NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022.
• Identify typical scope of practice of the RN, LPN/VN, and assistive personnel roles
• Identify tasks that can and cannot be delegated to members of the nursing team
• Describe the five rights of effective delegation
• Explain the responsibilities of the RN when delegating and supervising tasks
• Explain the responsibilities of the delegatee when performing delegated tasks
• Outline the responsibilities of the employer and nurse leader regarding delegation
• Describe supervision of delegated acts
As health care technology continues to advance, clients require increasingly complex nursing care, and as staffing becomes more challenging, health care agencies respond with an evolving variety of nursing and assistive personnel roles and responsibilities to meet these demands. As an RN, you are on the frontlines caring for ill or injured clients and their families, advocating for clients’ rights, creating nursing care plans, educating clients on how to self-manage their health, and providing leadership throughout the complex health care system. Delivering safe, effective, quality client care requires the RN to coordinate care by the nursing team as tasks are assigned, delegated, and supervised. Nursing team members include advanced practice registered nurses (APRN), registered nurses (RN), licensed practical/vocational nurses (LPN/VN), and assistive personnel (AP).[1] Assistive personnel (AP) (formerly referred to as ‘‘unlicensed” assistive personnel [UAP]) are any assistive personnel trained to function in a supportive role, regardless of title, to whom a nursing responsibility may be delegated. This includes, but is not limited to, certified nursing assistants or aides (CNAs), patient-care technicians (PCTs), certified medical assistants (CMAs), certified medication aides, and home health aides.[2] Making assignments, delegating tasks, and supervising delegatees are essential components of the RN role and can also provide the RN more time to focus on the complex needs of clients. For example, an RN may delegate to AP the attainment of vital signs for clients who are stable, thus providing the nurse more time to closely monitor the effectiveness of interventions in maintaining complex clients’ hemodynamics, thermoregulation, and oxygenation. Collaboration among the nursing care team members allows for the delivery of optimal care as various skill sets are implemented to care for the patient.
Properly assigning and delegating tasks to nursing team members can promote efficient client care. However, inappropriate assignments or delegation can compromise client safety and produce unsatisfactory client outcomes that may result in legal issues. How does the RN know what tasks can be assigned or delegated to nursing team members and assistive personnel? What steps should the RN follow when determining if care can be delegated? After assignments and delegations are established, what is the role and responsibility of the RN in supervising client care? This chapter will explore and define the fundamental concepts involved in assigning, delegating, and supervising client care according to the most recent joint national delegation guidelines published by the National Council of State Boards of Nursing (NCSBN) and the American Nurses Association (ANA).[3]
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
• Identify typical scope of practice of the RN, LPN/VN, and assistive personnel roles
• Identify tasks that can and cannot be delegated to members of the nursing team
• Describe the five rights of effective delegation
• Explain the responsibilities of the RN when delegating and supervising tasks
• Explain the responsibilities of the delegatee when performing delegated tasks
• Outline the responsibilities of the employer and nurse leader regarding delegation
• Describe supervision of delegated acts
As health care technology continues to advance, clients require increasingly complex nursing care, and as staffing becomes more challenging, health care agencies respond with an evolving variety of nursing and assistive personnel roles and responsibilities to meet these demands. As an RN, you are on the frontlines caring for ill or injured clients and their families, advocating for clients’ rights, creating nursing care plans, educating clients on how to self-manage their health, and providing leadership throughout the complex health care system. Delivering safe, effective, quality client care requires the RN to coordinate care by the nursing team as tasks are assigned, delegated, and supervised. Nursing team members include advanced practice registered nurses (APRN), registered nurses (RN), licensed practical/vocational nurses (LPN/VN), and assistive personnel (AP).[1] Assistive personnel (AP) (formerly referred to as ‘‘unlicensed” assistive personnel [UAP]) are any assistive personnel trained to function in a supportive role, regardless of title, to whom a nursing responsibility may be delegated. This includes, but is not limited to, certified nursing assistants or aides (CNAs), patient-care technicians (PCTs), certified medical assistants (CMAs), certified medication aides, and home health aides.[2] Making assignments, delegating tasks, and supervising delegatees are essential components of the RN role and can also provide the RN more time to focus on the complex needs of clients. For example, an RN may delegate to AP the attainment of vital signs for clients who are stable, thus providing the nurse more time to closely monitor the effectiveness of interventions in maintaining complex clients’ hemodynamics, thermoregulation, and oxygenation. Collaboration among the nursing care team members allows for the delivery of optimal care as various skill sets are implemented to care for the patient.
