nursing assignment vs delegation

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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022.

Nursing Management and Professional Concepts [Internet].

• About Open RN

Chapter 3 - Delegation and Supervision

3.1. delegation & supervision introduction, learning objectives.

• Identify typical scope of practice of the RN, LPN/VN, and assistive personnel roles

• Identify tasks that can and cannot be delegated to members of the nursing team

• Describe the five rights of effective delegation

• Explain the responsibilities of the RN when delegating and supervising tasks

• Explain the responsibilities of the delegatee when performing delegated tasks

• Outline the responsibilities of the employer and nurse leader regarding delegation

• Describe supervision of delegated acts

As health care technology continues to advance, clients require increasingly complex nursing care, and as staffing becomes more challenging, health care agencies respond with an evolving variety of nursing and assistive personnel roles and responsibilities to meet these demands. As an RN, you are on the frontlines caring for ill or injured clients and their families, advocating for clients’ rights, creating nursing care plans, educating clients on how to self-manage their health, and providing leadership throughout the complex health care system. Delivering safe, effective, quality client care requires the RN to coordinate care by the nursing team as tasks are assigned, delegated, and supervised.  Nursing team members  include advanced practice registered nurses (APRN), registered nurses (RN), licensed practical/vocational nurses (LPN/VN), and assistive personnel (AP).[ 1 ]  Assistive personnel (AP)  (formerly referred to as ‘‘unlicensed” assistive personnel [UAP]) are any assistive personnel trained to function in a supportive role, regardless of title, to whom a nursing responsibility may be delegated. This includes, but is not limited to, certified nursing assistants or aides (CNAs), patient-care technicians (PCTs), certified medical assistants (CMAs), certified medication aides, and home health aides.[ 2 ] Making assignments, delegating tasks, and supervising delegatees are essential components of the RN role and can also provide the RN more time to focus on the complex needs of clients. For example, an RN may delegate to AP the attainment of vital signs for clients who are stable, thus providing the nurse more time to closely monitor the effectiveness of interventions in maintaining complex clients’ hemodynamics, thermoregulation, and oxygenation. Collaboration among the nursing care team members allows for the delivery of optimal care as various skill sets are implemented to care for the patient.

Properly assigning and delegating tasks to nursing team members can promote efficient client care. However, inappropriate assignments or delegation can compromise client safety and produce unsatisfactory client outcomes that may result in legal issues. How does the RN know what tasks can be assigned or delegated to nursing team members and assistive personnel? What steps should the RN follow when determining if care can be delegated? After assignments and delegations are established, what is the role and responsibility of the RN in supervising client care? This chapter will explore and define the fundamental concepts involved in assigning, delegating, and supervising client care according to the most recent joint national delegation guidelines published by the National Council of State Boards of Nursing (NCSBN) and the American Nurses Association (ANA).[ 3 ]

3.3. ASSIGNMENT

Nursing team members working in inpatient or long-term care settings receive patient assignments at the start of their shift.  Assignment  refers to routine care, activities, and procedures that are within the legal scope of practice of registered nurses (RN), licensed practical/vocational nurses (LPN/VN), or assistive personnel (AP).[ 1 ] Scope of practice for RNs and LPNs is described in each state’s Nurse Practice Act. Care tasks for AP vary by state; regulations are typically listed on sites for the state’s Board of Nursing, Department of Health, Department of Aging, Department of Health Professions, Department of Commerce, or Office of Long-Term Care.[ 2 ]

See Table 3.3a for common tasks performed by members of the nursing team based on their scope of practice. These tasks are within the traditional role and training the team member has acquired through a basic educational program. They are also within the expectations of the health care agency during a shift of work. Agency policy can be more restrictive than federal or state regulations, but it cannot be less restrictive.

Patient assignments are typically made by the charge nurse (or nurse supervisor) from the previous shift. A charge nurse is an RN who provides leadership on a patient-care unit within a health care facility during their shift. Charge nurses perform many of the tasks that general nurses do, but also have some supervisory duties such as making assignments, delegating tasks, preparing schedules, monitoring admissions and discharges, and serving as a staff member resource.[ 3 ]

Nursing Team Members’ Scope of Practice and Common Tasks[ 4 ]

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An example of a patient assignment is when an RN assigns an LPN/VN to care for a client with stable heart failure. The LPN/VN collects assessment data, monitors intake/output throughout the shift, and administers routine oral medication. The LPN/VN documents this information and reports information back to the RN. This is considered the LPN/VN’s “assignment” because the skills are taught within an LPN educational program and are consistent with the state’s Nurse Practice Act for LPN/VN scope of practice. They are also included in the unit’s job description for an LPN/VN. The RN may also assign some care for this client to AP. These tasks may include assistance with personal hygiene, toileting, and ambulation. The AP documents these tasks as they are completed and reports information back to the RN or LPN/VN. These tasks are considered the AP’s assignment because they are taught within a nursing aide’s educational program, are consistent with the AP’s scope of practice for that state, and are included in the job description for the nursing aide’s role in this unit. The RN continues to be accountable for the care provided to this client despite the assignments made to other nursing team members.

Special consideration is required for AP with additional training. With increased staffing needs, skills such as administering medications, inserting Foley catheters, or performing injections are included in specialized training programs for AP. Due to the impact these skills can have on the outcome and safety of the client, the National Council of State Board of Nursing (NCSBN) recommends these activities be considered delegated tasks by the RN or nurse leader. By delegating these advanced skills when appropriate, the nurse validates competency, provides supervision, and maintains accountability for client outcomes. Read more about delegation in the “ Delegation ” section of this chapter.

