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Joint Statement on Nursing Delegation: ANA and NCSBN Guidelines, Study Guides, Projects, Research of Nursing

A joint statement from the American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN) on the importance and safe practices of nursing delegation. It outlines the principles, considerations, and resources for effective delegation in nursing. The statement emphasizes the accountability and responsibility of RNs in delegating tasks, the importance of communication, and the role of organizational support.

What you will learn

  • What are the principles of delegation according to the ANA and NCSBN?
  • What considerations should RNs take into account when delegating tasks?
  • What resources are available from the ANA and NCSBN to support effective delegation in nursing?

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Joint Statement on Delegation
American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN)
Introduction
There is more nursing to do than there are nurses to do it. Many nurses are stretched to the limit in the
current chaotic healthcare environment. Increasing numbers of people needing healthcare combined with
increasing complexity of therapies create a tremendous demand for nursing care. More than ever, nurses
need to work effectively with assistive personnel. The abilities to delegate, assign, and supervise are
critical competencies for the 21st century nurse.
In 2005, both the American Nurses Association and the National Council of State Boards of Nursing
adopted papers on delegation.1 Both papers presented the same message: delegation is an essential
nursing skill. This joint statement was developed to support the practicing nurse in using delegation safely
and effectively.
Terminology
Although there is considerable variation in the language used to talk about delegation, ANA and NCSBN
both defined delegation as the process for a nurse to direct another person to perform nursing tasks and
activities. NCSBN describes this as the nurse transferring authority while ANA calls this a transfer of
responsibility. Both mean that a registered nurse (RN) can direct another individual to do something that
that person would not normally be allowed to do. Both papers stress that the nurse retains accountability
for the delegation.
Both papers define assignment as the distribution of work that each staff member is responsible for
during a given work period. The NCSBN uses the verb “assign” to describe those situations when a nurse
directs an individual to do something the individual is already authorized to do, e.g., when an RN directs
another RN to assess a patient, the second RN is already authorized to assess patients in the RN scope
of practice.
Both papers consider supervision2 to be the provision of guidance and oversight of a delegated nursing
task. ANA refers to on-site supervision and NCSBN refers to direct supervision, but both have to do with
the physical presence and immediate availability of the supervising nurse. The ANA refers to off-site
supervision, and NCSBN refers to indirect supervision. Both have to do with availability of the supervising
nurse through various means of written and verbal communication.
1 ANA and NCSBN have different constituencies. The constituency of ANA is state nursing associations and member
RNs. The constituency of NCSBN is state boards of nursing and all licensed nursing. Although for the purpose of
collaboration, this joint paper refers to registered nurse practice, NCSBN acknowledges that in many states LPN/VNs
have limited authority to delegate.
2 ANA defines supervision to be the active process of directing, guiding, and influencing the outcome of an individual’s
performance of a task. Similarly, NCSBN defines supervision as the provision of guidance or direction, oversight,
evaluation and follow-up by the licensed nurse for the accomplishment of a delegated nursing task by assistive
personnel. Individuals engaging in supervision of patient care should not be construed to be managerial supervisors
on behalf of the employer under federal labor law.
ANA 8515 Georgia Avenue, Suite 400 Silver Spring Maryland 20910-3492 301.628.6500 Fax 301.628.5001 www.nursingworld.org
NCSBN 111 E. Wacker Drive, Suite 2900 Chicago, Illinois 60601-4277 312.525.3600 Fax 301.279.1032 www.ncsbn.org
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American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN)

Introduction

There is more nursing to do than there are nurses to do it. Many nurses are stretched to the limit in the

current chaotic healthcare environment. Increasing numbers of people needing healthcare combined with

increasing complexity of therapies create a tremendous demand for nursing care. More than ever, nurses

need to work effectively with assistive personnel. The abilities to delegate, assign, and supervise are

critical competencies for the 21

st

century nurse.

In 2005, both the American Nurses Association and the National Council of State Boards of Nursing

adopted papers on delegation.

1

Both papers presented the same message: delegation is an essential

nursing skill. This joint statement was developed to support the practicing nurse in using delegation safely

and effectively.

