The NHS workforce continues to be understaffed and under-resourced with one in 10 nursing posts vacant (Campbell, 2022). Registered nurses delegate tasks to junior colleagues, support workers, students and relatives to help manage their workload and ensure that patients receive timely care. Safe delegation is encouraged by the Nursing and Midwifery Council (NMC) as a way of managing workload, but the NMC (2018)Code reminds nurses that the delegation must be safe and that nurses are accountable for their delegation decisions.
Health Education and Improvement Wales (HEIW) (2019:10) defines delegation as:
‘… the process by which you (the delegator) allocate clinical or non-clinical care and support to a competent person (the delegatee). The delegator will remain responsible for the overall management of the individual, and accountable for their decision to delegate.’
To support that definition, HEIW (2019) proposes a number of principles for safe delegation, including:
- Every delegation has to be safe
- Registered practitioners cannot delegate the initial assessment of the individual
- The primary motivation for delegation is to meet the health and social care needs of the individual
- The person delegated to undertake a task must have the right level of experience and competence to carry it out
- The delegator must be satisfied that the delegatee is competent to undertake the task
- Staff must feel able to refuse to accept a delegation if they consider it to be inappropriate, unsafe or if they think they lack the necessary competency or confidence to undertake it
- Supervision and feedback appropriate to the task being delegated must be provided.
These principles are reflected in the professional standard imposed by the NMC.
Professional duty to delegate safely
Standard 11 of the NMC Code (2018) places a professional duty on nurses to be accountable for their decisions to delegate tasks and duties to other people. Nurses must:
- Delegate tasks and duties that are only within the other person's scope of competence, making sure that they fully understand the instructions
- Make sure that everyone who is delegated tasks is adequately supervised and supported, so they can provide safe and compassionate care
- Confirm that the outcome of any task that has been delegated to someone else meets the required standard
- Delegate tasks and duties that are within the other person's scope of competence.
It is essential that nurses ensure that the person to whom they delegate a task is competent to undertake it and fully understands the instructions given. This might require the delegating nurse to provide further explanation and, in some cases, demonstration and training to ensure that the task is carried out correctly and safely.
Case 1
In the case of one patient (Robinson, 2016), the coroner described a district nursing service as being unfit for purpose, and its staff as unprofessional, following the death of a patient in a care home. District nurses had failed to delegate tasks safely to care home staff and had failed to ensure the care home staff had understood their instructions.
The patient was an 82-year-old woman who had died from a stroke, but the coroner ruled that pressure ulcers, which she had developed after the district nurses failed to tell care assistants how to prevent them, had contributed to her death (Robinson, 2016).
The inquest heard that the deceased had dementia. When her condition deteriorated staff at the care home sought help from the district nurse team, who made several visits to the woman.
The coroner held that the district nursing service had been aware that the woman had rapidly deteriorating dementia, was immobile, had poor nutrition, poor hydration, and was doubly incontinent, and that these factors put her at significant risk of developing pressure ulcers.
However, there were no indications in the district nurse records of:
- A completed pressure damage risk assessment
- A plan for managing the woman's pressure damage risk
- Any information relating to the care of the deceased had been communicated and safely delegated to the care home.
This led the coroner to raise concerns about the unprofessional behaviour of the district nursing service.
In response to these criticisms, the district nurse manager, in evidence, claimed that the district nursing service had been too busy to write records and that all of their interactions with residential and care homes were verbal as they did not have time to do anything else.
The coroner held that failing to meet the standards on record-keeping and delegation compromised patient care, communication of care and continuity of care. The outcome was that the patient did not have a preventative care plan to manage the high risk of developing pressure ulcers (Robinson, 2016).
The coroner was confident that care home staff would have followed any care plan drawn up by the district nursing staff to prevent pressure damage developing. In the absence of a plan, the untrained care staff were unaware that blisters that the deceased developed indicated that she was likely to suffer from pressure ulcers in the future.
The coroner was sufficiently concerned that the failings of the district nursing service would result in further deaths to make the decision to issue a report on the case to the director of nursing at the trust, the chief executive, the medical director, and the Care Quality Commission. The report stated that, it was clear from the evidence that the care provided is unfit for service.
Preventing further deaths
Coroners have the authority to take action to prevent further deaths
‘… [and] may announce at the inquest that he is reporting the matter in writing to the person or authority who may have power to take such action and he may report the matter accordingly.’
Registered nurses must ensure that the task and duty they have delegated has been carried out to the required standard and make a note that they have undertaken the check to ensure this (NMC, 2018: Standard 11.3).
In addition, where registered nurses delegate a task to support staff, students or relatives, they may also be required to exercise their professional judgement by evaluating the significance of the finding.
When delegating risk assessments and monitoring assessments, such as recording vital signs for National Early Warning Score (NEWS) charts or pressure ulcer assessments, it is the registered nurse's role to come to a conclusion on the significance of the readings/assessment and take further action, if necessary, in accordance with standard 3 of the NMC Code (2018). Standard 3 places a professional duty on the nurse to ensure that ‘people's physical, social and psychological needs are assessed and responded to’ (NMC, 2018).
A registered nurse's legal duty of care may be breached, and the nurse could be found liable in negligence if their failure to evaluate the outcome of a delegated task results in harm to the patient.
Case 2
In XM v Leicestershire Partnership Trust [2020], a health visitor was held negligent for failing to follow a head circumference measurement they had delegated to a nursery nurse. The child had a rare and benign brain tumour that caused an accumulation of cerebrospinal fluid that caused the brain to grow abnormally fast.
When the nursery nurse undertook the measurement, the head circumference was recorded as being on the 99.6th centile, but the reading was not checked by the health visitor and no evaluation was made of its significance. By the time the tumour was discovered permanent brain damage had occurred: it was accepted that, had action been taken before the reading crossed the 99.6th centile, no permanent disability would have occurred.
The court held that the health visitor had been negligent for not following up the delegation of the task by checking the reading and coming to a professional judgement as to its significance. On the role of the nursery nurse, the court found that they had not been negligent.
The nursery nurse was not in breach of duty by failing to appreciate that XM's head was disproportionately large. The standard of care expected of a nursery nurse was different from that expected of a health visitor. Although they performed certain delegated health-visitor tasks, nursery nurses were not qualified nurses, were not trained to take or interpret head circumference measurements and would not look at head measurement charts.
Delegation of a task or duty does not end at the point of delegation. The registered nurse who initiated the delegation had a duty to follow up, check that the task has been completed properly and safely, and come to a professional judgement on any measurement or assessments that had been completed.
Conclusion
The use of delegation is considered a sensible response to the increasing demands and challenges facing registered nurses. It is approved of and encouraged by the NMC as long as it is done safely. The Code (2018) reminds registered nurses that they are accountable for their delegation decisions, and standards for delegation are set out in the code under standard 11.
A nurse should delegate tasks and duties where this will facilitate timely, appropriate and safe care, but nurses must ensure that they discharge the requirements of the Code and their duty of care. In particular, nurses must be satisfied that they have given clear instructions to the person undertaking the task, follow up to ensure that it has been carried out properly, and come to a professional judgement on any findings or measurements arising from the delegated task. Failure to do so could result in the nurse being held to account by the profession and the law for inappropriate delegation.
KEY POINTS
- The use of delegation is considered a sensible response to the increasing demands and challenges facing registered nurses
- Delegation is described as the process by which the nurse allocates clinical or non-clinical care and support to a competent person
- Nurses must be satisfied that they have given clear instructions to the person undertaking the task, follow up to ensure that it has been carried out properly, and come to a professional judgement on any findings or measurements arising from the delegated task