When making assignments to other nursing team members, it is essential for the RN to keep in mind specific tasks that cannot be delegated to other nursing team members based on federal and/or state regulations. These tasks include, but are not limited to, those tasks described in Table 3.3b .

Examples of Tasks Outside the Scope of Practice of Nursing Assistive Personnel

As always, refer to each state’s Nurse Practice Act and other state regulations for specific details about nursing team members’ scope of practice when providing care in that state.

Find and review Nurse Practice Acts by state at  www.ncsbn.org/npa. Read more about the Wisconsin’s Nurse Practice Act and the standards and scope of practice for RNs and LPNs  Wisconsin’s Legislative Code Chapter N6. Read more about scope of practice, skills, and practices of nurse aides in Wisconsin at  DHS 129.07 Standards for Nurse Aide Training Programs.

3.4. DELEGATION

There has been significant national debate over the difference between assignment and delegation over the past few decades. In 2019 the National Council of State Boards of Nursing (NCSBN) and the American Nurses Association (ANA) published updated joint National Guidelines on Nursing Delegation (NGND).[ 1 ] These guidelines apply to all levels of nursing licensure (advanced practice registered nurses [APRN], registered nurses [RN], and licensed practical/vocational nurses [LPN/VN]) when delegating when there is no specific guidance provided by the state’s Nurse Practice Act (NPA).[ 2 ] It is important to note that states have different laws and rules/regulations regarding delegation, so it is the responsibility of all licensed nurses to know what is permitted in their jurisdiction.

The NGND defines a  delegatee  as an RN, LPN/VN, or AP who is delegated a nursing responsibility by either an APRN, RN, or LPN/VN, is competent to perform the task, and verbally accepts the responsibility.[ 3 ] D elegation  is allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and not routinely performed, but the individual has obtained additional training and validated their competence to perform the delegated responsibility.[ 4 ] However, the licensed nurse still maintains accountability for overall client care.  Accountability  is defined as being answerable to oneself and others for one’s own choices, decisions, and actions as measured against a standard. Therefore, if a nurse does not feel it is appropriate to delegate a certain responsibility to a delegatee, the delegating nurse should perform the activity themselves.[ 5 ]

Delegation is summarized in the NGND as the following[ 6 ]:

• A delegatee is allowed to perform a specific nursing activity, skill, or procedure that is outside the traditional role and basic responsibilities of the delegatee’s current job.
• The delegatee has obtained the additional education and training and validated competence to perform the care/delegated responsibility. The context and processes associated with competency validation will be different for each activity, skill, or procedure being delegated. Competency validation should be specific to the knowledge and skill needed to safely perform the delegated responsibility, as well as to the level of the practitioner (e.g., RN, LPN/VN, AP) to whom the activity, skill, or procedure has been delegated. The licensed nurse who delegates the “responsibility” maintains overall accountability for the client, but the delegatee bears the responsibility for completing the delegated activity, skill, or procedure.
• The licensed nurse cannot delegate nursing clinical judgment or any activity that will involve nursing clinical judgment or critical decision-making to AP.
• Nursing responsibilities are delegated by a licensed nurse who has the authority to delegate and the delegated responsibility is within the delegator’s scope of practice.

An example of delegation is medication administration that is delegated by a licensed nurse to AP with additional training in some agencies, according to agency policy. This task is outside the traditional role of AP, but the delegatee has received additional training for this delegated responsibility and has completed competency validation in completing this task accurately.

An example illustrating the difference between assignment and delegation is assisting patients with eating. Feeding patients is typically part of the routine role of AP. However, if a client has recently experienced a stroke (i.e., cerebrovascular accident) or is otherwise experiencing swallowing difficulties (e.g., dysphagia), this task cannot be assigned to AP because it is not considered routine care. Instead, the RN should perform this task themselves or delegate it to an AP who has received additional training on feeding assistance.

The delegation process is multifaceted. See Figure 3.2 [ 7 ] for an illustration of the intersecting responsibilities of the employer/nurse leader, licensed nurse, and delegatee with two-way communication that protects the safety of the public. “Delegation begins at the administrative/nurse leader level of the organization and includes determining nursing responsibilities that can be delegated, to whom, and under what circumstances; developing delegation policies and procedures; periodically evaluating delegation processes; and promoting a positive culture/work environment. The licensed nurse is responsible for determining client needs and when to delegate, ensuring availability to the delegatee, evaluating outcomes, and maintaining accountability for delegated responsibility. Finally, the delegatee must accept activities based on their competency level, maintain competence for delegated responsibility, and maintain accountability for delegated activity.”[ 8 ]

Multifaceted Delegation Process

Five Rights of Delegation

How does the RN determine what tasks can be delegated, when, and to whom? According to the National Council of State Boards of Nursing (NCSBN), RNs should use the five rights of delegation to ensure proper and appropriate delegation: right task, right circumstance, right person, right directions and communication, and right supervision and evaluation[ 9 ]:

