are accountable (liable). Although organizational policies and job descriptions require UAP to perform certain tasks, they cannot contradict the mandates of practice acts. However, state variations, which sometimes interchange the terms “delegation” and “assignment,” can confuse the issue, and some states are now adding language that ensures that nurses have control over UAP delegation.
Delegation has traditionally been thought of as a management function for RNs, who retain ultimate responsibility, accountability and legal liability for delegation. However, many practice acts now acknowledge LPNs’/LVNs’ participation in the delegation/assignment of functions to other caregivers in a variety of healthcare settings.11
Although UAP may be responsible for performing specific duties just as any other employee does, nurses who make inappropriate work assignments and provide inadequate supervision can be found negligent. In the effort of cost containment, nurses may elect to delegate more tasks to the UAP, but this may be considered negligent according to the policies of the facility or the board of nursing in that state.12 Nurses who inappropriately delegate can also be disciplined by the state board of nursing. Additionally, nurses can be held accountable by their organizations if they do not delegate according to their policies, job descriptions and standards of care. In turn, a hospital may be liable for the nurses’ actions under “respondent superior” — let the employer respond — a principle that does not diminish the responsibility of the nurse for his or her delegation.13