Healthcare is becoming increasingly complex in today’s world. The delegation of care forms part of that complexity. This article describes how registered nurses in the United Kingdom (UK), which includes England, Scotland, Wales, and Northern Ireland, delegate some nursing activities to support workers who assist them in providing patient care.

The role of registered nurses has increased over the past decade. Nurses now carry out more highly technical care, sometimes taking on the work of junior doctors. This has resulted in some patient care being shifted to Health Care Assistants (HCAs) who are also know as support workers and care assistants. While there have always been nursing auxiliaries, such as HCAs, providing care to patients, the emphasis has now moved to the HCA as a more formal care worker (Spilsbury & Meyer, 2004).

The global shortage of qualified nurses and the ageing nursing population has meant that there is a growing dependency on non-qualified personnel, such as Health Care Assistants (HCAs) within the U.K. care setting. Qualified nurses in the UK are those nurses who are registered with the Nursing and Midwifery Council (NMC); they are the nurses who have undertaken an NMC-approved course of education. As a result of this change in skill mix, nurses need to able to delegate tasks to HCAs so that appropriate and safe care is delivered to patients. Clear procedures are required to clarify the roles of the registered nurse and HCAs in relation to delegated tasks so as to ensure that patients receive a high standard of care from the most appropriate healthcare staff member.

We will begin this article by presenting the differing nursing staff roles in the UK along with the legal and professional aspect of this delegation. Next we will discuss the benefits, facilitators, and barriers related to delegation. We will conclude by describing changes in role expectations, the various settings in which delegation occurs within the UK, and nursing delegation challenges within the UK.

Differences in Nursing Staff Roles Related to Delegation

...only those whose name is registered with the Nursing and Midwifery Council (NMC), the governing body for Registered Nurses in the UK, are legally permitted to call themselves registered nurses. In order to explain the process of delegation in the UK, we will first describe what we mean when we use the term ‘nurse’ and what we mean when we use the term ‘Health Care Assistant.’ In 2006, the Royal College of Nursing (RCN), the major nursing professional body in the UK, acknowledged some difficulty in defining a nurse. While a nurse may be described “as a person qualified and authorised to practise nursing” (RCN, 2003, p. 18), in the UK there is no legal definition of a nurse. Indeed, the term nurse is commonly used by others who work in dental, nursery, and veterinary care environments. However, only those whose name is registered with the Nursing and Midwifery Council (NMC), the governing body for Registered Nurses in the UK, are legally permitted to call themselves registered nurses (henceforth referred to as nurses) (RCN, 2003). In order to be registered as a nurse, the person needs to have successfully completed an education programme which adheres to NMC standards for Preregistration Nurse Education (NMC 2004, currently being updated). Health Care Assistants (or support workers or care assistants) are less clearly defined. They are generally accepted to be persons who work in the capacity of support workers in an area of healthcare and who normally work under the guidance of a registered practitioner (NHS, 2009).

We want to emphasize that the term ‘non-qualified’ is used to denote the person to whom an aspect of care is delegated. It does not mean that the person is not of paramount importance, nor that they have not been trained to carry out that aspect of care. Rather it means that the nature of the duty being delegated and/or the consequence(s) of delivering the care to the patient do not carry as high a level of risk and associated responsibility for patient safety and welfare as the duties performed by nurses who are qualified, i.e. registered.

Spilsbury and Meyer (2004) have identified three main areas of HCA work, namely direct patient care, housekeeping duties, and clerical tasks. Direct patient care includes washing and dressing the patient, assisting with feeding, taking observations, and assisting with toileting. Housekeeping involves cleaning equipment and sorting laundry. The clerical aspects relate to a range of duties, such as ordering supplies. The duties that are most often delegated by nurses to HCAs include those of providing assistance with washing and dressing, feeding, mobilising, toileting, and bedmaking (NHS, 2009).