• Right task:  The activity falls within the delegatee’s job description or is included as part of the established policies and procedures of the nursing practice setting. The facility needs to ensure the policies and procedures describe the expectations and limits of the activity and provide any necessary competency training.
• Right circumstance:  The health condition of the client must be stable. If the client’s condition changes, the delegatee must communicate this to the licensed nurse, and the licensed nurse must reassess the situation and the appropriateness of the delegation.[ 10 ]
• Right person:  The licensed nurse, along with the employer and the delegatee, is responsible for ensuring that the delegatee possesses the appropriate skills and knowledge to perform the activity.[ 11 ]
• Right directions and communication:  Each delegation situation should be specific to the client, the nurse, and the delegatee. The licensed nurse is expected to communicate specific instructions for the delegated activity to the delegatee; the delegatee, as part of two-way communication, should ask any clarifying questions. This communication includes any data that need to be collected, the method for collecting the data, the time frame for reporting the results to the licensed nurse, and additional information pertinent to the situation. The delegatee must understand the terms of the delegation and must agree to accept the delegated activity. The licensed nurse should ensure the delegatee understands they cannot make any decisions or modifications in carrying out the activity without first consulting the licensed nurse.[ 12 ]
• Right supervision and evaluation:  The licensed nurse is responsible for monitoring the delegated activity, following up with the delegatee at the completion of the activity, and evaluating client outcomes. The delegatee is responsible for communicating client information to the licensed nurse during the delegation situation. The licensed nurse should be ready and available to intervene as necessary. The licensed nurse should ensure appropriate documentation of the activity is completed.[ 13 ]

Simply stated, the licensed nurse determines the right person is assigned the right tasks for the right clients under the right circumstances. When determining what aspects of care can be delegated, the licensed nurse uses clinical judgment while considering the client’s current clinical condition, as well as the abilities of the health care team member. The RN must also consider if the circumstances are appropriate for delegation. For example, although obtaining routine vitals signs on stable clients may be appropriate to delegate to assistive personnel, obtaining vitals signs on an unstable client is not appropriate to delegate.

After the decision has been made to delegate, the nurse assigning the tasks must communicate appropriately with the delegatee and provide the right directions and supervision. Communication is key to successful delegation. Clear, concise, and closed-loop communication is essential to ensure successful completion of the delegated task in a safe manner. During the final step of delegation, also referred to as  supervision , the nurse verifies and evaluates that the task was performed correctly, appropriately, safely, and competently. Read more about supervision in the following subsection on “ Supervision .” See Table 3.4 for additional questions to consider for each “right” of delegation.

Rights of Delegation[ 14 ]

Keep in mind that any nursing intervention that requires specific nursing knowledge, clinical judgment, or use of the nursing process can only be delegated to another RN. Examples of these types of tasks include initial preoperative or admission assessments, client teaching, and creation and evaluation of a nursing care plan. See Figure 3.3 [ 15 ] for an algorithm based on the 2019 National Guidelines for Nursing Delegation that can be used when deciding if a nursing task can be delegated.[ 16 ]

Delegation Algorithm

Responsibilities of the Licensed Nurse

The licensed nurse has several responsibilities as part of the delegation process. According to the NGND, any decision to delegate a nursing responsibility must be based on the needs of the client or population, the stability and predictability of the client’s condition, the documented training and competence of the delegatee, and the ability of the licensed nurse to supervise the delegated responsibility and its outcome with consideration to the available staff mix and client acuity. Additionally, the licensed nurse must consider the state Nurse Practice Act regarding delegation and the employer’s policies and procedures prior to making a final decision to delegate. Licensed nurses must be aware that delegation is at the nurse’s discretion, with consideration of the particular situation. The licensed nurse maintains accountability for the client, while the delegatee is responsible for the delegated activity, skill, or procedure. If, under the circumstances, a nurse does not feel it is appropriate to delegate a certain responsibility to a delegatee, the delegating nurse should perform the activity.[ 17 ]

The licensed nurse must determine when and what to delegate based on the practice setting, the client’s needs and condition, the state’s/jurisdiction’s provisions for delegation, and the employer’s policies and procedures regarding delegating a specific responsibility. The licensed nurse must determine the needs of the client and whether those needs are matched by the knowledge, skills, and abilities of the delegatee and can be performed safely by the delegatee. The licensed nurse cannot delegate any activity that requires clinical reasoning, nursing judgment, or critical decision-making. The licensed nurse must ultimately make the final decision whether an activity is appropriate to delegate to the delegatee based on the “Five Rights of Delegation.”

• Rationale:  The licensed nurse, who is present at the point of care, is in the best position to assess the needs of the client and what can or cannot be delegated in specific situations.[ 18 ]

The licensed nurse must communicate with the delegatee who will be assisting in providing client care.  This should include reviewing the delegatee’s assignment and discussing delegated responsibilities, including information on the client’s condition/stability, any specific information pertaining to a certain client (e.g., no blood draws in the right arm), and any specific information about the client’s condition that should be communicated back to the licensed nurse by the delegatee.

• Rationale:  Communication must be a two-way process involving both the licensed nurse delegating the activity and the delegatee being delegated the responsibility. Evidence shows that the better the communication between the nurse and the delegatee, the more optimal the outcome. The licensed nurse must provide information about the client and care requirements. This includes any specific issues related to any delegated responsibilities. These instructions should include any unique client requirements. The licensed nurse must instruct the delegatee to regularly communicate the status of the client.[ 19 ]

The licensed nurse must be available to the delegatee for guidance and questions, including assisting with the delegated responsibility, if necessary, or performing it themselves if the client’s condition or other circumstances  warrant doing so.