Properly assigning and delegating tasks to nursing team members can promote efficient client care. However, inappropriate assignments or delegation can compromise client safety and produce unsatisfactory client outcomes that may result in legal issues. How does the RN know what tasks can be assigned or delegated to nursing team members and assistive personnel? What steps should the RN follow when determining if care can be delegated? After assignments and delegations are established, what is the role and responsibility of the RN in supervising client care? This chapter will explore and define the fundamental concepts involved in assigning, delegating, and supervising client care according to the most recent joint national delegation guidelines published by the National Council of State Boards of Nursing (NCSBN) and the American Nurses Association (ANA).[3]
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
Nursing team members working in inpatient or long-term care settings receive patient assignments at the start of their shift. Assignment refers to routine care, activities, and procedures that are within the legal scope of practice of registered nurses (RN), licensed practical/vocational nurses (LPN/VN), or assistive personnel (AP).[1] Scope of practice for RNs and LPNs is described in each state’s Nurse Practice Act. Care tasks for AP vary by state; regulations are typically listed on sites for the state’s Board of Nursing, Department of Health, Department of Aging, Department of Health Professions, Department of Commerce, or Office of Long-Term Care.[2]
See Table 3.3a for common tasks performed by members of the nursing team based on their scope of practice. These tasks are within the traditional role and training the team member has acquired through a basic educational program. They are also within the expectations of the health care agency during a shift of work. Agency policy can be more restrictive than federal or state regulations, but it cannot be less restrictive.
Patient assignments are typically made by the charge nurse (or nurse supervisor) from the previous shift. A charge nurse is an RN who provides leadership on a patient-care unit within a health care facility during their shift. Charge nurses perform many of the tasks that general nurses do, but also have some supervisory duties such as making assignments, delegating tasks, preparing schedules, monitoring admissions and discharges, and serving as a staff member resource.[3]
Nursing Team Members’ Scope of Practice and Common Tasks[4]
Create and implement individualized nursing care plans and revise as neededReview prescribed medications for safety concerns, administer medications, and titrate medications based on protocols or standing orders
Plan and provide client education Admit and discharge clientsMake referrals, such as to a caseworker, dietician, or chaplain, according to agency policy. (Many referrals to interprofessional team members require a provider order.)
Delegate appropriate tasks to LPN/VNs and APs Assess clients Initiate administration of blood products to a client Administer high-risk medications, including heparin and chemotherapeutic agents Establish intravenous (IV) access Initiate IV fluids and IV medications Administer IV push medications Titrate medications per provider order Perform any tasks that may be performed by a LPN/VN or AP Assist the RN by performing routine, basic nursing care with predictable outcomes Assist the RN with collecting data and monitoring client findings on stable clients Implement interventions outlined in the nursing care plan, as appropriate Reinforce client education as outlined in the nursing care plan Delegate tasks to AP Provide basic nursing care Assist with the collection of patient assessment data Assist the RN with the development and revision of a nursing care plan Reinforce teaching provided by an RN Administer medications that are not high-risk Administer enteral feeding Perform routine dressing changes Perform tracheostomy care on stable clients Perform suctioning on stable or routine clients Insert a urinary catheter Perform any of the tasks that APs are permitted to perform Tasks That Potentially Can Be Delegated According to the Five Rights of Delegation:Monitor the administration of blood products after they have been initiated by an RN and report findings to the RN
Assist with the administration of IV fluids and medications after they have been initiated by an RN and under the supervision of an RN; cannot hang the first dose or change medications
Assist clients with activities of daily living (ADLs), including: AmbulatingPerform routine data collection that does not require clinical assessment or critical thinking, such as:
Measuring vital signs, weight, and height Measuring intake and output (e.g., food and drink, urine, bowel movements)Assist stable clients with eating (although clients with dysphagia or at an aspiration risk require qualified health care members with specific training in this area)
Assist with personal hygiene, grooming, bathing, positioning, transfers, range of motion exercises, toileting, and making beds
Obtain vital signs on stable clients Transport clients Collect and transport routine urine specimens Restock suppliesReport to the RN if a change in client’s status is observed. Example, “Client is now complaining of pain at 9/10 when repositioned. Last time client was repositioned, no pain was reported.”
