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Accountability and delegation: What you need to know The principles of accountability and delegation for nurses, students, health care assistants and assistant practitioners. Accountability and delegation: What you need to know The p rinciples of accountability and delegation Whether y ou are a nurse, student, health care assistant (HCA) or assistant practitioner (AP), the principles of both delegation and accountab ility will be important to you and your patients. This booklet will outline the key issues so that you have a clear understanding of accountab ility in practice, wherever you work. The perso n in overall charge of the nursing care of the patient is usually the regisered nurse. But the nurse cannot perform every task for every patient and therefore s/he will need to delegate aspects of that care to colleagues . More tha n ever before, the health care team is made up of many different people who bring with them a range of skills, knowledge and compete n ce. The principles explained in this leaflet can be applied to any relevant member of the health care team. Butwho isaccountableforwhat?Shouldpatientsexpectasimilarstandard ofcareregardlessofwhen,whereandbywhomthatcareisdelivered? Accountability and delegation: What you need to know This applies whether they are performing straightforward tasks such as bathing p atients or undertaking complex surgery. In each instance there is an oppor tunity for harm to occur. Once a duty of care applies, the key question to ask is: what standard of care is expected of practitioners performi ng particular tasks or roles? HCAs, APs and students all have a duty of care and therefore a legal liability with regard to the patient. They must ensure that they perform compete ntly. They must also inform another when they are unable to perform competently. In order for anyone to be accountable they must: • have t he ability to perform the task • accept the responsibility for doing the task • have t he authority to perform the task within their job description, Y ou an d the law and the policies and protocols of the organisation. H ealth service providers are accountable to oth the criminal and civil Registere d nurses have a duty of care and a legal liability with regard to cou rts to ensurehtat their activities conforo legal requirements. In the patient. If they have delegated a task they must ensure that the task add ition, employees are accountable totheiremployer to follow their contract ofduty.Registered practitionersareal so accountableto regulatory has been appropriately delegated. bo dies in termsofstandards of practice and patient care (RCN et al., 2006). This mea ns that: Th e law impose sa duty of care on practitioners, whether they are • the task is necessary and delegation is in the patient’s best interest HCA s, APs, stude nts, registered nurses, doctors or others, when it is • the sup port worker understands the task and how it is to be performed “reasonably foreseeable” that they might ca use harm to patients through • thesupportworkerhastheskillsandabilitiestoperformthetask their actions or heir failure to act (Cox, 20). compe tently • thesup portworkeracceptstheresponsibilitytoperformthetask A nexample:Fo llowingtheprocess compe tently. Jo,anHCA,isworkingintherespiratoryclini ca tahospital.Sheperforms spirometryonapatient,havingbeenpreviou syassessedascompetent Delegat ion of duties is summarised in this statement from NHS to carrythisou tfollowingtrainingandeduca ioninspirometry(ability). Wales ( NLIAH, 2010) Th eroleforms partofherjobdescription(res ponsibility).Therespiratory “Delegat ion is the process by which you (the delegator) allocate clinical nursehasdelegatedthisactivity(authority)to herinfullknowledge or non-c liical treatment or care to a competent person (the delegatee). of herlevelofco m petenceandjobdescription .Thenurseretainsthe You willremain responsible for the overall management of the service professionalresponsibilityofappropriatedeleg ationandJo,thoughnot user, and accountable for your decision to delegate. You will not be cu rrentlyregulated,isaccountableforherac tions. accounta b le for the decisions and actions of the delegatee”. Accountability and delegation: What you need to know Employers have responsibilities too, and as HCAs and APs develop and extend their roles the employer must ensure that their staff are trained and supe rvised properly until they can demonstrate competence in their new roles (Cox, 2010). Employe rs accept ‘vicarious liability’ for their employees. This means that provded that the employee is working within their sphere of competence and in connection with their employment, the employer is also accountable for their actions. Principl es of delegation • delega tion must always be in the best interest of the patient and not performe d simply in an effort to save time or money • thesupportworkermusthavebeensuitablytrainedtoperformthetask Qu es tion s to consider • the support worker should always keep full records of training given, Wh en delegatin g atask there are three key questions to be asked: including dates • there sho uld be written evidence of competence assessment, • D oes the registered practitioner view thesupport worker as preferab ly against recognised standards such as National co mpetent to carry out the tasks? Occup ational Standards Ifthey do not believe that the support worker is competent to perform the task then the delegation would be inap propriate and not in the best interest of the patient. Anexa mple:Knowingtheboundaries • Does the support worker consider themse lves to be competent to AnHCAi s helpingadiabeticpatienttoremovetheirsockspriortoafoot p erform the activity? examinat onandnoticesthatthereisawoundonthepatient’slargetoe