• Rationale:  Delegation calls for nursing judgment throughout the process. The final decision to delegate rests in the hands of the licensed nurse as they have overall accountability for the client.[ 20 ]

The licensed nurse must follow up with the delegatee and the client after the delegated responsibility has been completed.

• Rationale:  The licensed nurse who delegates the “responsibility” maintains overall accountability for the client, while the delegatee is responsible for the delegated activity, skill, or procedure.[ 21 ]

The licensed nurse must provide feedback information about the delegation process and any issues regarding delegatee competence level to the nurse leader. Licensed nurses in the facility need to communicate to the nurse leader responsible for delegation any issues arising related to delegation and any individual whom they identify as not being competent in a specific responsibility or unable to use good judgment and decision-making.

• Rationale:  This will allow the nurse leader responsible for delegation to develop a plan to address the situation.[ 22 ]

The decision of whether or not to delegate or assign is based on the RN’s judgment concerning the condition of the client, the competence of the nursing team member, and the degree of supervision that will be required of the RN if a task is delegated.[ 23 ]

Responsibilities of the Delegatee

Everyone is responsible for the well-being of clients. While the nurse is ultimately accountable for the overall care provided to a client, the delegatee shares the responsibility for the client and is fully responsible for the delegated activity, skill, or procedure.[ 24 ] The delegatee has the following responsibilities:

The delegatee must accept only the delegated responsibilities that they are appropriately trained and educated to perform and feel comfortable doing given the specific circumstances in the health care setting and client’s condition. The delegatee should confirm acceptance of the responsibility to carry out the delegated activity. If the delegatee does not believe they have the appropriate competency to complete the delegated responsibility, then the delegatee should not accept the delegated responsibility. This includes informing the nursing leadership if they do not feel they have received adequate training to perform the delegated responsibility, do not perform the procedure frequently enough to do it safely, or their knowledge and skills need updating.

• Rationale:  The delegatee shares the responsibility to keep clients safe, and this includes only performing activities, skills, or procedures in which they are competent and comfortable doing.[ 25 ]

The delegatee must maintain competency for the delegated responsibility.

• Rationale:  Competency is an ongoing process. Even if properly taught, the delegatee may become less competent if they do not frequently perform the procedure. Given that the delegatee shares the responsibility for the client, the delegatee also has a responsibility to maintain competency.[ 26 ]

The delegatee must communicate with the licensed nurse in charge of the client.  This includes any questions related to the delegated responsibility and follow-up on any unusual incidents that may have occurred while the delegatee was performing the delegated responsibility, any concerns about a client’s condition, and any other information important to the client’s care.

• Rationale:  The delegatee is a partner in providing client care. They are interacting with the client/family and caring for the client. This information and two-way communication are important for successful delegation and optimal outcomes for the client.[ 27 ]

Once the delegatee verifies acceptance of the delegated responsibility, the delegatee is accountable for carrying out the delegated responsibility correctly and completing timely and accurate documentation per facility policy.

• Rationale:  The delegatee cannot delegate to another individual. If the delegatee is unable to complete the responsibility or feels as though they need assistance, the delegatee should inform the licensed nurse immediately so the licensed nurse can assess the situation and provide support. Only the licensed nurse can determine if it is appropriate to delegate the activity to another individual. If at any time the licensed nurse determines they need to perform the delegated responsibility, the delegatee must relinquish responsibility upon request of the licensed nurse.[ 28 ]

Responsibilities of the Employer/Nurse Leader

The employer and nurse leaders also have responsibilities related to safe delegation of client care:

The employer must identify a nurse leader responsible for oversight of delegated responsibilities for the facility.  If there is only one licensed nurse within the practice setting, that licensed nurse must be responsible for oversight of delegated responsibilities for the facility.

• Rationale:  The nurse leader has the ability to assess the needs of the facility, understand the type of knowledge and skill needed to perform a specific nursing responsibility, and be accountable for maintaining a safe environment for clients. They are also aware of the knowledge, skill level, and limitations of the licensed nurses and AP. Additionally, the nurse leader is positioned to develop appropriate staffing models that take into consideration the need for delegation. Therefore, the decision to delegate begins with a thorough assessment by a nurse leader designated by the institution to oversee the process.[ 29 ]

The designated nurse leader responsible for delegation, ideally with a committee (consisting of other nurse leaders) formed for the purposes of addressing delegation, must determine which nursing responsibilities may be delegated, to whom, and under what circumstances. The nurse leader must be aware of the state Nurse Practice Act and the laws/rules and regulations that affect the delegation process and ensure all institutional policies are in accordance with the law.

• Rationale:  A systematic approach to the delegation process fosters communication and consistency of the process throughout the facility.[ 30 ]

Policies and procedures for delegation must be developed.  The employer/nurse leader must outline specific responsibilities that can be delegated and to whom these responsibilities can be delegated. The policies and procedures should also indicate what may not be delegated. The employer must periodically review the policies and procedures for delegation to ensure they remain consistent with current nursing practice trends and that they are consistent with the state Nurse Practice Act. (Institution/employer policies can be more restrictive, but not less restrictive.)

• Rationale:  Policies and procedures standardize the appropriate method of care and ensure safe practices. Having a policy and procedure specific to delegation and delegated responsibilities eliminates questions from licensed nurses and AP about what can be delegated and how they should be performed.[ 31 ]

The employer/nurse leader must communicate information about delegation to the licensed nurses and AP and educate them about what responsibilities can be delegated. This information should include the competencies of delegatees who can safely perform a specific nursing responsibility.

