In today’s busy health-care environments, delegation is a necessary component to assisting in facilitating effective and efficient patient care. However, when traditional nursing tasks are delegated to unregulated care providers (UCP) or workers, nurses should understand the associated implications for patient safety, quality of care and their own responsibility.
1. What is delegation?
Delegation occurs when either the employer or the nurse transfers authority to an unregulated care provider (UCP) in a selected situation to perform tasks that are traditionally performed by a nurse. These providers can include, but are not limited to, health-care aides, home support workers, and resident aides.1
In Canada, the practice of nursing is defined in very broad terms. The essence of nursing practice is the application of the nursing process, which provides the foundation for nursing diagnosis, outcome identification, and care planning.2 For instance, in British Columbia and Manitoba, they are also accountable for their work, and must take responsibility for their own nursing actions as well as their professional conduct.3 Nurses should not delegate the overarching nursing responsibilities. For example, a UCP may measure vital signs, but the nurse should analyze the data for comprehensive assessment, nursing diagnosis, and planning care. A nurse should act prudently when delegating tasks to a UCP, as they often do not have a legally defined scope of practice and are not accountable to a regulatory body.4 Through this process, it would be prudent for the nurse to provide supervision to directly assess the care given to the patient.
2. Who is responsible for what?
Responsibility for delegation is shared between the employer, the nurse and the UCP.5
a) The employer
The employer is usually responsible for hiring appropriate staff and for establishing written policies and procedures concerning delegation, including who the delegator is (employer or nurse), workers to whom authority has been or can be delegated, the process for delegation, and guidelines for care.6 Differences in the roles of nurses and UCPs must be reflected in these policies.
The employer is generally also responsible for:
- providing adequate education, training, and assessment of the competence of the UCPs;7
- establishing and maintaining quality control measures to ensure competent care;
- providing adequate time for nurses to assess patients and provide client care;
- ensuring adequate supervision of UCPs;8
- prohibiting delegation when no suitably qualified UCP is available; and
- outlining the responsibility and accountability of nurses and UCPs.9
b) The nurse
The nurse is responsible for knowing which tasks are approved by the employer for delegation and the circumstances under which work may be delegated. The nurse is also responsible for making an appropriate decision to delegate and for adequately supervising UCPs to whom tasks are delegated. In short, the management for the practice of nursing cannot be delegated.10 As such, despite delegation, the nurse remains in charge of the overall assessment and care planning of a patient.
In order to determine whether a decision to delegate is appropriate, the nurse should consider taking into account:
- the employer’s policies and the nursing regulator’s standards concerning delegation;
- the patient’s needs;
- the complexity of the patient’s health issues and condition;11
- the UCP’s job description, knowledge base, and demonstrated competency;
- This ensures that the task at hand is within their role description.
- the level of competency required to deliver the care;
- if the nurse is able to establish supervision and support mechanisms, and if the nurse has clarified responsibility and accountability with the UCP;12
- whether the task will be routinely performed (to maintain the UCPs level of performance);
- if the nurse has an opportunity to provide feedback; and
- the predictability of the anticipated outcome and specific risk factors.13
As the nurse is responsible for evaluating care by monitoring patient outcomes, the nurse must closely supervise workers to whom they have delegated. Supervision entails initial direction, feedback, periodic inspection, and corrective action when needed.14 The nurse should remember that they can decide that delegation is no longer appropriate at any time.
c) The unregulated care provider
The UCP’s responsibilities include, but are not limited to:
- being responsible for having sufficient knowledge, skill, and judgement to accept delegation;15
- following employer policies and procedures, and instructions given by the nurse;
- performing tasks and giving care safely, effectively and ethically;
- documenting the care given;
- reporting observations and patient information to the nurse supervising the patient’s care; and
- refusing to accept delegation of those acts for which they do not possess the required competency.16
3. How can a nurse delegate responsibly?
When delegating tasks to UCPs, considerations include the following:
- Do you understand your employer’s job descriptions and delegation policies, and have you read your nursing regulator’s standards and policies on delegation?
- Are you keenly aware of the UCP’s qualifications and competencies?
- Have you developed nursing care plans?
- Have you determined which interventions, if any, can be safely delegated and to whom?
- Have you ensured that the UCP is available to assist?
- Is the UCP being utilized disproportionately or inappropriately?
- Are the instructions given as specific as possible?
- Provide detail on who, what, where, when, and how. For example, include when and how to report outcomes and ask for assistance, such as “Tell me if Mr. Jones’ blood pressure is higher than 160/100.” This provides a reportable parameter, in contrast to “Check Mr. Jones’ BP”;
- Have you indicated which tasks should be prioritized?
- Does the UCP understand the request?
- Have you ensured that the patient knows who his/her nurse is and who his/her UCP is?
- Are you providing supervision and support mechanisms, either directly or indirectly, based on the patient’s condition, nature of delegated tasks, resources available and the UCP’s level of competency?
- Can you intervene if necessary?
- Are you considering the stability of the patient’s condition, and the risk for harm from the task assigned to the UCP?17
Nurses should remember that working relationships rely on communication, mutual respect and positive reinforcement. If you would like further guidance about the appropriateness of delegation, you may wish to consult your professional or territorial regulatory body or your employer. CNPS beneficiaries who have concerns about legal considerations may call the CNPS at 1-800-267-3390 to speak with legal counsel.
1. College of Registered Nurses of Manitoba, Practice Direction: Assignment and Delegation to Unregulated Care Providers, May 2018.
2. Canadian Nurses Association, Framework for the Practice of Registered Nurses in Canada, 2015.
3. British Columbia College of Nurses and Midwives, Professional Standards, Nov 2020; CRNM, Practice Direction: Practice Expectations for RNs, May 2018.
4. BCCNM, Assigning and Delegating to Unregulated Care Providers, Nov 2020.
5. College and Association of Registered Nurses of Alberta, Assignment of Client Care: Guidelines for Registered Nurses, May 2014.
6. BCCNM, Assigning and Delegating to Unregulated Care Providers, Nov 2020.
7. College of Registered Nurses of Newfoundland and Labrador, Unregulated Care Providers in Community Settings, 2019.
8. CRNM, Practice Direction: Assignment and Delegation to Unregulated Care Providers, May 2018.
11.College of Nurses of Ontario, Working with Unregulated Care Providers, 2013.
13. CRNNL, Unregulated Care Providers in Community Settings, 2019.
14. Nurses Association of New Brunswick Practice Guideline: A Collaborative Approach to Assigning, Delegating and Teaching in Health Care, 2019.
15. BCCNM, Assigning and Delegating to Unregulated Care Providers, Nov 2020.
THIS PUBLICATION IS FOR INFORMATION PURPOSES ONLY. NOTHING IN THIS PUBLICATION SHOULD BE CONSTRUED AS LEGAL ADVICE FROM ANY LAWYER, CONTRIBUTOR OR THE CNPS. READERS SHOULD CONSULT LEGAL COUNSEL FOR SPECIFIC ADVICE.