An example of a patient assignment is when an RN assigns an LPN/VN to care for a client with stable heart failure. The LPN/VN collects assessment data, monitors intake/output throughout the shift, and administers routine oral medication. The LPN/VN documents this information and reports information back to the RN. This is considered the LPN/VN’s “assignment” because the skills are taught within an LPN educational program and are consistent with the state’s Nurse Practice Act for LPN/VN scope of practice. They are also included in the unit’s job description for an LPN/VN. The RN may also assign some care for this client to AP. These tasks may include assistance with personal hygiene, toileting, and ambulation. The AP documents these tasks as they are completed and reports information back to the RN or LPN/VN. These tasks are considered the AP’s assignment because they are taught within a nursing aide’s educational program, are consistent with the AP’s scope of practice for that state, and are included in the job description for the nursing aide’s role in this unit. The RN continues to be accountable for the care provided to this client despite the assignments made to other nursing team members.
Special consideration is required for AP with additional training. With increased staffing needs, skills such as administering medications, inserting Foley catheters, or performing injections are included in specialized training programs for AP. Due to the impact these skills can have on the outcome and safety of the client, the National Council of State Board of Nursing (NCSBN) recommends these activities be considered delegated tasks by the RN or nurse leader. By delegating these advanced skills when appropriate, the nurse validates competency, provides supervision, and maintains accountability for client outcomes. Read more about delegation in the “Delegation” section of this chapter.
When making assignments to other nursing team members, it is essential for the RN to keep in mind specific tasks that cannot be delegated to other nursing team members based on federal and/or state regulations. These tasks include, but are not limited to, those tasks described in Table 3.3b.
Examples of Tasks Outside the Scope of Practice of Nursing Assistive Personnel
Cannot create nursing care plans, analyze patient assessment data, establish nursing diagnoses or expected outcomes, or evaluate the effectiveness of a nursing care plan. (However, LPN/VNs can collect data and contribute to the development and revision of a client’s nursing care plan in collaboration with the RN.)
Cannot administer high-risk medications (such as heparin and chemotherapeutic medications).Cannot titrate medications. (Titrate refers to adjusting the dosage of medication until the desired effects are achieved.)
Cannot independently provide client education. (However, they can implement client education that has been planned by the RN.)
Cannot perform admission assessments or initial postoperative assessments. Cannot discharge clients.Cannot complete tasks requiring clinical judgement and/or professional knowledge. For example, a nursing assessment of a client’s skin cannot be delegated to AP. However, AP are encouraged to report concerns about skin breakdown and other potential signs and symptoms to a licensed nurse.
Cannot delegate tasks.Cannot provide client education, but can reinforce education previously provided. For example, an AP can encourage a patient to keep their nasal cannula in place while eating.
Cannot complete tasks that require clinical expertise unless advanced training has been received and written agency policy allows, such as:
Administering medications and injections Inserting Foley catheters Administering tube feedings Performing wound care or dressing changes[5]As always, refer to each state’s Nurse Practice Act and other state regulations for specific details about nursing team members’ scope of practice when providing care in that state.
Find and review Nurse Practice Acts by state at www.ncsbn.org/npa.
Read more about the Wisconsin’s Nurse Practice Act and the standards and scope of practice for RNs and LPNs Wisconsin’s Legislative Code Chapter N6.
Read more about scope of practice, skills, and practices of nurse aides in Wisconsin at DHS 129.07 Standards for Nurse Aide Training Programs.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
McMullen, T. L., Resnick, B., Chin-Hansen, J., Geiger-Brown, J. M., Miller, N., & Rubenstein, R. (2015). Certified nurse aide scope of practice: State-by-state differences in allowable delegated activities. Journal of the American Medical Directors Association , 16(1), 20–24. ↵ 10.1016/j.jamda.2014.07.003 . [PubMed : 25239017 ] [CrossRef]
State of Wisconsin Department of Health Services. (2018). Medication administration by unlicensed assistive personnel (UAP): Guidelines for registered nurses delegating medication administration to unlicensed assistive personnel. https://www .dhs.wisconsin .gov/publications/p01908.pdf ↵.
There has been significant national debate over the difference between assignment and delegation over the past few decades. In 2019 the National Council of State Boards of Nursing (NCSBN) and the American Nurses Association (ANA) published updated joint National Guidelines on Nursing Delegation (NGND).[1] These guidelines apply to all levels of nursing licensure (advanced practice registered nurses [APRN], registered nurses [RN], and licensed practical/vocational nurses [LPN/VN]) when delegating when there is no specific guidance provided by the state’s Nurse Practice Act (NPA).[2] It is important to note that states have different laws and rules/regulations regarding delegation, so it is the responsibility of all licensed nurses to know what is permitted in their jurisdiction.