• Rationale:  Licensed nurses must be aware of the competence level of staff and expectations for delegation (as described within the policies and procedures) to make informed decisions on whether or not delegation is appropriate for the given situation. Licensed nurses maintain accountability for the client. However, the delegatee has responsibility for the delegated activity, skill, or procedure.

In summary, delegation is the transfer of the nurse’s responsibility for a task while retaining professional accountability for the client’s overall outcome. The decision to delegate is based on the nurse’s judgment, the act of delegation must be clearly defined by the nurse, and the outcomes of delegation are an extension of the nurse’s guidance and supervision. Delegation, when rooted in mutual respect and trust, is a key component to an effective health care team.

3.5. SUPERVISION

The licensed nurse has the responsibility to supervise, monitor, and evaluate the nursing team members who have received delegated tasks, activities, or procedures. As previously noted, the act of supervision requires the nurse to assess the staff member’s ability, competency, and experience prior to delegating. After the nurse has made the decision to delegate, supervision continues in terms of coaching, supporting, assisting, and educating as needed throughout the task to assure appropriate care is provided.

The nurse is accountable for client care delegated to other team members. Communication and supervision should be ongoing processes throughout the shift within the nursing care team. The nurse must ensure quality of care, appropriateness, timeliness, and completeness through direct and indirect supervision. For example, an RN may directly observe the AP reposition a client or assist them to the bathroom to assure both client and staff safety are maintained. An RN may also indirectly evaluate an LPN’s administration of medication by reviewing documentation in the client’s medical record for timeliness and accuracy. Through direct and indirect supervision of delegation, quality client care and compliance with standards of practice and facility policies can be assured.

Supervision also includes providing constructive feedback to the nursing team member.  Constructive feedback  is supportive and identifies solutions to areas needing improvement. It is provided with positive intentions to address specific issues or concerns as the person learns and grows in their role. Constructive feedback includes several key points:

• Was the task, activity, care, or procedure performed correctly?
• Were the expected outcomes involving delegation for that client achieved?
• Did the team member utilize effective and timely communication?
• What were the challenges of the activity and what aspects went well?
• Were there any problems or specific concerns that occurred and how were they managed?

After these questions have been addressed, the RN creates a plan for future delegation with the nursing team member. This plan typically includes the following:

• Recognizing difficulty of the nursing team member in initiating or completing the delegated activities.
• Observing the client’s responses to actions performed by the nursing team member.
• Following up in a timely manner on any problems, incidents, or concerns that arose.
• Creating a plan for providing additional training and monitoring outcomes of future delegated tasks, activities, or procedures.
• Consulting with appropriate nursing administrators per agency policy if the client’s safety was compromised.

3.6. SPOTLIGHT APPLICATION

You are an RN and are reporting to work on a 16-bed medical/renal unit in a county hospital for the 0700 – 1500 shift today. The client population is primarily socioeconomically disadvantaged. Staff for the shift includes four RNs, one LPN/VN, and two AP.

You are a new RN graduate on the unit, and your orientation was completed two weeks ago. The LPN/VN has been working on the unit for ten years. Both AP have been on the unit for six months and are certified nursing assistants after completing basic nurse aide training. You, as one of four RNs on the unit, have been assigned four clients. You share the LPN with the other RNs, and there is one AP for every two RNs.

The charge nurse has assigned you the following four clients. Scheduled morning medications are due at 0800 and all four require some assistance with their ADLs.

• Client A:  An obese 52-year-old male with hypertension and diabetes requiring insulin therapy. He has been depressed since recently being diagnosed with end-stage renal disease requiring hemodialysis. He needs his morning medications and assistance getting dressed for transport to hemodialysis in 30 minutes.
• Client B:  A 83-year-old female client with acute pyelonephritis admitted two days ago. She has a PICC line in place and is receiving IV vancomycin every 12 hours. The next dose is due at 0830 after a trough level is drawn.
• Client C:  A 78-year-old male recently diagnosed with bladder cancer. He has bright red urine today but reports it is painless. He has surgery scheduled at 0900 and the pre-op checklist has not yet been completed.
• Client D:  A malnourished 80-year-old male client admitted with dehydration and imbalanced electrolyte levels. He is being discharged home today and requires patient education.

Reflective Questions

At the start of the shift, you determine which tasks, cares, activities, and/or procedures you will delegate to the LPN and AP. What factors must you consider prior to delegation?

What tasks will you delegate to the LPN/VN?

What tasks will you delegate to the AP?

3.7. LEARNING ACTIVITIES

Learning activities.

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activities are provided as immediate feedback.)

Review the following case studies regarding nurse liability associated with inappropriate delegation:

• Nurse Case Study: Wrongful delegation of patient care to unlicensed assistive personnel
• Nurse Video Case Study: Failure to assess and monitor

Reflective Questions:  What delegation errors occurred in each of these scenarios and what were the repercussions of these errors for the nurses involved?

III. GLOSSARY

Being answerable to oneself and others for one’s own choices, decisions, and actions as measured against a standard.

Routine care, activities, and procedures that are within the authorized scope of practice of the RN, LPN/VN, or routine functions of the assistive personnel.

