Risk managers should educate nurses about the potential liability risks from wrongful delegation, which could threaten the nurse’s career and expose the hospital.
Wrongful delegation occurs when a task is assigned to a worker who doesn’t have the credentials to perform the task, says Jennifer Flynn, CPHRM, manager in the Healthcare Risk Management division of consulting firm Aon in Fort Washington, PA.
“Nurses are faced with this situation because of the push to cut costs and work with fewer people on staff, as well as the nursing shortage,” Flynn says. “It becomes a liability issue for the nurse because even if he or she has been put in a situation in which they feel they have to delegate tasks to an unlicensed staff member to get the job done, ultimately they are responsible for what happens to that patient.”
Effective delegation frees the nurse to focus on providing quality care to the patient rather than being bogged down with tasks that can be carried out safely by someone with less training, Flynn notes. Tasks that can be safely delegated are those that do not require nursing judgment, Flynn explains.
“Each patient is a case-by-case basis, and sometimes it will be a moment-to-moment basis as to whether it is safe to delegate or not,” Flynn says. “The nurse also has to consider the capabilities of the particular person that you are considering delegating this task to. Does that person have the competency to do what you’re considering delegating?”
Communication is key to safe delegation, Flynn says. The nurse must not assume what the unlicensed staff member is capable of doing or has experience with, she says.
In most healthcare settings, the roles of staff members and associated tasks for those staff members are clearly defined by regulations (such as state nurse practice acts for registered and licensed nurses), organization policy, and job descriptions, notes Bette McNee, RN, NHA, clinical risk management consultant at insurance broker Graham Company in Philadelphia.
“Allowing care to be provided by an unlicensed worker who may not have the skills or experience with specific techniques is considered wrongful delegation and should be avoided at all costs,” McNee says. “Nurses should get in the habit of asking themselves, ‘Does this patient require special care that is beyond the typical or usual patient care?’ If the answer is yes, the nurse must determine if the unlicensed worker or CNA [certified nursing assistant] is competent to provide the specialized care or task — as many would agree that a ‘reasonably prudent nurse’ would do so.”
The nurse may always choose to perform the task him- or herself rather than determining competency, McNee notes.
“Typically, it is not a true delegation issue like we see in the office setting where responsibilities are assigned as projects are planned. In healthcare, the roles and responsibilities are clearly defined: nurses take orders, administer medication and treatment, [and] make observations or perform assessments, whereas unlicensed workers like CNAs or rehab aides feed, bathe, toilet, groom, and transfer patients,” McNee says.
“The question of delegation — who is allowed to do what — seems to be a simple one, but that’s not always the case.”
The issue can arise when a task that is typically and appropriately completed by the lesser skilled or unlicensed worker is not appropriate in some circumstances. For instance, CNAs feed patients; it is a core responsibility of their position. However, if the CNA is assigned to feed a patient who had suffered a stroke, the patient must be fed in a particular way to prevent aspiration.
“If the nurse does not determine if the CNA is competent enough to feed this patient and the patient aspirates, the nurse’s delegation of the task of feeding can come under fire,” McNee says. “It actually isn’t a delegation at all. If the nurse allows the CNA to feed the patient as he or she normally would — because it is their responsibility — without establishing the CNA’s competency, the nurse is failing to undelegate the task.”
Ambulation is also a core responsibility of CNAs, McNee notes. Issues can arise in a situation where a patient walks too quickly or has a tendency to lose balance. The nurse must determine whether the CNA has competency before allowing him or her to perform the task they were hired to do, she says. Failing to ensure competency before allowing the CNA to ambulate the patient is a liability risk for the organization as well as the nurse, she says.
Although CNAs are trained and assigned to feed, transfer, toilet, groom, and bathe, it is the nurse’s responsibility to oversee the patient’s care, and it is something that needs to be taken very seriously, McNee says.
A risk manager can help nurses avoid wrongful delegation by sharing this potential risk with all licensed staff, supervisors, managers, and department directors within the organization, McNee suggests.
“To be proactive, they can ensure that the organization measures the competency of CNAs or rehab aides to care for patients with various needs,” McNee says. “It also makes sense to create a process so that CNAs or rehab aides are trained in the specific techniques required to care for each patient and are taught to request clarification of techniques before attempting to care for a patient who requires a specialized approach.”