Delegating Effectively to Nursing Assistants in Post-Acute Care

Nursing assistants, with their hands-on and eyes-on interactions with clients, serve a vital role in the healthcare system, and they are recognized during National Nursing Assistants Week, which is June 18 to 25 this year.

These unlicensed assistive personnel (UAP) conduct patient care activities under the delegation and supervision of a licensed practical nurse, licensed vocational nurse, or registered nurse. Nurses can promote effective teamwork in post-acute care by planning and communicating the activities to be delegated to nursing assistants. Besides unlicensed assistive personnel and certified nursing assistants (CNAs), these direct care workers may be known as home care aides, personal care assistants, or personal care aides.

A UAP may assist with a client’s activities of daily living (ADLs), such as bathing, eating, or toileting; or instrumental ADLs, such as managing medications, laundry, and shopping. The direct care worker also provides companionship while working with elderly clients.

Because nursing assistants work directly with long-term care residents regularly, they usually are closely attuned to their clients’ health status. As a veterans home administrator notes, CNAs “form a close bond with these individuals, and they often are the first to recognize a condition change—such as loss of appetite, problems sleeping, new or different behaviors, and signs of pain.”

Whether providing assistance in a skilled nursing facility or in a client’s home, the UAP is always expected to report any condition change or problems to the nurse or other supervising clinician.

Promoting Teamwork With Nursing Assistants

If you are a nurse working with a UAP, you can support effective teamwork in the following ways:

• Plan what tasks you will delegate.
• Communicate the tasks and expectations clearly, offering the opportunity for questions.
• Listen to the assistant’s questions and concerns.
• Ask for the assistant to restate the expectations to confirm understanding.
• Address any performance problems promptly and thoroughly.
• Provide immediate feedback and specific praise as appropriate.

The Quality and Safety Education for Nurses website identifies teamwork and collaboration as an important competency, defined in the following way: “Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect and shared decision making to achieve quality patient care.” Under this competency, a nurse must be able to identify and manage team member roles and accountabilities and to describe the impact of the team functions on patient safety and quality of care.

Choosing to Delegate Tasks to UAP

The skill and art of delegation for effective use of unlicensed assistive personnel is a critical nursing competency identified by the American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN). Nursing policies and guidelines determine what can be safely delegated, and all staff must be properly trained and supervised for activities they are required to perform.

State nurse practice acts define which level of licensed nurse is authorized to delegate to a nursing assistant. Although organizational policies and job descriptions require UAP to perform certain tasks, they cannot contradict the mandates of practice acts. After reviewing the nurse practice act in the state of practice, the nurse can then discern how to safely and effectively delegate to a UAP.

Supervising Goes Along With Delegating

Supervision and delegation are interlocking concepts essential to the appropriate use of the UAP, as noted in the Relias course Delegating to Unlicensed Assistive Personnel.

The NCSBN and ANA joint position paper on delegation and supervision provides operational definitions for the two terms.

“Supervision” is defined as guidance and oversight of the delegated nursing task. It is the active process of directing, guiding, and influencing the outcomes of an individual’s performance of a task. A nurse who makes patient care rounds to oversee the care delivered by staff members is performing an act of supervision.

The NCSBN and the ANA define “delegation” as the process during which a nurse directs another person to perform nursing tasks and activities.

Activities can be assigned only to someone who has the required skill, knowledge, and judgment as well as legal authority for that scope of practice. Nurses can never assign patient care activities to UAP; they can only delegate activities or tasks. The nursing process itself cannot be delegated. The nursing duties of assessment, planning and evaluation, and the use of nursing judgment remain solely within the scope of practice of the professional RN.

Responsible Delegation Pays Off

Some nurses decline to delegate tasks if they are responsible for the outcome; they prefer to do the task themselves. Unfortunately, when nurses avoid delegating tasks that others are competent to perform, the quality of patient care can suffer and valuable resources may be mismanaged.

The delegation of direct patient care needs to be assessed individually, based on each patient’s needs and circumstances and the qualifications of the UAP. For example, a trained UAP may easily handle the task of repositioning a long-term resident with a pressure injury, but not repositioning a newly admitted paraplegic resident. Likewise, a UAP may be able to independently bathe a comatose resident but not a resident who is persistently combative.

To avoid confusion and patient safety risks, the policy of an organization should dictate clearly which tasks and activities may be delegated. Some considerations include:

• Is the activity within the range of functions the UAP is trained to provide?
• Does the activity frequently recur among the patient group?
• Can the activity be performed according to an established sequence of steps?
• Does the activity involve little or no modifications from one patient or situation to another?
• Does the activity have a predictable outcome?
• Can the activity be clearly separated from any inherent ongoing assessment, interpretation, or decision-making component?
• Is the activity free of a risk to life or well-being?

If the answer is “yes” to each of these questions, then the task or activity is a good candidate for delegation.

The NCSBN and ANA endorse the Five Rights of Delegation, requiring that the nurse use critical thinking and professional judgment to be sure a delegated task or assignment meets the following criteria:

• Right task
• Right circumstances
• Right person
• Right directions and communication
• Right supervision and evaluation

Following Up: Analysis, Evaluation, and Coaching

Nurses are responsible for analyzing and evaluating the outcome of a delegated task. For example, a UAP may take vital signs, but the nurse needs to interpret them. Similarly, some UAP have been trained to suction chronically ventilated patients, but the nurse remains responsible for assessment of need, tolerance, and outcome of the procedure.

Delegation works best when it is part of a comprehensive program that includes clear job descriptions, thorough initial and ongoing training, and coaching. Healthcare leaders emphasize the importance of providing engaging learning opportunities for staff to enhance competence and benefit patient care.

If nurses take a team approach and the whole team is trained appropriately, nursing assistants can truly be assets in providing effective patient care in today’s hectic healthcare environment.