Any assistive personnel (formerly referred to as ‘‘unlicensed” assistive personnel [UAP]) trained to function in a supportive role, regardless of title, to whom a nursing responsibility may be delegated. This includes, but is not limited to, certified nursing assistants or aides (CNAs), patient-care technicians (PCTs), certified medical assistants (CMAs), certified medication aides, and home health aides. [1]

A process that enables the person giving the instructions to hear what they said reflected back and to confirm that their message was, in fact, received correctly.

Supportive feedback that offers solutions to areas of weakness.

An RN, LPN/VN, or AP who is delegated a nursing responsibility by either an APRN, RN, or LPN/VN who is competent to perform the task and verbally accepts the responsibility.

Allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role but in which they have received additional training.

An APRN, RN, or LPN/VN who requests a specially trained delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role.

Right task, right circumstance, right person, right directions and communication, and right supervision and evaluation.

Advanced practice registered nurses (APRN), registered nurses (RN), licensed practical/vocational nurses (LPN/VN), and assistive personnel (AP).

Procedures, actions, and processes that a health care practitioner is permitted to undertake in keeping with the terms of their professional license.

Appropriate monitoring of the delegated activity, evaluation of patient outcomes, and follow-up with the delegatee at the completion of the activity.

Making adjustments to medication dosage per an established protocol to obtain a desired therapeutic outcome.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 3 - Delegation and Supervision.
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• DELEGATION & SUPERVISION INTRODUCTION
• SUPERVISION
• SPOTLIGHT APPLICATION
• LEARNING ACTIVITIES

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3.4 Delegation

There has been significant national debate over the difference between assignment and delegation over the past few decades. In 2019 the National Council of State Boards of Nursing (NCSBN) and the American Nurses Association (ANA) published updated joint National Guidelines on Nursing Delegation (NGND). [1] These guidelines apply to all levels of nursing licensure (advanced practice registered nurses [APRN], registered nurses [RN], and licensed practical/vocational nurses [LPN/VN]) when delegating when there is no specific guidance provided by the state’s Nurse Practice Act (NPA). [2] It is important to note that states have different laws and rules/regulations regarding delegation, so it is the responsibility of all licensed nurses to know what is permitted in their jurisdiction.

The NGND defines a delegatee as an RN, LPN/VN, or AP who is delegated a nursing responsibility by either an APRN, RN, or LPN/VN, is competent to perform the task, and verbally accepts the responsibility. [3] Delegation is allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and not routinely performed, but the individual has obtained additional training and validated their competence to perform the delegated responsibility. [4]   However, the licensed nurse still maintains accountability for overall client care. Delegated responsibility is a nursing activity, skill, or procedure that is transferred from a licensed nurse to a delegatee. [5] Accountability is defined as being answerable to oneself and others for one’s own choices, decisions, and actions as measured against a standard. Therefore, if a nurse does not feel it is appropriate to delegate a certain responsibility to a delegatee, the delegating nurse should perform the activity themselves. [6]

Delegation is summarized in the NGND as the following [7] :

• A delegatee is allowed to perform a specific nursing activity, skill, or procedure that is outside the traditional role and basic responsibilities of the delegatee’s current job.
• The delegatee has obtained the additional education and training and validated competence to perform the care/delegated responsibility. The context and processes associated with competency validation will be different for each activity, skill, or procedure being delegated. Competency validation should be specific to the knowledge and skill needed to safely perform the delegated responsibility, as well as to the level of the practitioner (e.g., RN, LPN/VN, AP) to whom the activity, skill, or procedure has been delegated. The licensed nurse who delegates the “responsibility” maintains overall accountability for the client, but the delegatee bears the responsibility for completing the delegated activity, skill, or procedure.
• The licensed nurse cannot delegate nursing clinical judgment or any activity that will involve nursing clinical judgment or critical decision-making to AP.
• Nursing responsibilities are delegated by a licensed nurse who has the authority to delegate and the delegated responsibility is within the delegator’s scope of practice.

An example of delegation is medication administration that is delegated by a licensed nurse to AP with additional training in some agencies, according to agency policy. This task is outside the traditional role of AP, but the delegatee has received additional training for this delegated responsibility and has completed competency validation in completing this task accurately.

An example illustrating the difference between assignment and delegation is assisting patients with eating. Feeding patients is typically part of the routine role of AP. However, if a client has recently experienced a stroke (i.e., cerebrovascular accident) or is otherwise experiencing swallowing difficulties (e.g., dysphagia), this task cannot be assigned to AP because it is not considered routine care. Instead, the RN should perform this task themselves or delegate it to an AP who has received additional training on feeding assistance.

The delegation process is multifaceted. See Figure 3.2 [8] for an illustration of the intersecting responsibilities of the employer/nurse leader, licensed nurse, and delegatee with two-way communication that protects the safety of the public. “Delegation begins at the administrative/nurse leader level of the organization and includes determining nursing responsibilities that can be delegated, to whom, and under what circumstances; developing delegation policies and procedures; periodically evaluating delegation processes; and promoting a positive culture/work environment. The licensed nurse is responsible for determining client needs and when to delegate, ensuring availability to the delegatee, evaluating outcomes, and maintaining accountability for delegated responsibility. Finally, the delegatee must accept activities based on their competency level, maintain competence for delegated responsibility, and maintain accountability for delegated activity.” [9]

Five Rights of Delegation

How does the RN determine what tasks can be delegated, when, and to whom? According to the National Council of State Boards of Nursing (NCSBN), RNs should use the five rights of delegation to ensure proper and appropriate delegation: right task, right circumstance, right person, right directions and communication, and right supervision and evaluation [10] :