The NGND defines a delegatee as an RN, LPN/VN, or AP who is delegated a nursing responsibility by either an APRN, RN, or LPN/VN, is competent to perform the task, and verbally accepts the responsibility.[3] Delegation is allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and not routinely performed, but the individual has obtained additional training and validated their competence to perform the delegated responsibility.[4] However, the licensed nurse still maintains accountability for overall client care. Accountability is defined as being answerable to oneself and others for one’s own choices, decisions, and actions as measured against a standard. Therefore, if a nurse does not feel it is appropriate to delegate a certain responsibility to a delegatee, the delegating nurse should perform the activity themselves.[5]
Delegation is summarized in the NGND as the following[6]:
A delegatee is allowed to perform a specific nursing activity, skill, or procedure that is outside the traditional role and basic responsibilities of the delegatee’s current job.
The delegatee has obtained the additional education and training and validated competence to perform the care/delegated responsibility. The context and processes associated with competency validation will be different for each activity, skill, or procedure being delegated. Competency validation should be specific to the knowledge and skill needed to safely perform the delegated responsibility, as well as to the level of the practitioner (e.g., RN, LPN/VN, AP) to whom the activity, skill, or procedure has been delegated. The licensed nurse who delegates the “responsibility” maintains overall accountability for the client, but the delegatee bears the responsibility for completing the delegated activity, skill, or procedure.
The licensed nurse cannot delegate nursing clinical judgment or any activity that will involve nursing clinical judgment or critical decision-making to AP.
Nursing responsibilities are delegated by a licensed nurse who has the authority to delegate and the delegated responsibility is within the delegator’s scope of practice.
An example of delegation is medication administration that is delegated by a licensed nurse to AP with additional training in some agencies, according to agency policy. This task is outside the traditional role of AP, but the delegatee has received additional training for this delegated responsibility and has completed competency validation in completing this task accurately.
An example illustrating the difference between assignment and delegation is assisting patients with eating. Feeding patients is typically part of the routine role of AP. However, if a client has recently experienced a stroke (i.e., cerebrovascular accident) or is otherwise experiencing swallowing difficulties (e.g., dysphagia), this task cannot be assigned to AP because it is not considered routine care. Instead, the RN should perform this task themselves or delegate it to an AP who has received additional training on feeding assistance.
The delegation process is multifaceted. See Figure 3.2[7] for an illustration of the intersecting responsibilities of the employer/nurse leader, licensed nurse, and delegatee with two-way communication that protects the safety of the public. “Delegation begins at the administrative/nurse leader level of the organization and includes determining nursing responsibilities that can be delegated, to whom, and under what circumstances; developing delegation policies and procedures; periodically evaluating delegation processes; and promoting a positive culture/work environment. The licensed nurse is responsible for determining client needs and when to delegate, ensuring availability to the delegatee, evaluating outcomes, and maintaining accountability for delegated responsibility. Finally, the delegatee must accept activities based on their competency level, maintain competence for delegated responsibility, and maintain accountability for delegated activity.”[8]
Multifaceted Delegation Process
How does the RN determine what tasks can be delegated, when, and to whom? According to the National Council of State Boards of Nursing (NCSBN), RNs should use the five rights of delegation to ensure proper and appropriate delegation: right task, right circumstance, right person, right directions and communication, and right supervision and evaluation[9]:
Right task: The activity falls within the delegatee’s job description or is included as part of the established policies and procedures of the nursing practice setting. The facility needs to ensure the policies and procedures describe the expectations and limits of the activity and provide any necessary competency training.
Right circumstance: The health condition of the client must be stable. If the client’s condition changes, the delegatee must communicate this to the licensed nurse, and the licensed nurse must reassess the situation and the appropriateness of the delegation.[10]
Right person: The licensed nurse, along with the employer and the delegatee, is responsible for ensuring that the delegatee possesses the appropriate skills and knowledge to perform the activity.[11]
Right directions and communication: Each delegation situation should be specific to the client, the nurse, and the delegatee. The licensed nurse is expected to communicate specific instructions for the delegated activity to the delegatee; the delegatee, as part of two-way communication, should ask any clarifying questions. This communication includes any data that need to be collected, the method for collecting the data, the time frame for reporting the results to the licensed nurse, and additional information pertinent to the situation. The delegatee must understand the terms of the delegation and must agree to accept the delegated activity. The licensed nurse should ensure the delegatee understands they cannot make any decisions or modifications in carrying out the activity without first consulting the licensed nurse.[12]
Right supervision and evaluation: The licensed nurse is responsible for monitoring the delegated activity, following up with the delegatee at the completion of the activity, and evaluating client outcomes. The delegatee is responsible for communicating client information to the licensed nurse during the delegation situation. The licensed nurse should be ready and available to intervene as necessary. The licensed nurse should ensure appropriate documentation of the activity is completed.[13]
Simply stated, the licensed nurse determines the right person is assigned the right tasks for the right clients under the right circumstances. When determining what aspects of care can be delegated, the licensed nurse uses clinical judgment while considering the client’s current clinical condition, as well as the abilities of the health care team member. The RN must also consider if the circumstances are appropriate for delegation. For example, although obtaining routine vitals signs on stable clients may be appropriate to delegate to assistive personnel, obtaining vitals signs on an unstable client is not appropriate to delegate.