Terminology

Although there is considerable variation in the language used to talk about delegation, ANA and NCSBN

both defined delegation as the process for a nurse to direct another person to perform nursing tasks and

activities. NCSBN describes this as the nurse transferring authority while ANA calls this a transfer of

responsibility. Both mean that a registered nurse (RN) can direct another individual to do something that

that person would not normally be allowed to do. Both papers stress that the nurse retains accountability

for the delegation.

Both papers define assignment as the distribution of work that each staff member is responsible for

during a given work period. The NCSBN uses the verb “assign” to describe those situations when a nurse

directs an individual to do something the individual is already authorized to do, e.g., when an RN directs

another RN to assess a patient, the second RN is already authorized to assess patients in the RN scope

of practice.

Both papers consider supervision

2

to be the provision of guidance and oversight of a delegated nursing

task. ANA refers to on-site supervision and NCSBN refers to direct supervision, but both have to do with

the physical presence and immediate availability of the supervising nurse. The ANA refers to off-site

supervision, and NCSBN refers to indirect supervision. Both have to do with availability of the supervising

nurse through various means of written and verbal communication.

1 ANA and NCSBN have different constituencies. The constituency of ANA is state nursing associations and member

RNs. The constituency of NCSBN is state boards of nursing and all licensed nursing. Although for the purpose of

collaboration, this joint paper refers to registered nurse practice, NCSBN acknowledges that in many states LPN/VNs

have limited authority to delegate.

2

ANA defines supervision to be the active process of directing, guiding, and influencing the outcome of an individual’s

performance of a task. Similarly, NCSBN defines supervision as the provision of guidance or direction, oversight,

evaluation and follow-up by the licensed nurse for the accomplishment of a delegated nursing task by assistive

personnel. Individuals engaging in supervision of patient care should not be construed to be managerial supervisors

on behalf of the employer under federal labor law.

ANA • 8515 Georgia Avenue, Suite 400 • Silver Spring Maryland 20910-3492 • 301.628.6500 • Fax 301.628.5001 • www.nursingworld.org

American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN)

Policy Considerations

ƒ State nurse practice acts define the legal parameters for nursing practice. Most states authorize RNs

to delegate.

ƒ There is a need and a place for competent, appropriately supervised nursing assistive personnel in

the delivery of affordable, quality health care.

ƒ The RN assigns or delegates tasks based on the needs and condition of the patient, potential for

harm, stability of the patient’s condition, complexity of the task, predictability of the outcomes, abilities

of the staff to whom the task is delegated, and the context of other patient needs.

ƒ All decisions related to delegation and assignment are based on the fundamental principles of

protection of the health, safety and welfare of the public.

Principles of Delegation

ƒ The RN takes responsibility and accountability for the provision of nursing practice.

ƒ The RN directs care and determines the appropriate utilization of any assistant involved in providing

direct patient care.

ƒ The RN may delegate components of care but does not delegate the nursing process itself. The

practice pervasive functions of assessment, planning, evaluation and nursing judgment cannot be

delegated.

ƒ The decision of whether or not to delegate or assign is based upon the RN’s judgment concerning the

condition of the patient, the competence of all members of the nursing team and the degree of

supervision that will be required of the RN if a task is delegated.

ƒ The RN delegates only those tasks for which she or he believes the other health care worker has the

knowledge and skill to perform, taking into consideration training, cultural competence, experience

and facility/agency policies and procedures.

ƒ The RN individualizes communication regarding the delegation to the nursing assistive personnel and

client situation and the communication should be clear, concise, correct and complete. The RN

verifies comprehension with the nursing assistive personnel and that the assistant accepts the

delegation and the responsibility that accompanies it.

ƒ Communication must be a two-way process. Nursing assistive personnel should have the opportunity

to ask questions and/or for clarification of expectations.

ƒ The RN uses critical thinking and professional judgment when following the Five Rights of Delegation,

to be sure that the delegation or assignment is:

1. The right task

2. Under the right circumstances

3. To the right person

4. With the right directions and communication; and

5. Under the right supervision and evaluation.

ƒ Chief Nursing Officers are accountable for establishing systems to assess, monitor, verify and

communicate ongoing competence requirements in areas related to delegation.

