The Risks of Wrongful Delegation

The Risks of Wrongful Delegation

Although delegating tasks occurs all the time in the workplace, there are often times in which nurses may not effectively delegate to unlicensed personnel. This carries major risk—to the nurse, the staff member, the patients, and the health care facility. Jennifer Flynn, CPHRM, Risk Manager, Nurses Service Organization (NSO), answered our questions about wrongful delegation.

What kinds of tasks could nurses be inappropriately delegating?

Unlicensed Assistive Personnel (UAP) assist registered nurses in the provision of patient care as delegated by and under the supervision of the registered nurse. UAPs assist nurses by performing patient care-related tasks that do not require nursing skill or judgment. Such activities can include the following: activities of daily living (feeding, drinking, ambulating, turning, grooming, toileting, dressing); collecting data (vital signs, weights); collecting simple specimens (stool, urine); transporting patients; restocking supplies; clerical duties; and housekeeping tasks.

To say that another way, a UAP cannot be asked to perform any activities on patients whose status is unstable—activities which require assessment, problem solving, judgment, or evaluation.

Before deciding on whether to assign a task to a UAP, nurses must first determine what your state’s nurse practice act and your facility policies say about task delegation.

What are the risks in delegating to non-nurse personnel?

Improper delegation can negatively impact patient care while also potentially exposing the nurse to liability lawsuits or Board of Nursing complaints. Effective delegation allows the nurse to do what they have been educated to do, that is, make effective judgements about patients and coordinate care. However, the nurse always maintains accountability for the task’s completion and is always accountable for the overall outcome of the patient.

The American Nurses Association developed the five rights of delegation to assist nurses in making safe decisions:

1. Right Task – Determine which tasks are appropriate for delegation. Some questions to ask include (1) Do your state rules and regulations support delegation? (2) Can I delegate these tasks based on my facility’s policies and procedures?

2. Right Circumstance – Consider the appropriateness of the patient setting and other relevant factors. Some questions to ask include (1) Are there appropriate resources available to perform the task? (2) Does the UAP have the appropriate supervision to accomplish the task? And, (3) Is the situation favorable for delegation? For example, a UAP may be allowed to feed a patient but if a high-risk stroke patient requires feeding, the nurse must first assess if the patient can safely swallow. The UAP can’t make that determination, and the nurses are expected to foresee possible harm to patients before delegating tasks.

3. Right Person – Ensure the right person is delegating the right task to the right person, to be performed on the right patient. Consider the UAP’s knowledge and experience to complete delegated tasks safely. Ask the UAP the following key questions before assigning the task:

  • Have you been trained to do this task?
  • Have you ever performed this task with a patient?
  • Have you ever done this task unsupervised?
  • How confident are you about performing this task accurately?
  • What problems have you encountered with this task in the past?

Based on these answers, the nurse may decide to delegate, not to delegate, or provide direct supervision while the UAP is performing the task.

4. Right Supervision – Nurses are required to provide appropriate monitoring, evaluation, intervention, and supervision for all delegated tasks. Remember, nurses are accountable for the outcome of the patient.

5. Right Direction and Communication – Nurses must communicate a clear description of the task, including its objective, limits, and expectations. Consider telling the UAP exactly what you want them to do and by what time to do it. Also request specific feedback about the task at a specific time. Even if you’ve worked with the UAP for a long time, don’t make assumptions about what they may understand. Delegation requires mutual understanding and trust on the part of both the nurse and the UAP. The UAP should be allowed to ask questions, seek clarification, and request additional training.

What kinds of lawsuits/actions from nursing boards could a nurse face by doing this?

If nurses perform activities which are a violation of nursing laws and rules, this may result in either a malpractice lawsuit or even disciplinary action by the Board of Nursing. The most common potential violations related to delegation are failure to supervise over those who practice under the supervision of a nurse, and inappropriate delegation when the nurse may have reason to know the UAP was not qualified to perform the task. In a malpractice lawsuit, your actions or failure to act will be judged against professional practice standards in your state.

Consider this question before deciding to delegate “Would a reasonable prudent person have delegated this task given all aspects of the situation, and under similar circumstances?” If a nurse is unsure of the answer, it is recommended to contact your facility’s risk manager, ask an experienced colleague for advice, practice delegation with written or simulated cases, or request a peer review of your delegation decisions.

Can you give me any real-world examples of wrongful delegation claims?

Some examples of wrongful delegation would include allowing a UAP to feed a high-risk stroke patient without the nurse first assessing the patient’s ability to swallow. You may allow the UAP to report on a patient’s urine output for a determined timeframe, but the UAP shouldn’t report the output is “low” for that requires interpreting assessment date which only the nurse can do.

How could this become even worse with the continuing nursing shortage?

Nursing shortages and increases in patient complexity have driven the need for delegation to be a necessary component of today’s health care environment. In response to various economic and business pressures, the health care industry has sought to increase the utilization of UAPs to refocus the role of nurses on patient care and coordination. Both the ANA and the National Council of State Boards of Nursing have provided insight and direction to address this process, so that nurses can practice safely. Nurses who are familiar with their state’s practice act, applicable state rules and regulations, their facility policies and procedures, and the ethics of the profession will be well positioned to appropriately use UAPs in delivering safe patient care. A clear understanding of these guidelines is a nurse’s best protection against inappropriate delegation and reducing the likelihood of a malpractice lawsuit or disciplinary action.