After the decision has been made to delegate, the nurse assigning the tasks must communicate appropriately with the delegatee and provide the right directions and supervision. Communication is key to successful delegation. Clear, concise, and closed-loop communication is essential to ensure successful completion of the delegated task in a safe manner. During the final step of delegation, also referred to as supervision, the nurse verifies and evaluates that the task was performed correctly, appropriately, safely, and competently. Read more about supervision in the following subsection on “Supervision.” See Table 3.4 for additional questions to consider for each “right” of delegation.
Rights of Delegation[14]
Is this task legally appropriate to delegate to this team member according to the state’s Nurse Practice Act and written agency policy and procedures?
Has the team member been trained and demonstrated competency in performing this task? Does the team member feel comfortable and willing to perform the task? Is there enough staffing to support delegation in this circumstance? What is the client’s current status? What are the client’s current needs? Is the delegatee suitable to meet the client’s needs? Is the delegatee willing to accept the delegated task? Has the delegatee demonstrated competence to perform the task? Have clear communication and instructions been given regarding the task?Did the instructions include data that need to be collected, the method for collecting the data, the time frame for reporting the results to the licensed nurse, and additional information pertinent to the situation?
Does the delegatee understand what needs to be done? Is the delegatee aware of what should be reported and when it needs to be reported? Has the delegatee accepted the delegated task? Has the time frame to complete the task been defined?Does the delegatee understand they cannot make any decisions or modifications in carrying out the activity without first consulting the licensed nurse?
Was closed-loop communication used?When and how will the RN connect with the delegatee to discuss the completion of the activity and communication of patient information?
How often should the RN directly or indirectly observe the team member’s performance? When will the RN evaluate client outcomes? When will the RN provide feedback to the team member? Has documentation of the activity been completed?Keep in mind that any nursing intervention that requires specific nursing knowledge, clinical judgment, or use of the nursing process can only be delegated to another RN. Examples of these types of tasks include initial preoperative or admission assessments, client teaching, and creation and evaluation of a nursing care plan. See Figure 3.3[15] for an algorithm based on the 2019 National Guidelines for Nursing Delegation that can be used when deciding if a nursing task can be delegated.[16]
The licensed nurse has several responsibilities as part of the delegation process. According to the NGND, any decision to delegate a nursing responsibility must be based on the needs of the client or population, the stability and predictability of the client’s condition, the documented training and competence of the delegatee, and the ability of the licensed nurse to supervise the delegated responsibility and its outcome with consideration to the available staff mix and client acuity. Additionally, the licensed nurse must consider the state Nurse Practice Act regarding delegation and the employer’s policies and procedures prior to making a final decision to delegate. Licensed nurses must be aware that delegation is at the nurse’s discretion, with consideration of the particular situation. The licensed nurse maintains accountability for the client, while the delegatee is responsible for the delegated activity, skill, or procedure. If, under the circumstances, a nurse does not feel it is appropriate to delegate a certain responsibility to a delegatee, the delegating nurse should perform the activity.[17]
The licensed nurse must determine when and what to delegate based on the practice setting, the client’s needs and condition, the state’s/jurisdiction’s provisions for delegation, and the employer’s policies and procedures regarding delegating a specific responsibility. The licensed nurse must determine the needs of the client and whether those needs are matched by the knowledge, skills, and abilities of the delegatee and can be performed safely by the delegatee. The licensed nurse cannot delegate any activity that requires clinical reasoning, nursing judgment, or critical decision-making. The licensed nurse must ultimately make the final decision whether an activity is appropriate to delegate to the delegatee based on the “Five Rights of Delegation.”
