As you can see, these are generic definitions, used as standards across the country; most states have incorporated similar definitions into their nurse practice acts. A good deal of decision making is left to you as the RN and is also guided by your state’s nursing practice act. You will be selecting the task and the situation in which to delegate or assign work. You will make a decision to delegate based on your assessment of the desired outcome and the competency of the individual delegate. These clinical decisions require complex critical thinking skills and are certainly more involved than a simple process for time management! In the pages ahead, we discuss steps that use the “five rights” that will assist you in this practice, making it easier for you to maximize safely the work of your team.

Nurses are often confused regarding supervision. This responsibility does not belong to only the one with the title of manager or house supervisor; rather, the expectation by law is that any time you delegate a task to someone else, you will be held accountable for the initial direction you give and the timely follow-up (periodic inspection) to evaluate the performance of the task.

Some nurses equate accountability with “I am the one to blame.” With that kind of attitude, no wonder there is reluctance to delegate! What is the point of delegating if someone else is going to make a mistake and you are going to take the blame? Let’s not forget that accountability also means taking the credit for the positive results we achieve through the actions and decisions we make, as well as our freedom to act because of our licensure. Our individual choice to take actions (personal accountability) is based on our professional knowledge and judgment, unleashing the art and science of nursing as applied to real-time individual patient and family situations using the gifts and skills of team members each day (Samuel, 2006). An important reminder about accountability before you take the weight of the world on your shoulders is:

It is important to focus on what you are accountable for in this process and to let the delegate also assume his or her own level of accountability. Remember, you are accountable for the following:

What if the delegate makes a mistake in completing the task? For what are you accountable? Let us consider the following example:

Based on a review of the previous guidelines, we can say that you did indeed delegate appropriately. Your communication may or may not have been as complete as it needed to be (more about that later). You are accountable for correcting the clinical effects of this error: Did the patient eat or drink too much, requiring the delay or cancellation of surgery? If so, you will call the operating room and make the appropriate adjustments in this patient’s care based on the decision regarding her surgery time. What about the nursing assistant? You are also accountable for following up with her regarding her performance, providing appropriate feedback so that she understands her level of personal accountability as well. For more on the how-tos, read on as we discuss the Five Rights of Delegation.

In comparison, other nurses may be all too eager to delegate the least desirable tasks to someone else. A word of caution is necessary here: If we focus only on making task lists for people to do, we eliminate the very core of our purpose. Remember, your role as the RN on the team involves the coordination and planning of care, with your primary focus on identifying, with the patient and the physician, the desired outcomes for your patients. Once determined, interventions will be readily apparent, and the decision regarding possible delegation of these tasks must be made.

Reflection: Do I personally tend toward being a “supernurse” or “supermartyr” wanting to do everything myself, because I won’t let go of nursing tasks? Or do I tend to be a “dumper” who would rather let the assistive personnel do all messy or difficult tasks? Or do I tend to be afraid to give direction and correct others for fear of not being “liked”? What kind of feedback could I ask for that would help me monitor my tendencies and improve my leadership?

At this point, the majority of state boards have addressed the issue of delegation or assignment and have developed rules that may offer information regarding who can do what. The scope of practice for each care-provider level usually includes a description of the processes that may be performed at that level. In an attempt to clarify the role of the licensed practical nurse (LPN), the National Council of State Boards of Nursing constructed the Practical Nurse Scope of Practice White Paper (NCSBN, 2005), calling for nursing education programs, regulatory agencies, and practice settings to educate nursing professionals about the differences in LPN and RN roles and to articulate clearly the LPN and RN scope of practice regulations. Traditionally, clinical experiences have provided students an opportunity to observe how registered nurses communicate and delegate tasks to LPNs. However, clinical site availability in settings where LPNs are employed has dramatically decreased, preventing the students from observing the delegation of tasks by the registered nurse to the LPN (Garneau, 2012). Therefore, decreased clinical site experiences, coupled with unfamiliarity regarding the scope of practice regulations for the LPN, have also contributed to ineffective delegation (Mole & McLafferty, 2004; NCSBN, 2006).

A key distinction between RNs and LPNs is related to the first step of the nursing process: assessment. The LPN collects data during the health history and physical examination, whereas the RN conducts a comprehensive physical assessment and develops a plan of care for the patient based on assessment findings. Moreover, the RN initiates and provides patient teaching and discharge planning, as well as evaluates the patient’s response to the plan of care and his or her understanding of the information provided (NCSBN, 2016a). The LPN contributes to the development and/or updates the plan of care and reinforces patient teaching and discharge instructions (NCSBN, 2014). In the midst of health care payment reform and attempts to connect all parts of the care continuum for the provision of better health care for entire populations, state practice rules for care providers may be changing quickly. For example, more states have recently promulgated rules related to certified medication aides in long-term care or community settings. These aides are certified nursing assistants who may, with additional training and certification, administer some routine medications, functioning under the supervision of an RN (or possibly LPN, depending on the state). In addition, community health care lay assistants are often deployed out of medical homes (ambulatory care clinics) or public health departments. These workers, following procedural rules, may function as case finders or perform such tasks as vital signs or home checks in the community. An RN or a physician supervises these community health aides. Medical assistants (MAs) in ambulatory clinics are not always specifically addressed by state practice regulations and have functioned under the direct supervision of physicians in their offices, but presently their roles are being regulated in some states. Creative roles will emerge in the future as states and municipalities attempt to find better, more cost-effective ways to deliver care. RNs should remain tuned in to their state’s health division’s regulatory changes as new roles and responsibilities emerge. Whatever roles appear, RNs remain accountable for the nursing care of their patients, even though those they supervise actually may complete tasks. One of the causes of disciplinary action that is listed in many nurse practice codes under “professional misconduct” is “delegating to an unlicensed person activities that can only be performed by licensed professionals” or “failure to adequately supervise or monitor those to whom care has been delegated” (Brous, 2012, p. 55).

The next place to look is in your organization, obtaining a copy of the job description, nursing responsibilities, and the skills checklist for each care provider. This will give you a very specific list of tasks from which to work, but remember, there are other considerations. Simply because the skills checklist includes ambulation of patients, it may not be advisable to delegate the first ambulation of a postoperative total hip replacement patient to the new patient care assistant (Critical Thinking Box 14.1).

If you have questions and need clarification for your state, go online to your board of nursing to consult statutes, rules, regulations, and advisory opinions or call your nursing regulatory body for assistance. (See www.ncsbn.org for links to your state’s nursing regulatory commission.) Be aware that your state may have introduced or passed a bill that may affect your practice in relation to residents of neighboring states. As of July 2015, 25 states had passed legislation approving interstate compact licensure regulation legislation designed to allow nurses to practice across state lines because of e-consultation, telenursing, or other technology that would broadcast nursing practice across state borders, and 7 more states had pending legislation (NCSBN, 2016b).

Beyond the law, your employer will have job descriptions and skills checklists that may clearly define the role of the caregiver. If you have not seen these documents, be sure to review them soon. This is the baseline for determining “who does what” and selecting the right task to delegate. As many organizations develop creative assistant roles to leverage the professional judgment of registered nursing personnel, the scope of practice of each role is defined first by law. If the organization extends the role of a patient care technician to include preoperative teaching, you want to be aware that this is clearly an RN function and by law is not allowed to be delegated to the technician.