Unlicensed assistive personnel (UAP) are a ubiquitous presence in nurses’ workplaces. The American Nurses Association (ANA) and National Council of State Boards of Nursing (NCSBN) have concluded that the skill and art of delegation for effective use of nursing assistive personnel is critical for nursing excellence, particularly considering the looming critical nursing shortage.¹ Encompassing more than 50 different job titles, UAP are healthcare workers who assist in patient care activities under the delegation and supervision of a registered nurse (RN). Although professional organizations endorse this role^1,2,3,4,5 and most hospitals employ them,⁶ there are no universal hiring, training, or job descriptions. Nursing policies and guidelines determine what can be safely delegated, and the Joint Commission on Accreditation of Healthcare Organizations requires that all staff be properly trained and supervised for those activities they are required to perform.⁷ Strategies can to help discern how to delegate properly to UAP.

The use of unlicensed assistive personnel evolved in the late 1980s in response to emerging nursing shortages as well as to rising healthcare costs.⁷ Therefore, there are many RNs practicing today who entered nursing with little or no experience with the art of delegation. Additionally, the average age of RNs is increasing, while the work remains physically demanding.⁸ These factors together help explain why many organizations now use less-expensive, less-skilled workers who still must be supervised by professional nurses, although the effectiveness of these workers has yet to be fully demonstrated.⁷

Supervision and delegation are interlocking concepts essential to the appropriate use of UAP. The NCSBN and ANA have issued a joint position paper on delegation and supervision, providing operational definitions for the two terms that provides a baseline standard for legal language. Supervision is defined as “the provision of guidance and oversight of the delegated nursing task by assistive personnel.” It is further described as “the active process of directing, guiding, and influencing the outcomes of an individual’s performance of a task.” A nurse who makes patient care rounds to oversee the care delivered by staff members is performing an act of supervision. The ANA and NCSBN have included language in the joint statement on delegation, noting that individuals engaging in the supervision of patient care should not be construed to be managerial supervisors on behalf of the employer under federal labor law.¹

Delegation is defined by the NCSBN and the ANA as “the process for a nurse to direct another person to perform nursing tasks and activities.” The decision to delegate is of utmost importance in terms of nursing accountability.

Assignment shifts an activity from one person to another, including the responsibility and the accountability. Activities can only be assigned to someone who has the requisite skill, knowledge, and judgment as well as legal authority for that scope of practice. A charge nurse who designates total responsibility for a group of patients to another RN is an example of assignment. The charge nurse is accountable for the assignment decision, whereupon the caregiver assumes responsibility and accountability for actual care of the patient. In this sense, nurses can never assign patient care activities to UAP; they can only delegate activities or tasks. The nursing process itself cannot be delegated. The nursing duties of assessment, planning, and evaluation, as well as the use of nursing judgment, remain solely within the scope of practice of the professional registered nurse.¹

Responsibility and risk

Only RNs have the formal authority to practice nursing and to delegate nursing acts. The legal definition of nursing practice is ultimately determined by each state’s Nurse Practice Act. These practice acts are state laws that protect the health and safety of the public by regulating practice and establishing the educational preparation and legal qualifications for who can practice nursing. These acts define expectations for which nurses are accountable (liable). Although organizational policies and job descriptions require UAP to perform certain tasks, they cannot contradict the mandates of practice acts. However, state variations, which sometimes interchange the terms “delegation” and “assignment,” can confuse the issue and some states are now adding language that ensures that nurses have control over UAP delegation.

RNs not only retain ultimate responsibility, accountability, and legal liability for delegation, but also for any associated problems. Although UAP may be responsible for performing hired duties just as any other employee does, nurses who make inappropriate work assignments and provide inadequate supervision can be found negligent. Negligence may be established by showing that a reasonably prudent nurse would not have assigned a particular task to UAP or would have supervised the work differently. Nurses who inappropriately delegate can be disciplined by the state board of nursing. In addition, nurses can be held accountable by their organization if they do not delegate according to their policies, job descriptions, and standards of care. In turn, a hospital may be liable for the nurses’ actions under respondent superior — let the employer respond — a principle that does not diminish RNs’ responsibilities for their nursing delegation.⁹

Delegating responsibly

No one is born knowing how to delegate. RNs may believe their delegation ability is excellent, even though they may have been trained under a nurse-intensive, primary care model. A small 2001 national study of nurses’ beliefs about their ability to delegate found that nurses in three practice settings — home health, acute care, and long-term care — were equally comfortable in a self-assessment of their delegation skills.¹⁰ Nurses can usually safely delegate repetitive, supportive, and nonnursing tasks, such as indirect patient care or support activities, which may be clerical, transportation, housekeeping, and dietary. Simple examples include answering telephones and paging, transporting patients and specimens, cleaning up after procedures, making beds, stocking and ordering supplies, and delivering dietary trays. More sophisticated tasks involve data collection (vital signs) without analysis, diagnostic procedures (reporting bedside blood glucose testing), and assisting with procedures (positioning a patient during a lumbar puncture).