If not they must inform the delegating nurse or a senior colleague that they are not com petent. whichlo oksinflamed.AlthoughtheHCAisexperiencedandcompetent atbasic dressingssheisawareoftherisksassociatedwithwoundson • D oesthetaskr equireanongoingassessm entofthepatienttobemade? thefeetofdiabeticpatientsandthereforeknowsthattotreatthiswould If the task itself is complex and the planfcare may change ‘in the beoutsideofhersphereofcompetence.Sheisalsoawarethatthe woundh asnotyetbeenassessedbyaregisterednurse. m oment’ then this may not be an appropria te task to be delegated. A risk assessme nt must be performed to ensure that delegation is TheHCAreportsthewoundtotheregisterednursewhotakesoverthe appropriate an d in the best interest of thpatient. careoft hatwound.TheHCAhasactedaccordingtotheprotocolsofthe workplac eandcanjustifyheractions.Shehasdemonstratedthatshe understan dsheraccountabilityandresponsibilitiestowardsthatpatient. Accountability and delegation: What you need to know • there should be clear guidelines and proocols in place so that the s upport worke ris not required to make a linical judgement that they Everyone are not comp etent to make Best intrest knows task Supervision of patnt has been and • the role should be within the support worke r’s job description delegated mentorship • the team and a ny support staff need to be nformed that the task has b een delegate d (e.g. a receptionist in a Gurgery or ward clerk in a h ospital setnig) • the person w ho delegates the task must en sure that an appropriate On-going level of supervision is available and thathe support worker has the Education Job professional opportunity for mentorship. The level of supervision and feedback and traing Description development provided mus t be appropriate to the taskbeing delegated. This will be based on t he recorded knowledge and competence of the support worker, the ne eds of the patient/client, tservice setting and the tasks assigned (RCN et al., 2006) • ongoing devel o pment to ensure that com pe tency is maintained Compe tent and writtn Protocols Risk is essential evidence of management • the whole pro cess must be assessed for the degree of risk. assessme nt Th e Nursing & Midwifery Council (200 8) summarises the d elegator’s accountability: “Ifthe nurse or midwife is delegating careto another professional, Anexamp le:Assessingtherisk health care support staff, carer or relativh,ey must delegate JohnisatrainedandcompetentHCAandassistswiththeseasonal effectively and are accountable for the appropriateness of the influenz a vaccinationsathisplaceofwork,aGPsurgery.Heis delegation. The Code requires that nurses and midwives must: supervisedbythepracticenurseandworkswithinprotocolsandto • establish that anyone they delegate to isable to carry out their patientspecificdirections.AnewpracticemanagersuggeststhatJohn instructions shoulda ssistwiththechildhoodvaccinationclinics. • confirm that the outcome of any delegat ed task meets required Suzann e,thepracticenurse,informsthepracticemanagerthatthistask standards carriesamuchhigherrisk,i.e.havingtomakeaclinicaldecisionabout • make sure t hat everyone they are respo nsible for is supervised whichva ccinationstogiveandthe complexityofvaccinatingchildren. and supporte d .” Johnag reesthatthisisaninappropriatetaskforhimtoperform. Accountability and delegation: What you need to know S umma r y All patients shold expect the same standard o f care, whoever delivers it. Wh en delegating any aspect of care, it musbe determined that delegation is in ehbest interest of the patienThe person who delegates the task is accounable for the appropriateness of the delegation. If he delegation of a task to another person s appropriate, the support wo rker is accountable for the standard of perormance. Th e level of suervision provided must be a ppropriate to the situation and take into account the complexity of the task, the competence of the sup port worker, he needs of the patient and the setting in which the care is being givn . Re fere n c es Co x C: Legal reponsibility and accountabiliy; Nursing Management 17: 3: 8 -20 June 2010 NLIAH (National L eadership and Innovations Agency for Healthcare): All W ales Guidelines for Delegation; Septembe r 2010 N MC (Nursing & Midwifery Council) Advice on Accountability for registered nurses (2010). Available at: www .nmc-uk.org/Nurses-and- m idwives/Advice -by-topic/A/Advice/Account ability/ (accessed 16 Dec 2010 ) RCN (Royal Colle ge of Nursing) et al,: Intellegiate paper: Supervision, acco untability ad delegation of activities tsupport workers: a guide forregistered practitioners and support work ers; Jan 2006 RC N (Royal College of Nursing): Health careassistants and assistant practitioners. Deegation and Accountability; 2 008As an HCA or AP you can join the Royal College of Nursing The RCN is the largest union and professional body in the UK dedicated solely to the nursing and health care profession. Join over 400,000 other members and get your voice heard. We offer: • a £3 million indemnity scheme • expert support and advice from nursing professionals • expert employment and legal advice, plus we use only lawyers who are specialists in nursing issues to ensure we achieve the best possible outcomes for our members • the first HCA/AP network • a whole host of HCA and AP specific learning and development opportunities, including one of the largest nursing libraries in the world. As an HCA or AP, can you afford to be without the RCN? To join: Visit www.rcn.org.uk/join Call 0345 772 6100 To find out more about the HCA and AP team at the RCN and for up to the minute news, important documents and useful links, go to www.rcn.org.uk/hca View tand delegation hereountability Publication code 003 942 Published October 2011