ANA • 8515 Georgia Avenue, Suite 400 • Silver Spring Maryland 20910-3492 • 301.628.6500 • Fax 301.628.5001 • www.nursingworld.org

American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN)

The NCSBN paper discusses these elements as part of the preparation to delegate. The NCSBN paper

also articulates the following steps of the delegation process:

ƒ Assess and plan the delegation, based on the patient needs and available resources.

ƒ Communicate directions to the delegate including any unique patient requirements and

characteristics as well as clear expectations regarding what to do, what to report, and when to ask for

assistance.

ƒ Surveillance and supervision of the delegation, including the level of supervision needed for the

particular situation and the implementation of that supervision, including follow-up to problems or a

changing situation.

ƒ Evaluation and feedback to consider the effectiveness of the delegation, including any need to adjust

the plan of care.

Delegation skills are developed over time. Nursing employers need to recognize that a newly licensed

nurse is a novice who is still acquiring foundational knowledge and skills. In addition, many nurses lack

the knowledge, the skill and the confidence to delegate effectively, so ongoing opportunities to enforce

the theory and apply the principles of delegation is an essential part of employment orientation and staff

development.

Many nurses are reluctant to delegate. This is reflected in NCSBN research findings and a review of the

literature as well as anecdotal accounts from nursing students and practicing nurses. There are many

contributing factors, ranging from not having had educational opportunities to learn how to work with

others effectively to not knowing the skill level and abilities of nursing assistive personnel to simply the

work pace and turnover of patients. At the same time, NCSBN research shows an increase in the

complexity of the nursing tasks performed by assistive personnel. With the demographic changes and

resultant increase in the need for nursing services, plus the nursing shortage, nurses need the support of

nursing assistive personnel.

Conclusions

The topic of delegation has never been timelier. Delegation is a process that, used appropriately, can

result in safe and effective nursing care. Delegation can free the nurse for attending more complex patient

care needs, develop the skills of nursing assistive personnel and promote cost containment for the

healthcare organization. The RN determines appropriate nursing practice by using nursing knowledge,

professional judgment and the legal authority to practice nursing. RNs must know the context of their

practice, including the state nurse practice act and professional standards as well as the

facility/organization’s policies and procedures related to delegation. Facing a shortage of epic proportions,

the nursing community needs to plan how we can continue to accomplish nursing care while assuring the

public access to safe, competent nursing care. RNs are urged to seek guidance and appropriate direction

from supervisors or mentors when considering decisions about delegation. Mastering the skill and art of

delegation is a critical step on the pathway to nursing excellence.

Attachments:

Attachment A: ANA Principles of Delegation

Attachment B: NCSBN Decision Tree – Delegation to Nursing Assistive Personnel

ANA • 8515 Georgia Avenue, Suite 400 • Silver Spring Maryland 20910-3492 • 301.628.6500 • Fax 301.628.5001 • www.nursingworld.org

American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN)

Appendix A

American Nurses Association Principles for Delegation

The following principles have remained constant since the early 1950s.

Overarching Principles:

ƒ The nursing profession determines the scope of nursing practice.

ƒ The nursing profession defines and supervises the education, training and utilization for any

assistant roles involved in providing direct patient care.

ƒ The RN takes responsibility and accountability for the provision of nursing practice.

ƒ The RN directs care and determines the appropriate utilization of any assistant involved in

providing direct patient care.

ƒ The RN accepts aid from nursing assistive personnel in providing direct patient care.

Nurse-related Principles:

ƒ The RN may delegate elements of care but does not delegate the nursing process itself.

ƒ The RN has the duty to answer for personal actions relating to the nursing process.

ƒ The RN takes into account the knowledge and skills of any individual to whom the RN may

delegate elements of care.

ƒ The decision of whether or not to delegate or assign is based upon the RN’s judgment concerning

the condition of the patient, the competence of all members of the nursing team and the degree of

supervision that will be required of the RN if a task is delegated.

ƒ The RN delegates only those tasks for which she or he believes the other health care worker has

the knowledge and skill to perform, taking into consideration training, cultural competence

experience and facility/agency policies and procedures.