Rationale: The licensed nurse, who is present at the point of care, is in the best position to assess the needs of the client and what can or cannot be delegated in specific situations.[18]
The licensed nurse must communicate with the delegatee who will be assisting in providing client care. This should include reviewing the delegatee’s assignment and discussing delegated responsibilities, including information on the client’s condition/stability, any specific information pertaining to a certain client (e.g., no blood draws in the right arm), and any specific information about the client’s condition that should be communicated back to the licensed nurse by the delegatee.
Rationale: Communication must be a two-way process involving both the licensed nurse delegating the activity and the delegatee being delegated the responsibility. Evidence shows that the better the communication between the nurse and the delegatee, the more optimal the outcome. The licensed nurse must provide information about the client and care requirements. This includes any specific issues related to any delegated responsibilities. These instructions should include any unique client requirements. The licensed nurse must instruct the delegatee to regularly communicate the status of the client.[19]
The licensed nurse must be available to the delegatee for guidance and questions, including assisting with the delegated responsibility, if necessary, or performing it themselves if the client’s condition or other circumstances warrant doing so.
Rationale: Delegation calls for nursing judgment throughout the process. The final decision to delegate rests in the hands of the licensed nurse as they have overall accountability for the client.[20]
The licensed nurse must follow up with the delegatee and the client after the delegated responsibility has been completed.
Rationale: The licensed nurse who delegates the “responsibility” maintains overall accountability for the client, while the delegatee is responsible for the delegated activity, skill, or procedure.[21]
The licensed nurse must provide feedback information about the delegation process and any issues regarding delegatee competence level to the nurse leader. Licensed nurses in the facility need to communicate to the nurse leader responsible for delegation any issues arising related to delegation and any individual whom they identify as not being competent in a specific responsibility or unable to use good judgment and decision-making.
Rationale: This will allow the nurse leader responsible for delegation to develop a plan to address the situation.[22]
The decision of whether or not to delegate or assign is based on the RN’s judgment concerning the condition of the client, the competence of the nursing team member, and the degree of supervision that will be required of the RN if a task is delegated.[23]
Everyone is responsible for the well-being of clients. While the nurse is ultimately accountable for the overall care provided to a client, the delegatee shares the responsibility for the client and is fully responsible for the delegated activity, skill, or procedure.[24] The delegatee has the following responsibilities:
The delegatee must accept only the delegated responsibilities that they are appropriately trained and educated to perform and feel comfortable doing given the specific circumstances in the health care setting and client’s condition. The delegatee should confirm acceptance of the responsibility to carry out the delegated activity. If the delegatee does not believe they have the appropriate competency to complete the delegated responsibility, then the delegatee should not accept the delegated responsibility. This includes informing the nursing leadership if they do not feel they have received adequate training to perform the delegated responsibility, do not perform the procedure frequently enough to do it safely, or their knowledge and skills need updating.
Rationale: The delegatee shares the responsibility to keep clients safe, and this includes only performing activities, skills, or procedures in which they are competent and comfortable doing.[25]
The delegatee must maintain competency for the delegated responsibility.
Rationale: Competency is an ongoing process. Even if properly taught, the delegatee may become less competent if they do not frequently perform the procedure. Given that the delegatee shares the responsibility for the client, the delegatee also has a responsibility to maintain competency.[26]
The delegatee must communicate with the licensed nurse in charge of the client. This includes any questions related to the delegated responsibility and follow-up on any unusual incidents that may have occurred while the delegatee was performing the delegated responsibility, any concerns about a client’s condition, and any other information important to the client’s care.
Rationale: The delegatee is a partner in providing client care. They are interacting with the client/family and caring for the client. This information and two-way communication are important for successful delegation and optimal outcomes for the client.[27]
Once the delegatee verifies acceptance of the delegated responsibility, the delegatee is accountable for carrying out the delegated responsibility correctly and completing timely and accurate documentation per facility policy.
Rationale: The delegatee cannot delegate to another individual. If the delegatee is unable to complete the responsibility or feels as though they need assistance, the delegatee should inform the licensed nurse immediately so the licensed nurse can assess the situation and provide support. Only the licensed nurse can determine if it is appropriate to delegate the activity to another individual. If at any time the licensed nurse determines they need to perform the delegated responsibility, the delegatee must relinquish responsibility upon request of the licensed nurse.[28]
The employer and nurse leaders also have responsibilities related to safe delegation of client care:
The employer must identify a nurse leader responsible for oversight of delegated responsibilities for the facility. If there is only one licensed nurse within the practice setting, that licensed nurse must be responsible for oversight of delegated responsibilities for the facility.
