Recent reforms in aged care have led to some employers reducing the number of enrolled nurses, leaving a skills gap which has brought to the fore concerns around delegation of work by registered nurses to unregulated health workers.
Delegation can be fraught with tension over concerns for patient safety and confusion over where professional accountability lies.
“There has been a dramatic increase in the use of unregulated healthcare workers due to rising demands for healthcare and nursing workforce shortages,” says senior lecturer in nursing and midwifery at Edith Cowan University (ECU) Dr Carol Crevacore.
Dr Crevacore led a team that researched factors that impact the decision making in delegation by RNs to AINs in the acute care setting.
“Delegation care is a complex decision-making process that requires the nurse to use leadership and change management skills to demonstrate assertiveness within the teams they work, advocate for patients and ensure nursing activities are effectively executed.”
Accountability
The biggest confusion for nurses around delegation appears to be that of accountability. AINs are not regulated by the Nursing and Midwifery Board of Australia (NMBA). The RN delegating care to an AIN or personal care worker is responsible for determining that the delegation is appropriate, and that the outcome is evaluated and recorded.
“In Australia, a job description for the AIN typically includes a list of approved activities the RN is permitted to delegate to the AIN. With each delegation, the RN needs to undertake a risk assessment, assess the AIN regarding their competence and willingness to complete the delegated task in line with their scope of practice (SOP) and the approved list of activities,” says Dr Crevacore.
“Where RNs do not do this, it may result in AINs being delegated activities outside of their SOP and job description.”
The AIN’s scope of practice is influenced by the context in which they are working, their own level of competence, qualification and experience and the culture, policies and procedures of the facility in which they are working. These factors result in AINs having variable abilities or skill sets based on their SOP.
In reality, the difficulty lies in practitioners themselves being unaware that they are not competent or RNs pressured to delegate to others but not being assured of their competence for the task. Of great concern has been AINs observed to be working independently and making clinical decisions that appeared to be beyond their scope of practice (Crevacore et al., 2022).
Some RNs are unable to differentiate between a SOP and the AIN job description and do not believe they are delegating if the activities are part of the AIN job description, says Dr Crevacore.
“If they don’t consider or are unaware that they are accountable then they are unlikely to provide appropriate supervision to the AIN to complete these tasks. Lack of supervision may lead to omissions of care and adverse events which compromise patient safety.”
RNs have a duty of care and legal liability for patients and are accountable for the decision to delegate a task or duty. The adoption of a risk management approach when delegating as as outlined by the NMBA decision-making framework for nursing and midwifery (DMF) is critical.
Safe delegation and the law
Under the framework, the delegation must be appropriate. In delegating, a RN must ensure an AIN has the competence to perform the task, they fully understand the instructions, they are adequately supervised and supported, and the outcome of the delegated task will meet the required standard.
If these elements are in place, the RN is not accountable for the decisions and actions of the AIN for the task/s accepted. Accountability and responsibility are retained by the AIN who need to ensure that the work is completed appropriately. They must inform the RN if they are unable to perform a task competently and not attempt to do this.
A duty of care is enshrined in law on all practitioners, be they RNs, ENs or AINs. The key point is that practitioners must be competent to perform their role and meet the expected standard of care when associated with this regarding the completion of clinical tasks, decision making and supervision and delegation of care.
Nurse academic and expert in nursing and the law, Associate Professor Linda Starr says despite circumstances where it is appropriate for AINs to carry out specific tasks, these should always be decided by the RN who must be mindful of their own accountability when making decisions regarding the delegation of care and how inappropriate delegation might impact on their registration.
“There are legal and ethical risks around improper delegation and supervision of AINs particularly if these leads to them working outside of their SOP,” says A/Prof Starr.
“If there’s a gap [in who can competently undertake a task], nurses must go back to management and say ‘I am unable to complete these tasks and I have no one with the necessary scope of practice to delegate this to – there is a real risk that this will lead to missed care’.”
Service providers are accountable for appropriate levels of staffing that meet the needs of their organisation and must make sure that any guidelines regarding delegation of care by a RN are consistent with the expected professional standards for RN’s, says A/Prof Starr. It is incumbent on the RN to ensure that they work to these standards and avoid workplace practices that are inconsistent with this.
According to Clarke & Peters, the literature shows that decisions related to delegation are often made at a service management level, arguably as re-distribution of part of the RN scope of practice to cheaper and unregulated support workers.
“In effect, workers who are not registered nurses, are carrying out regulated nursing work without a licence to do so.”
“We have to start saying no to unsafe delegation and practices that can lead to missed care,” urges A/Prof Starr.
Employers must ensure staff are trained and supervised until they can demonstrate competence, especially if that role is being extended as with AINs, and that they work within their SOP.
“The bottom line for employers is that they need to have very clear guidelines for their staff about who, and what, RNs can delegate. From the perspective of the RN, they need to know and understand what the AIN can do.
“There’s a lot of risks with improper delegation. If the AIN undertakes a task outside of their scope of practice under direction by the RN which results in an adverse outcome or other incident, it puts both the public at risk and their registration,” says A/Prof Starr.
Resources
ANMF Guideline: Delegation by registered nurses
ANMF Position Statement: Assistants in nursing providing aspects of nursing care
Nursing and Midwifery Board of Australia: Decision-making framework for nursing and midwifery