Those HCAs who have received the appropriate training and who have been assessed as competent may undertake patient observations including (but not limited to) temperature, pulse, respirations, and weight (NHS, 2009). In order to prepare for an increased level of responsibility within their role, HCAs may be offered the opportunity to undertake one of the National Vocational Qualification (NVQ) programs. These are programs in which HCAs are taught the skills and knowledge necessary to practice competently as HCAs. In these programs participants' competency is assessed at various levels to determine the level of proficiency at which they are able to provide patient care. The programs provide levels of skill that can be transferred from one setting to another during the HCA’s work life. These NVQs are the most recognised form of vocational training for HCAs (Skills for Health, 2010). An NVQ Level 2 prepares the HCA to take on further responsibilities than they have in their current role. The NVQ Level 3 is recognised as meeting the entry requirement to a Pre-Registration Nurse Education programme.

Legal and Professional Aspects of Delegation

A number of definitions of delegation can be found within the nursing literature. The important emphasis within each definition is that the work is being done by another (the delegatee) who accepts responsibility for carrying out the delegated work and is accountable as to how the work is carried out. It is emphasized, however, that the accountability and responsibility also remain with the delegator who needs to be sure that the work is delegated appropriately (Hansten & Jackson 2004; Marquis & Huston 2009; McEachen & Keogh 2007; Quallich, 2005). Dimond (2008) has described the legal responsibility of the nurse undertaking delegation by noting, “it is the personal and professional responsibility of each practitioner who delegates activities to ensure that the person to carry out that activity is trained, competent, and has the necessary experience to undertake the activity safely” (p. 570).

Although the NMC does not offer a definition of delegation, it does emphasise the importance of delegation by including within the NMC Code the following statement regarding standards for conduct, performance, and ethics for nurses and midwives:

• You must establish that anyone you delegate to is able to carry out your instructions
• You must confirm that the outcome of any delegated task meets the required standards
• You must make sure that everyone you are responsible for is supervised and supported (NMC, 2008a, p.6)

It stresses the need to ensure that delegation only takes place when it is in the best interests of the person receiving the care... In addition, the NMC (2008) has established principles which should be adhered to by nurses when delegating to others. It stresses the need to ensure that delegation only takes place when it is in the best interests of the person receiving the care and when a holistic assessment of need has been undertaken by the nurse who delegates the care. It emphasises the importance of accountability and responsibility within the process of delegation. The nurse who delegates remains accountable for the appropriateness of the delegation and making a judgement about the supervision required by the person carrying out the delegated task. Overall the employer has the responsibility to ensure that the persons to whom nurses may delegate tasks have the appropriate education, training, and skills to carry those tasks that a nurse may be expected to delegate to them.

However, the nurse who delegates the task retains the responsibility to judge the appropriateness of the delegation by:

• Reassessing the condition of the person in the care of the nurse or midwife at appropriate intervals and determining that it remains stable and predictable; and
• Observing the competence of the caregiver(s) and determining that they remain competent to safely perform the delegated task of care safely and effectively
• Evaluating whether or not to continue delegation of the task” (NMC, 2008b, p. 3)

Thus the NMC provides considerable guidance related to delegation in nursing.

The RCN, too, does not offer a definition of delegation, although it also provides guidance and an emphasis on the nature of delegation. It has determined that the following factors need to be considered by the delegator when considering what to delegate and to whom:

• the individual’s skills, competence, attitudes and experience;
• the requirements of the patient/client/client group;
• the nature of the task in the specific circumstance (RCN. 2006, p. 11).

It is important to note that in the UK, just as in other countries such as the United States (US), a basic guideline for delegation decision making focuses on the Five Rights of Decision Making as described by the U.S. National Council of State Boards of Nursing (1995).

The UK has developed legal definitions relating to delegation, encompassing the following factors: (a) leadership functions and delegation, (b) management roles and delegation, (c) information on tasks that can be delegated, including legislation, guides, job descriptions, policies and procedures, and patient needs, and (d) guidelines on how to delegate (Dimond, 2008).

Benefits of Delegation

Delegation builds the confidence and self-esteem of HCAs by allowing them to hone their caring skills under supervision. Delegation has many positive outcomes for both patients and staff. Barker, Sullivan, and Emery (2006) have explained that delegation is a trust-building activity as it allows HCAs to demonstrate that they can accomplish tasks delegated by registered nurses, thus showing the valuable contribution they can make to patient care. As a consequence, nurses feel more confident about delegating duties to HCAs. Delegation builds the confidence and self-esteem of HCAs by allowing them to hone their caring skills under supervision. Delegation helps HCAs grow, learn, and become leaders as they see more of the ‘big picture.’

