Registered nurses (RNs) often delegate to other RNs, licensed practical nurses/vocational nurses (LPN/LVNs), and assistive personnel (AP). (In some states or jurisdictions, LPN/LVNs may be allowed to delegate, so “licensed nurses” will be used in this article.) Delegating appropriately protects patients and reduces the risk of legal liability, yet the parameters of delegation often are not fully understood.
One common area of misunderstanding is delegation vs. assignment. Knowing the differences between the two is essential to ensure you delegate appropriately. The primary difference relates to scope of practice and where the clinician learned the activities to be carried out.
Assignment
According to national guidelines for nursing delegation from the National Council of State Boards of Nursing (NCSBN) and American Nurses Association (ANA), an assignment refers to the “routine care, activities, and procedures that are within the authorized scope of practice of the RN or LPN/VN or part of the routine functions of the AP.” This definition covers fundamental skills that the assignee would have learned in a basic education program. A licensed nurse is still responsible for ensuring the assignment is carried out correctly.
Delegation
According to the NCSBN/ANA guideline, delegation applies when the delegatee is performing a “specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and not routinely performed.” As opposed to work that is part of an assignment, the work associated with delegation was not learned in a basic education program. Therefore, the delegatee must have obtained additional education and have verified competence in the delegated area for which they will be responsible. The licensed nurse maintains overall accountability for the patient, but the delegatee is responsible for the delegated activity, skill, or procedure.
Licensed nurses can’t delegate activities that involve clinical reasoning, nursing judgment, or critical decision making, and the delegated responsibility has to be within the delegator’s scope of practice under the state’s or jurisdiction’s nurse practice act (NPA).
Responsibilities
Organizational administrators, the delegator, and the delegatee each have responsibilities when an activity, skill, or procedure is delegated.
Professionals who work at the administrative or managerial level of the organization set the cultural tone for the nursing work environment and are responsible for managing the delegation processes. Those at the administrative level within an organization define what nursing responsibilities may be delegated, to whom, and under what set(s) of circumstances. They are also responsible for developing and maintaining policies and procedures associated with delegation, periodically evaluating the efficacy and safety of delegation processes, and training and educating staff.
The delegator is responsible for determining the needs of the patient, when delegation is appropriate, and if the delegatee is competent to complete the delegated task. Delegators must follow delegation guidelines in the NPA and relevant organizational policies and procedures. Clear communication is key, and the delegator must be available as a resource to the delegatee. Delegators also need to evaluate outcomes as they maintain overall accountability for the patient. Delegators must be prepared to step in at any point if it appears the delegatee is not handling the assignment appropriately. Any problems should be reported to nursing leadership.
The delegatee is responsible for only accepting activities that fall within their competence and that they feel comfortable completing safely. Delegatees must communicate with the delegator, particularly if the patient’s condition changes, and complete the activity correctly, including fulfilling any documentation requirements. Delegatees maintain accountability for the delegated activity and need to notify the delegator immediately if they have difficulty completing the task.
One special case
NCSBN notes that in some cases, APs are taught how to perform skills that were previously thought to be exclusively RN and LPN/LVN responsibilities, such as certified medical assistants administering injections. In these cases, it’s best to consider such tasks as being delegated and, therefore, validate competency.
Keeping patients safe
Knowing the differences between assigning and delegating helps protect patients and avoid legal action should an error occur. Assignments involve routine tasks learned in basic education and that fall under designated scope of practice, while delegation involves tasks that were learned through additional education and for which competency has been determined.
Good communication and an understanding of the responsibilities of delegators and delegatees is essential to avoid misunderstanding. Remember, the licensed nurse remains accountable for the patient, but the delegatee is responsible for the delegated task.
Five rights of delegation
The NCSBN outlines five rights of delegation. In the case of a lawsuit, a key component would be whether you adhered to these rights:
- Right task. The task needs to fall within the delegatee’s job description or is part of organizational policies and procedures.
- Right circumstance. The patient must be stable.
- Right person. The delegatee must have the appropriate skills and knowledge to perform the task.
- Right directions and communication. Clear directions need to be given, with the delegator verifying understanding by the delegatee. Communication must be two-way, with the delegatee asking questions as needed.
- Right supervision and evaluation. The delegator needs to monitor the delegated activity, including evaluating patient outcomes.
Article by: Cynthia Saver, MS, RN, President of CLS Development, Inc., in Columbia, Md and Georgia Reiner, MS, CPHRM, Risk Analyst, NSO
References
National Council of State Boards of Nursing. National guidelines for nursing delegation. J Nurs Reg. 2016;7(1):5-12.
NCSBN, ANA. National guidelines for nursing delegation. 2019.