ƒ The RN uses critical thinking and professional judgment when following The Five Rights of

Delegation:

1. Right task

2. Right circumstances

3. Right person

4. Right directions and communication

5. Right supervision and evaluation (NCSBN 1995)

ƒ The RN acknowledges that there is a relational aspect to delegation and that communication is

culturally appropriate and the person receiving the communication is treated respectfully.

ƒ Chief nursing officers are accountable for establishing systems to assess, monitor, verify and

communicate ongoing competence requirements in areas related to delegation, both for RNs and

delegates.

ƒ RNs monitor organizational policies, procedures and position descriptions to ensure there is no

violation of the nurse practice act, working with the state board of nursing if necessary.

ANA • 8515 Georgia Avenue, Suite 400 • Silver Spring Maryland 20910-3492 • 301.628.6500 • Fax 301.628.5001 • www.nursingworld.org

American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN)

Appendix B National Council of State Boards of Nursing

Decision Tree for Delegation to Nursing Assistive Personnel

Step One – Assessment and Planning

NO^ Do not delegate

Is the task within the scope of the

delegating nurse?

Is the delegating nurse competent to make

delegation decisions?

Has there been assessment of the client

needs?

NO

NO

NO

If not in the licensed nurse’s scope of

practice, then cannot delegate to the

nursing assistive personnel (NAP).

Authority to delegate varies; so

licensed nurses must check the

jurisdiction’s statutes and

regulations.

Do not delegate

Assess client needs and then proceed

to a consideration of delegation

Do not delegate until can provide and

document additional education, then

reconsider delegation; otherwise do

not delegate

YES

YES

YES

NO

YES

Is the task consistent with the recommended criteria

for delegation to nursing assistive personnel (NAP)?

Must meet all the following criteria:

ƒ Is within the NAP range of functions ƒ Frequently recurs in the daily care of a client or group of clients; ƒ Is performed according to an established sequence of steps; ƒ Involves little or no modification from one client-care situation to another; ƒ May be performed with a predictable outcome; ƒ Does not inherently involve ongoing assessment, interpretation, or decision-making which cannot be logically separated from the procedure(s) itself; and ƒ Does not endanger a client’s life or well-being

Are there laws and rules in place that

support the delegation?

Do not delegate until evidence of

education and validation of

competency available, then reconsider

delegations; otherwise do not

delegate

YES

Does the nursing assistive personnel have the

appropriate knowledge, skills and abilities (KSA) to

accept the delegation?

Does the ability of the NAP match the care needs of

the client?

NO

YES

ANA • 8515 Georgia Avenue, Suite 400 • Silver Spring Maryland 20910-3492 • 301.628.6500 • Fax 301.628.5001 • www.nursingworld.org

American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN)

NO^ Do not delegate

NO

Are there agency policies, procedures and/or

protocols in place for this task/activity?

Is appropriate supervision available?

Do not proceed without evaluation

of need for policy, procedures

and/or protocol or determination

that it is in the best interest of the

YES client to proceed to delegation.

Proceed with delegation*

YES

Step Two – Communication

Communication must be a two-way process

The nurse: ƒ Assesses the assistant’s understanding o How the task is to be accomplished o When and what information is to be reported, including 9 Expected observations to report and record 9 Specific client concerns that would require prompt reporting. ƒ Individualizes for the nursing assistive personnel and client situation ƒ Addresses any unique client requirements and characteristics, and clear expectations of: ƒ Assesses the assistant’s understanding of expectations, providing clarification if needed. ƒ Communicates his or her willingness and availability to guide and support assistant. ƒ Assures appropriate accountability by verifying that the receiving person accepts the delegation and accompanying responsibility

The nursing assistive personne l ƒ Ask questions regarding the delegation and seek clarification of expectations if needed ƒ Inform the nurse if the assistant has not done a task/function/activity before, or has only done infrequently ƒ Ask for additional training or supervision ƒ Affirm understanding of expectations ƒ Determine the communication method between the nurse and the assistive personnel ƒ Determine the communication and plan of action in emergency situations.

Documentation : Timely, complete and accurate documentation of provided care ƒ Facilitates communication with other members of the healthcare team ƒ Records the nursing care provided.

ANA • 8515 Georgia Avenue, Suite 400 • Silver Spring Maryland 20910-3492 • 301.628.6500 • Fax 301.628.5001 • www.nursingworld.org