Significant changes in health care over the past century have included implementation of a universal health care system, a rapidly aging population, technological advances, and scientific discoveries, and have culminated in increased stress upon the system and rapidly escalating costs. Health care leaders searched for ways to meet the increasing demands placed on the system. One solution that has been successfully implemented over the past 20 to 30 years, in response to these pressures on health care, is delegation of care. Delegation of care refers to “the transfer of responsibility for a task when it is not part of the scope of practice or scope of employment of the care provider” (SRNA, 2015, p. 8). Delegation of care most often occurs between an RN and an unregulated care provider or between a physician and an RN. Guidelines have been established to ensure the quality of patient care throughout the delegation process.
Delegation and Assignment of Nursing Care
The RN is responsible for the coordination of patient care, which may include assessment, assignment, care planning, supervision, ongoing monitoring, decision making, and evaluation of care (SRNA, 2015). The RN assigns provision of the client’s care to the most appropriate care provider based on the previously completed RN assessment.
Assignment occurs when the required care falls within the scope of practice (i.e., LPN [licensed practical nurse], RN, RPN [registered psychiatric nurse]) or the job description (i.e., UCP [unregulated care provider]) of the care provider who accepts the assignment from the RN. . . . The RN at the point of care retains the overall accountability for the appropriate assignment and oversight of client care. This responsibility cannot be delegated. (SRNA, 2015, p. 8)
Delegation of nursing care is different than assignment since it refers to “the transfer of responsibility for a task when it is not part of the scope of practice or scope of employment of the care provider” (SRNA, 2015, p. 8). It is important to remember that only the task can be delegated; the RN retains the responsibility for coordination of patient care. Nurse leaders must ensure the following delegation principles (SRNA, 2015, p. 9) are present in their organization before delegation takes place:
- Formal processes and policies must be in place to support the delegator (the one who does the delegating) and delegatee (the one who receives the delegation);
- At no time should the safety of the client be compromised by substituting less qualified workers to provide care and/or perform an intervention when the competencies and scope of the RN’s knowledge, skill and judgment are required;
- A delegated task cannot be sub-delegated; and
- The delegating RN is accountable for appropriate delegation of tasks and for the overall assessment, care planning, intervention and care evaluation. (SRNA, 2015, p. 9)
This accountability requires the RN to monitor the performance and completion of the delegated tasks by the unregulated care provider. Regular communication with the unregulated care provider is required during the initial delegation of the task, throughout the performance of the task, and when the delegated task is completed.
Essential Learning Activity 5.4.1
The five rights of delegation provide an excellent mental checklist for RN delegation of patient care. They include right task, right circumstances, right person, right direction/communication, and right supervision/evaluation. Read more about the five rights of delegation on pages 21–23 of the “SRNA Interpretation of the RN Scope of Practice.”
Delegation by Physician to RN
In September 2014, The Medical Profession Act, 1981, was amended to give the College of Physicians and Surgeons of Saskatchewan (CPSS) “the authority to adopt bylaws that can allow physicians to delegate activities described in the College bylaw to other health care professionals” (CPSS, 2015, p. 7). Consequently, the CPSS bylaws were changed to allow physicians to delegate certain activities to RNs. The transfer of medical function (TMF) allows RNs “to perform complex, highly-skilled activities which are outside the scope of registered nursing and within the scope of the practice of medicine” (SRNA, 2016, p. 1).
CPSS principles for delegation include the following:
- Delegation will be from a particular physician to a particular registered nurse. Delegation will not be by “category”;
- The activities which may be delegated are specified in the [CPSS] bylaw;
- When there is a specific program which is identified (such as the Neonatal Intensive Transport Team, the RN Pediatric Transport Team or Air Ambulance), it is not necessary to identify the specific procedures that may be provided by an RN as part of the program;
- It will be the responsibility of the physician who delegates the activity to assess the RN’s skill and knowledge to determine if, in the physician’s opinion, the RN has the appropriate skill and knowledge to perform the delegated activity;
- Delegation must be done in writing, except in the case of an emergency;
- The physician who delegates the authority to the RN must have a process in place to provide appropriate supervision. (CPSS, 2015, pp. 7–8)
Essential Learning Activity 5.4.2
RN Evolving Scope of Practice
Read pages 9–13 of the “SRNA Interpretation of the RN Scope of Practice,” then answer the following questions:
- Why is RN scope of practice evolving?
- Describe RN speciality practices. What standards is RN speciality practice built upon?
- What is the scope of practice for the RN with “additional authorized practice”? What is required for a nurse to assume the role of an RN with “additional authorized practice”?
Collaboration between RNs, RPNs, and LPNs in Saskatchewan
Read “Collaborative Decision-Making Framework: Quality Nursing Practice” (approved by the Saskatchewan Association of Licensed Practical Nurses, SRNA, and the Registered Psychiatric Nurses Association of Saskatchewan on September 9, 2017), then answer the following questions:
- What factors should patient care assignments be based on?
- What are the four main factors that influence scope of practice? Outline what nurses are educated and authorized to do.
- The Continuum of Care model on page 11 requires an analysis of which three factors when making decisions about the most effective utilization of LPNs, RNs, and RPNs?