Rationale: The nurse leader has the ability to assess the needs of the facility, understand the type of knowledge and skill needed to perform a specific nursing responsibility, and be accountable for maintaining a safe environment for clients. They are also aware of the knowledge, skill level, and limitations of the licensed nurses and AP. Additionally, the nurse leader is positioned to develop appropriate staffing models that take into consideration the need for delegation. Therefore, the decision to delegate begins with a thorough assessment by a nurse leader designated by the institution to oversee the process.[29]
The designated nurse leader responsible for delegation, ideally with a committee (consisting of other nurse leaders) formed for the purposes of addressing delegation, must determine which nursing responsibilities may be delegated, to whom, and under what circumstances. The nurse leader must be aware of the state Nurse Practice Act and the laws/rules and regulations that affect the delegation process and ensure all institutional policies are in accordance with the law.
Rationale: A systematic approach to the delegation process fosters communication and consistency of the process throughout the facility.[30]
Policies and procedures for delegation must be developed. The employer/nurse leader must outline specific responsibilities that can be delegated and to whom these responsibilities can be delegated. The policies and procedures should also indicate what may not be delegated. The employer must periodically review the policies and procedures for delegation to ensure they remain consistent with current nursing practice trends and that they are consistent with the state Nurse Practice Act. (Institution/employer policies can be more restrictive, but not less restrictive.)
Rationale: Policies and procedures standardize the appropriate method of care and ensure safe practices. Having a policy and procedure specific to delegation and delegated responsibilities eliminates questions from licensed nurses and AP about what can be delegated and how they should be performed.[31]
The employer/nurse leader must communicate information about delegation to the licensed nurses and AP and educate them about what responsibilities can be delegated. This information should include the competencies of delegatees who can safely perform a specific nursing responsibility.
Rationale: Licensed nurses must be aware of the competence level of staff and expectations for delegation (as described within the policies and procedures) to make informed decisions on whether or not delegation is appropriate for the given situation. Licensed nurses maintain accountability for the client. However, the delegatee has responsibility for the delegated activity, skill, or procedure.
In summary, delegation is the transfer of the nurse’s responsibility for a task while retaining professional accountability for the client’s overall outcome. The decision to delegate is based on the nurse’s judgment, the act of delegation must be clearly defined by the nurse, and the outcomes of delegation are an extension of the nurse’s guidance and supervision. Delegation, when rooted in mutual respect and trust, is a key component to an effective health care team.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
“Delegation.png” by Meredith Pomietlo for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
NCSBN. (n.d.). Delegation. https://www .ncsbn.org/1625.htm ↵."Delegation Decision Tree.png" by Meredith Pomietlo for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www .ncsbn.org/NGND-PosPaper_06 .pdf ↵.
The licensed nurse has the responsibility to supervise, monitor, and evaluate the nursing team members who have received delegated tasks, activities, or procedures. As previously noted, the act of supervision requires the nurse to assess the staff member’s ability, competency, and experience prior to delegating. After the nurse has made the decision to delegate, supervision continues in terms of coaching, supporting, assisting, and educating as needed throughout the task to assure appropriate care is provided.
The nurse is accountable for client care delegated to other team members. Communication and supervision should be ongoing processes throughout the shift within the nursing care team. The nurse must ensure quality of care, appropriateness, timeliness, and completeness through direct and indirect supervision. For example, an RN may directly observe the AP reposition a client or assist them to the bathroom to assure both client and staff safety are maintained. An RN may also indirectly evaluate an LPN’s administration of medication by reviewing documentation in the client’s medical record for timeliness and accuracy. Through direct and indirect supervision of delegation, quality client care and compliance with standards of practice and facility policies can be assured.
Supervision also includes providing constructive feedback to the nursing team member. Constructive feedback is supportive and identifies solutions to areas needing improvement. It is provided with positive intentions to address specific issues or concerns as the person learns and grows in their role. Constructive feedback includes several key points:
Was the task, activity, care, or procedure performed correctly? Were the expected outcomes involving delegation for that client achieved? Did the team member utilize effective and timely communication? What were the challenges of the activity and what aspects went well? Were there any problems or specific concerns that occurred and how were they managed?After these questions have been addressed, the RN creates a plan for future delegation with the nursing team member. This plan typically includes the following:
Recognizing difficulty of the nursing team member in initiating or completing the delegated activities.
Observing the client’s responses to actions performed by the nursing team member. Following up in a timely manner on any problems, incidents, or concerns that arose.Creating a plan for providing additional training and monitoring outcomes of future delegated tasks, activities, or procedures.
Consulting with appropriate nursing administrators per agency policy if the client’s safety was compromised.