Delegation benefits the patient in that it can match the right person with the right expertise for the right job. If used judiciously, delegation can ensure that HCAs can perform caring roles that have a beneficial effect on patient health outcomes. Keeney et al. (2004) have reported that HCAs were viewed positively by patients. However, there needs to be a concerted effort to discover how delegation of duties to HCAs in the UK healthcare...there needs to be a concerted effort to discover how delegation of duties to HCAs...correlates with positive patient outcomes. setting correlates with positive patient outcomes. Unfortunately, there is a dearth of literature that has identified specifically how delegation benefits patient care. Spilsbury and Meyer (2004) have acknowledged this lack of literature on “the impact on care when HCAs substitute for RNs” (p. 416).

Delegation frees managers from more routine tasks, allowing them the time for relatively more important activities relating to patient care. It is also an important tool in succession planning, i.e., the process for developing internal personnel with the potential to fill key organisational positions. Succession planning ensures the availability of experienced and capable employees that are prepared to assume more advanced roles as they become available.

Facilitators of Delegation in the United Kingdom

The Cambridgeshire NHS Primary Care Trust...has produced comprehensive guidelines which include guidance on recruitment, induction, development, and training of support workers. One important delegation facilitator is that of an organisational culture that cultivates professional development. In recent years HCAs have been actively encouraged to undertake National Vocational Qualifications (NVQs) (described above) to increase their knowledge and skills needed to perform in their roles. It is also important that nurses be encouraged to continue developing their professional skills and knowledge base.

Clear organisational and departmental policies that provide coherent guidance on the proper utilisation of delegation also facilitate the delegation process. The publication of comprehensive, professional-practice guidelines that equip the nurse with the fundamentals of her role vis-à-vis delegation is a major facilitator. Some Health Trusts (these are the organisations that provide health and in some instances social care for patient/clients) have policies in place with regard to delegation of duties to Health Care Assistants. They take into account the training needs and skills required to safely undertake delegated tasks. The Cambridgeshire NHS Primary Care Trust (2006), for example, has produced comprehensive guidelines which include guidance on recruitment, induction, development, and training of support workers (Cambridgeshire HCT 2006).

Barriers to Delegation in the United Kingdom

The three key elements in the act of delegation include the delegator, the delegatee, and the situational context (Carr & Pearson, 2005: Swansburg & Swansburg, 2002). Any of these elements, or a combination of any of them, can become a barrier to the delegation process. Barriers ascribed to delegators include their preference to work alone, lack of experience, insecurity, lack of confidence in subordinates, desire for control, lack of organisational/managerial skills, and/or unwillingness to develop subordinates and help them grow in their roles (Mackenzie, 2009). Barriers that may arise from the perspective of the delegatee include lack of experience, lack of competence, avoidance of responsibility, lack of organizational skills, and/or excessive amounts of work (Mackenzie, 2009). The barriers that may arise as a result of the situational context include the critical nature of decisions, the urgency of those decisions, confusion relating to responsibility and authority, and understaffing (Mackenzie, 2009). Although barriers to effective delegation exist, many of these barriers can be overcome through effective education and training of both the delegator and the delegatee.

Changes in Role Expectations

The provision of care in the community has evolved to meet the needs of the patients. Nurses now have variety of job titles and roles, some of which were previously the remit of medical staff. These roles range from the more traditional staff nurse and ward manager roles to those of nurse practitioner, specialist nurse, and nurse consultant roles. As noted earlier, the context of care, within which nurses in the UK are required to deliver a high standard of efficient and effective care, has been subject to profound and enduring change (Department of Health [DH], 2006). These changes to the roles and context within which care is delivered have led to changes in the organisation of care and an increasing need to delegate some of the more traditional nursing roles to HCAs.