• Right task: The activity falls within the delegatee’s job description or is included as part of the established policies and procedures of the nursing practice setting. The facility needs to ensure the policies and procedures describe the expectations and limits of the activity and provide any necessary competency training.
• Right circumstance: The health condition of the client must be stable. If the client’s condition changes, the delegatee must communicate this to the licensed nurse, and the licensed nurse must reassess the situation and the appropriateness of the delegation. [11]
• Right person: The licensed nurse, along with the employer and the delegatee, is responsible for ensuring that the delegatee possesses the appropriate skills and knowledge to perform the activity. [12]
• Right directions and communication: Each delegation situation should be specific to the client, the nurse, and the delegatee. The licensed nurse is expected to communicate specific instructions for the delegated activity to the delegatee; the delegatee, as part of two-way communication, should ask any clarifying questions. This communication includes any data that need to be collected, the method for collecting the data, the time frame for reporting the results to the licensed nurse, and additional information pertinent to the situation. The delegatee must understand the terms of the delegation and must agree to accept the delegated activity. The licensed nurse should ensure the delegatee understands they cannot make any decisions or modifications in carrying out the activity without first consulting the licensed nurse. [13]
• Right supervision and evaluation: The licensed nurse is responsible for monitoring the delegated activity, following up with the delegatee at the completion of the activity, and evaluating client outcomes. The delegatee is responsible for communicating client information to the licensed nurse during the delegation situation. The licensed nurse should be ready and available to intervene as necessary. The licensed nurse should ensure appropriate documentation of the activity is completed. [14]

Simply stated, the licensed nurse determines the right person is assigned the right tasks for the right clients under the right circumstances. When determining what aspects of care can be delegated, the licensed nurse uses clinical judgment while considering the client’s current clinical condition, as well as the abilities of the health care team member. The RN must also consider if the circumstances are appropriate for delegation. For example, although obtaining routine vital signs on stable clients may be appropriate to delegate to assistive personnel, obtaining vital signs on an unstable client is not appropriate to delegate.

After the decision has been made to delegate, the nurse assigning the tasks must communicate appropriately with the delegatee and provide the right directions and supervision. Communication is key to successful delegation. Clear, concise, and closed-loop communication is essential to ensure successful completion of the delegated task in a safe manner. During the final step of delegation, also referred to as supervision , the nurse verifies and evaluates that the task was performed correctly, appropriately, safely, and competently. Read more about supervision in the following section on “ Supervision .” See Table 3.4 for additional questions to consider for each “right” of delegation.

Table 3.4. Rights of Delegation [15]

Keep in mind that any nursing intervention that requires specific nursing knowledge, clinical judgment, or use of the nursing process can only be delegated to another RN. Examples of these types of tasks include initial preoperative or admission assessments, client teaching, and creation and evaluation of a nursing care plan. See Figure 3.3 [16] for an algorithm based on the 2019 National Guidelines for Nursing Delegation that can be used when deciding if a nursing task can be delegated. [17]

Responsibilities of the Licensed Nurse

The licensed nurse has several responsibilities as part of the delegation process. According to the NGND, any decision to delegate a nursing responsibility must be based on the needs of the client or population, the stability and predictability of the client’s condition, the documented training and competence of the delegatee, and the ability of the licensed nurse to supervise the delegated responsibility and its outcome with consideration to the available staff mix and client acuity. Additionally, the licensed nurse must consider the state Nurse Practice Act regarding delegation and the employer’s policies and procedures prior to making a final decision to delegate. Licensed nurses must be aware that delegation is at the nurse’s discretion, with consideration of the particular situation. The licensed nurse maintains accountability for the client, while the delegatee is responsible for the delegated activity, skill, or procedure. If, under the circumstances, a nurse does not feel it is appropriate to delegate a certain responsibility to a delegatee, the delegating nurse should perform the activity. [18]

1. The licensed nurse must determine when and what to delegate based on the practice setting, the client’s needs and condition, the state’s/jurisdiction’s provisions for delegation, and the employer’s policies and procedures regarding delegating a specific responsibility. The licensed nurse must determine the needs of the client and whether those needs are matched by the knowledge, skills, and abilities of the delegatee and can be performed safely by the delegatee. The licensed nurse cannot delegate any activity that requires clinical reasoning, nursing judgment, or critical decision-making. The licensed nurse must ultimately make the final decision whether an activity is appropriate to delegate to the delegatee based on the “Five Rights of Delegation.”

• Rationale: The licensed nurse, who is present at the point of care, is in the best position to assess the needs of the client and what can or cannot be delegated in specific situations. [19]

2. The licensed nurse must communicate with the delegatee who will be assisting in providing client care. This should include reviewing the delegatee’s assignment and discussing delegated responsibilities, including information on the client’s condition/stability, any specific information pertaining to a certain client (e.g., no blood draws in the right arm), and any specific information about the client’s condition that should be communicated back to the licensed nurse by the delegatee.

• Rationale: Communication must be a two-way process involving both the licensed nurse delegating the activity and the delegatee being delegated the responsibility. Evidence shows that the better the communication between the nurse and the delegatee, the more optimal the outcome. The licensed nurse must provide information about the client and care requirements. This includes any specific issues related to any delegated responsibilities. These instructions should include any unique client requirements. The licensed nurse must instruct the delegatee to regularly communicate the status of the client. [20]

3. The licensed nurse must be available to the delegatee for guidance and questions, including assisting with the delegated responsibility, if necessary, or performing it themselves if the client’s condition or other circumstances warrant doing so.