You are an RN and are reporting to work on a 16-bed medical/renal unit in a county hospital for the 0700 – 1500 shift today. The client population is primarily socioeconomically disadvantaged. Staff for the shift includes four RNs, one LPN/VN, and two AP.
You are a new RN graduate on the unit, and your orientation was completed two weeks ago. The LPN/VN has been working on the unit for ten years. Both AP have been on the unit for six months and are certified nursing assistants after completing basic nurse aide training. You, as one of four RNs on the unit, have been assigned four clients. You share the LPN with the other RNs, and there is one AP for every two RNs.
The charge nurse has assigned you the following four clients. Scheduled morning medications are due at 0800 and all four require some assistance with their ADLs.
Client A: An obese 52-year-old male with hypertension and diabetes requiring insulin therapy. He has been depressed since recently being diagnosed with end-stage renal disease requiring hemodialysis. He needs his morning medications and assistance getting dressed for transport to hemodialysis in 30 minutes.
Client B: A 83-year-old female client with acute pyelonephritis admitted two days ago. She has a PICC line in place and is receiving IV vancomycin every 12 hours. The next dose is due at 0830 after a trough level is drawn.
Client C: A 78-year-old male recently diagnosed with bladder cancer. He has bright red urine today but reports it is painless. He has surgery scheduled at 0900 and the pre-op checklist has not yet been completed.
Client D: A malnourished 80-year-old male client admitted with dehydration and imbalanced electrolyte levels. He is being discharged home today and requires patient education.
Reflective Questions
At the start of the shift, you determine which tasks, cares, activities, and/or procedures you will delegate to the LPN and AP. What factors must you consider prior to delegation?
What tasks will you delegate to the LPN/VN?
What tasks will you delegate to the AP?
(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activities are provided as immediate feedback.)
Review the following case studies regarding nurse liability associated with inappropriate delegation:
Reflective Questions: What delegation errors occurred in each of these scenarios and what were the repercussions of these errors for the nurses involved?
The RN is delegating tasks to the LPN/VN and AP on a medical-surgical unit. Using the columns as reference, indicate where delegation errors occurred using the 5 Rs of delegation.
| Right Person | Right Task | Right Circumstance | Right Direction and Communication | Right Supervision and Evaluation |
|---|---|---|---|---|
| Directs the AP to assess the pain level of a client who is post-op Day 3 after a hip replacement and report back the finding. | ||||
| Directs the LPN to give 1 mg IV push morphine to a patient who is 2-hours post total left knee replacement and ensure documentation. | ||||
| Assigns the AP to collect blood pressures on all clients on the unit by 0800. Assumes the AP will report back any abnormal blood pressures. | ||||
| Directs a new AP to ambulate a patient who is post-op Day 2 from a shoulder replacement who needs the assistance of one person and an adaptive walker. The AP voices concerns about never having used an adaptive walker before. The RN directs the AP to get another AP to help. |
Being answerable to oneself and others for one’s own choices, decisions, and actions as measured against a standard.
Routine care, activities, and procedures that are within the authorized scope of practice of the RN, LPN/VN, or routine functions of the assistive personnel.
Assistive Personnel (AP)
Any assistive personnel (formerly referred to as ‘‘unlicensed” assistive personnel [UAP]) trained to function in a supportive role, regardless of title, to whom a nursing responsibility may be delegated. This includes, but is not limited to, certified nursing assistants or aides (CNAs), patient-care technicians (PCTs), certified medical assistants (CMAs), certified medication aides, and home health aides.[1]
A process that enables the person giving the instructions to hear what they said reflected back and to confirm that their message was, in fact, received correctly.
Supportive feedback that offers solutions to areas of weakness.
An RN, LPN/VN, or AP who is delegated a nursing responsibility by either an APRN, RN, or LPN/VN who is competent to perform the task and verbally accepts the responsibility.
Allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role but in which they have received additional training.
An APRN, RN, or LPN/VN who requests a specially trained delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role.
Five rights of delegation
Right task, right circumstance, right person, right directions and communication, and right supervision and evaluation.
Nursing team members
Advanced practice registered nurses (APRN), registered nurses (RN), licensed practical/vocational nurses (LPN/VN), and assistive personnel (AP).
Scope of practice
Procedures, actions, and processes that a health care practitioner is permitted to undertake in keeping with the terms of their professional license.
Appropriate monitoring of the delegated activity, evaluation of patient outcomes, and follow-up with the delegatee at the completion of the activity.
Making adjustments to medication dosage per an established protocol to obtain a desired therapeutic outcome.