The delegation of direct patient care needs to be assessed individually. The nurse should consistently use the nursing process to assess each patient’s needs and circumstances individually and analyze the need and appropriateness of delegating tasks.¹¹ For example, trained UAP may easily handle the task of taking vital signs of a stable individual three days after a cesarean section, but not of a new post-operative patient who is hemorrhaging. Likewise, UAP may be able to suction a stable comatose patient, but not a person with a closed head injury and increased intracranial pressure. To avoid confusion and avoid patient safety risks, organizational policy usually dictates clearly what tasks and activities may be delegated within its jurisdiction. Activities that may be delegated to UAPs should meet the criteria established by the ANA and NCSBN.¹ Adherence to these criteria may be determined by asking the following questions:

1. Is the activity within the range of functions the UAP is trained to provide?
2. Does the activity frequently recur among the patient group?
3. Can the activity be performed according to an established sequence of steps?
4. Does the activity involve little or no modifications from one patient or situation to another?
5. Does the activity have a predictable outcome?
6. Can the activity be clearly separated from any inherent ongoing assessment, interpretation, or decision-making component?
7. Is the activity free of a risk to life or well-being?

If the answer is “yes” to each of these questions, then the task or activity is a good candidate for delegation.

RNs are responsible for analyzing or evaluating the outcome of a delegated task. For example, UAP may take vital signs, but the RN needs to interpret them. Similarly, some UAP have been trained to apply a posterior plaster mold casting to a broken ankle, but the nurse remains responsible for assessment of the application, capillary refill, and cast care teaching.

What can’t be delegated

Activities that rely on the nursing process or require specialized skill, expert knowledge, or professional judgment cannot be delegated. Assessing and making nursing diagnoses, establishing plans of care, extensive teaching or counseling, evaluating outcomes, and discharging, including documentation of these activities, can only be performed by a professional nurse.¹ Examples are ED triage, assessing chest pain, teaching insulin injection, or evaluating the outcome of a respiratory treatment.

Handling appropriate delegation

Nurses vary in their own understanding and use of delegation, depending on the delivery system used in their institution, hospital size, years of nursing experience, level of education, and length of employment.⁶ For example, one study reported that RNs with less work experience and shorter length of employment tend to believe that they should perform more non-nursing tasks.¹² Nurses can analyze the seven criteria listed above for determining if a task can be delegated within the context of three areas:¹³

1. Identify the purpose. Take the time to assess the entire situation and why something needs to be done. In the case of a bed bath, if the patient is stable and the focus is hygiene, UAP could probably complete the task safely. If the patient is unstable and other goals are paramount, such as assessing skin integrity or teaching the family range-of-motion (ROM) exercises, then an otherwise simple activity may need the expertise of a professional.
2. Know the abilities of individual UAP. Before delegating, nurses need to verify whether UAP have the required training, orientation, and documented competencies. Institutions set their own standards for hiring and training UAP, but they must be commensurate with tasks to be done in the job. Nurses can improve the outcomes of delegation by tailoring explanations and directions according to their knowledge of UAPs’ backgrounds. Anticipate variations depending on training, experience, personality, and maturity. For instance, an individual who has been a parent may be especially soothing with children, or another with experience as a cardiopulmonary (CPR) instructor may be particularly adept in emergency situations. Check and recheck until you are able to rely on the abilities and work habits of the UAP with whom you work.
3. Be familiar with your organization’s job descriptions and policies. Institutional guidelines should establish specific conditions for delegation. For instance, one hospital allows UAP to transport critical patients from the ED to the ICU with an RN or MD, provided they have a current CPR card. This awareness can help limit UAP who seek on their own initiative to function beyond defined tasks. For instance, venipuncture for drawing blood specimens does not include handling IV lines. Some policies stipulate certain behaviors that are strictly within the nursing domain, such as dispensing medications, as grounds for immediate discipline if performed by a UAP. Nurses need to be ready to deal immediately with any incidents of performance beyond UAP designated capabilities and roles. Clearly state, “I am not delegating that to you,” and follow-up with an explanation. Adherence to institutional standards can counter the impression that a lack of personal trust is involved.