In 2007 the Health Care Assistant (HCA) toolkit was developed by the Working in Partnership Programme (WiPP) in collaboration with Staffordshire University. This program has outlined how HCAs can be incorporated into the primary care team by undertaking certain aspects of patient care that previously were the remit of nurses and general practitioners (GPs). In the UK, GPs are defined as “personal doctors, primarily responsible for the provision of comprehensive and continuing medical care to patients irrespective of age, sex and illness” within the primary care setting (Royal College of General Practitioners, 2010). This setting is most often that of a health centre located in the community. The provision of care in the community has evolved to meet the needs of the patients. Part of this evolution has included HCAs taking on a wider range of tasks than previously was the case. The care they provide may now range from personal care and monitoring patients’ conditions to performing venipunctures and assisting with minor operations (RCN, 2010). These new roles require training that is focused on the specific tasks the HCA will be expected to undertake while working in these new areas.

Variety of Nursing Settings in which Delegation Occurs

Current literature regarding the HCA role concentrates on hospital-based settings (Bach, Kessler, & Heron 2008; Spilsbury & Meyer, 2004; Thornley, 2007). Within hospitals HCAs are employed in medical and surgical wards, operating theatres, and also accident/emergency, maternity, and outpatient departments. Nurses, too, now work within a wide range of settings within the hospital and community and undertake increasingly diverse roles within the wider parameters of the healthcare team. The tasks that are delegated to the HCA depend on the location of the care delivery. These locations may include not only the hospital or community, but also patients’ homes, day centres, nursing and residential homes, and prisons. When the skill mix includes non-registered healthcare workers, it is likely that nurses will be involved in the delegation of care.

Nursing Delegation Challenges in the United Kingdom

There remains ongoing confusion as to the boundaries of HCAs’ roles because there is no standardised role for HCAs. The individual HCA’s work is dependent upon a number of factors, including the specific clinical area, the means by which delegation occurs, and the particular ideological thinking of the healthcare setting (Keeney et al. 2005). This lack of standardization is reflected in the variation of job descriptions for HCAs in UK hospitals (Wakefield et al., 2009). Such variation leads to confusion for both the registered nurses and HCAs who work together in a clinical area. It is expected that all three of the areas identified by Spilsbury and Meyer (2004) as being included in the HCA job responsibilities, namely direct patient care, housekeeping duties, and clerical tasks, will be delegated and supervised by registered nursing staff. However, in the reality of the clinical setting, there is a wide variation in how these duties are carried out, depending on the hospital and ward. The overall findings in Spilsbury and Meyer’s study demonstrated that HCAs often worked alone and with minimal supervision and/or delegation. The implication was that, on the whole, they worked in a manner that did not comply with official hospital policy (Spilsbury & Meyer, 2004).

Conclusion

Due to the changing nature and context of care, nurses need to have an ongoing, comprehensive understanding of delegation and the role that it plays in current nursing care. The American Nurses Association (2005) has cautioned nurses to engage in a critical-thinking process before delegating care responsibilities to assistive personnel. As part of this critical thinking process, the delegator must ensure the appropriate assessment, planning, implementation, and evaluation regarding the patients’ care, so that patients receive not only safe, quality care but also that this care is delivered by an appropriate person, i.e., one who has the requisite knowledge, skill, and competency to carry out that care.

Authors

Patricia Gillen, PhD, RN, RM, RNT, MSc, BSc
E-mail: p.gillen@ulster.ac.uk

Patricia Gillen has been a Registered Nurse (RN) since 1984 and a Registered Midwife (RM) since 1987. She has worked as a nurse, a midwife, and a midwife sister and manager in both rural and urban hospitals. In January 2002, she began serving as a lecturer in the University of Ulster. She completed her PhD in 2007 in the area of workplace bullying. Dr. Gillen teaches both pre- and post-registration students across a range of areas, including nursing management.

Sean Graffin, RN, RMN, RNT, BSc
E-mail: s.graffin@ulster.ac.uk

Seán Graffin has been a Registered Mental Nurse (RMN) since 1984 and a Registered General Nurse (RGN) since 1986. He has been working for a number of years in a Coronary Care Unit at a major hospital in Belfast, Northern Ireland and has been managing Clinical Trials for several years in the same hospital. He has served as a Registered Nurse Teacher (RNT) and has been a lecturer in Nursing at the University of Ulster since 2001. His main teaching areas have been cardiac nursing and nursing management.

© 2010 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2010