The process of delegation

The NCSBN and ANA endorse the Rive Rights of Delegation, requiring that the RN use critical thinking and professional judgment to be sure a delegation or assignment is —

• The right task
• Under the right circumstances
• To the right person
• With the right directions and communication; and
• Under the right supervision and evaluation.

There are both individual and organizational accountabilities for delegation. The organization must provide sufficient staffing with an appropriate staff mix for patient safety, documentation of competencies, and assurances that the RN has access to this information for any staff taking assignments from the RN, and include nurses in the development of organizational policies. The individual is accountable for becoming educated about policies and requirements for appropriate delegation as it is used in professional practice. The national NCLEX-RN Examination includes questions related to delegation to establish baseline competencies. The ANA, in its Principles for Delegation acknowledges a relational aspect to delegation. RNs need to use communication styles that are culturally appropriate and always treat the person receiving the communications respectfully.¹

Consistency in delegation is important. For example, consider the confusion that may occur in a unit if one RN expects UAP to discontinue IVs and another becomes upset when they do. Consistency and successful delegation may be achieved by following a systematic process.

1. Start with a positive attitude. People like to be respected for their contributions at work, and your words and actions can communicate the appreciation you have for the UAP with whom you work. Acknowledge a job well done. Public praise after a hectic period or a well-timed written note builds a sense of team effort.
   Establish good working relationships with effective two-way communication. Provide assistants with rationale that underlie tasks and observations that may enhance their growth. Be sure to listen attentively, and remain attentive to details to encourage the flow of important information in the future. And don’t forget common courtesies, like saying please and thank you.
2. Clarify availability. Delegation works best when caregivers are assigned to a specific nurse, rather than to a group of patients. Nevertheless, UAP may receive multiple requests from different people at the same time. You can help assistants through conflicts in delegation by scheduling their availability for when you need them, by assigning tasks within a reasonably structured time period, and by checking with other RNs to coordinate utilization. If UAP are overwhelmed by simultaneous requests from several nurses, a mechanism, such as coordination by a charge nurse, may be helpful.
3. Be careful how you provide direction. Avoid barking orders; a harsh direct approach is often perceived as offensive. A more effective style is to indirectly frame your direction as a request, for example, asking, “Could you please give the patient a bedpan?” However, avoid presenting an option when there isn’t one. Asking, “Would you like to pick up meal trays?” sends a mixed, incorrect message.
4. Use plain language and be fair. Provide clear instructions. Speak slowly, clearly, and distinctly. Avoid jargon, unit-specific language, acronyms, or other unnecessary abbreviations that may make messages incomprehensible. For instance, nurses on one unit ask UAP to “plug in” new patients, meaning assist them to change clothes and get situated in the room.
5. Define what needs to be done, by whom, how, and when. For complex tasks, include reportable parameters and rationale. Don’t leave assistants with vague directions, such as “Let me know if you need anything.” For example, which would you find easier to complete? “Check on the patients and see how they’re doing” or “Please tell me if blood glucose readings are below 60.” Finally, distribute what are perceived to be undesirable tasks equally among staff. And if there is time, contribute your own participation.
6. Clearly indicate priorities. Without adequate direction, UAP may not recognize or react appropriately to emergencies or critical incidents. For example, UAP should have clear directions about how to prioritize between a requested glass of water for a patient and reporting another’s complaint of chest pain. Words, such as “stat,” are often overused and become meaningless. Find a common language to identify true emergencies; for instance, communicating a phrase “This must be done right away” in a tone that conveys urgency. Remind UAP that they shouldn’t assume that their duties will remain the same from day to day: priorities can change daily, or even hourly, as patients’ conditions alter.
7. Verify comprehension. Don’t assume that your communication is better understood than it is. Follow-up with a confirmation statement, such as “Please repeat the assignment back to me,” rather than a nebulous “OK?” Reinforce accountability by checking back personally with the UAP. If you experience chronic problems with a particular UAP, examine the unit’s reporting and supervisory structure to see if conflicting messages are being given to the individual.
8. Give and receive feedback. Provide timely, honest, specific feedback. Be positive when appropriate. Also ask UAP for feedback — for example, “How did Mr. Jones respond to…?” Regularly evaluate your abilities as a delegator by asking UAP and coworkers for feedback. Feedback provides opportunities for professional and personal development and growth.

Properly utilized, UAP can be assets in providing effective patient care in today’s hectic healthcare environment. However, delegation works best when it is a component of a comprehensive program that includes clear job descriptions, thorough initial and ongoing training, and coaching. Nurses will find that, like other skills, delegation is easier with practice and experience.