• Rationale: Delegation calls for nursing judgment throughout the process. The final decision to delegate rests in the hands of the licensed nurse as they have overall accountability for the client. [21]

4. The licensed nurse must follow up with the delegatee and the client after the delegated responsibility has been completed.

• Rationale: The licensed nurse who delegates the “responsibility” maintains overall accountability for the client, while the delegatee is responsible for the delegated activity, skill, or procedure. [22]

5. The licensed nurse must provide feedback information about the delegation process and any issues regarding delegatee competence level to the nurse leader. Licensed nurses in the facility need to communicate to the nurse leader responsible for delegation any issues arising related to delegation and any individual whom they identify as not being competent in a specific responsibility or unable to use good judgment and decision-making.

• Rationale: This will allow the nurse leader responsible for delegation to develop a plan to address the situation. [23]

The decision of whether or not to delegate or assign is based on the RN’s judgment concerning the condition of the client, the competence of the nursing team member, and the degree of supervision that will be required of the RN if a task is delegated. [24]

Responsibilities of the Delegatee

Everyone is responsible for the well-being of clients. While the nurse is ultimately accountable for the overall care provided to a client, the delegatee shares the responsibility for the client and is fully responsible for the delegated activity, skill, or procedure. [25] The delegatee has the following responsibilities:

1. The delegatee must accept only the delegated responsibilities that they are appropriately trained and educated to perform and feel comfortable doing given the specific circumstances in the health care setting and client’s condition. The delegatee should confirm acceptance of the responsibility to carry out the delegated activity. If the delegatee does not believe they have the appropriate competency to complete the delegated responsibility, then the delegatee should not accept the delegated responsibility. This includes informing the nursing leadership if they do not feel they have received adequate training to perform the delegated responsibility, do not perform the procedure frequently enough to do it safely, or their knowledge and skills need updating.

• Rationale: The delegatee shares the responsibility to keep clients safe, and this includes only performing activities, skills, or procedures in which they are competent and comfortable doing. [26]

2. The delegatee m ust maintain competency for the delegated responsibility.

• Rationale: Competency is an ongoing process. Even if properly taught, the delegatee may become less competent if they do not frequently perform the procedure. Given that the delegatee shares the responsibility for the client, the delegatee also has a responsibility to maintain competency. [27]

3. The delegatee must communicate with the licensed nurse in charge of the client. This includes any questions related to the delegated responsibility and follow-up on any unusual incidents that may have occurred while the delegatee was performing the delegated responsibility, any concerns about a client’s condition, and any other information important to the client’s care.

• Rationale: The delegatee is a partner in providing client care. They are interacting with the client/family and caring for the client. This information and two-way communication are important for successful delegation and optimal outcomes for the client. [28]

4. Once the delegatee verifies acceptance of the delegated responsibility, the delegatee is accountable for carrying out the delegated responsibility correctly and completing timely and accurate documentation per facility policy.

• Rationale: The delegatee cannot delegate to another individual. If the delegatee is unable to complete the responsibility or feels as though they need assistance, the delegatee should inform the licensed nurse immediately so the licensed nurse can assess the situation and provide support. Only the licensed nurse can determine if it is appropriate to delegate the activity to another individual. If at any time the licensed nurse determines they need to perform the delegated responsibility, the delegatee must relinquish responsibility upon request of the licensed nurse. [29]

Responsibilities of the Employer/Nurse Leader

The employer and nurse leaders also have responsibilities related to safe delegation of client care:

1. The employer must identify a nurse leader responsible for oversight of delegated responsibilities for the facility. If there is only one licensed nurse within the practice setting, that licensed nurse must be responsible for oversight of delegated responsibilities for the facility.

• Rationale: The nurse leader has the ability to assess the needs of the facility, understand the type of knowledge and skill needed to perform a specific nursing responsibility, and be accountable for maintaining a safe environment for clients. They are also aware of the knowledge, skill level, and limitations of the licensed nurses and AP. Additionally, the nurse leader is positioned to develop appropriate staffing models that take into consideration the need for delegation. Therefore, the decision to delegate begins with a thorough assessment by a nurse leader designated by the institution to oversee the process. [30]

2. The designated nurse leader responsible for delegation, ideally with a committee (consisting of other nurse leaders) formed for the purposes of addressing delegation, must determine which nursing responsibilities may be delegated, to whom, and under what circumstances. The nurse leader must be aware of the state Nurse Practice Act and the laws/rules and regulations that affect the delegation process and ensure all institutional policies are in accordance with the law.

• Rationale: A systematic approach to the delegation process fosters communication and consistency of the process throughout the facility. [31]

3. Policies and procedures for delegation must be developed. The employer/nurse leader must outline specific responsibilities that can be delegated and to whom these responsibilities can be delegated. The policies and procedures should also indicate what may not be delegated. The employer must periodically review the policies and procedures for delegation to ensure they remain consistent with current nursing practice trends and that they are consistent with the state Nurse Practice Act. (Institution/employer policies can be more restrictive, but not less restrictive.)

• Rationale: Policies and procedures standardize the appropriate method of care and ensure safe practices. Having a policy and procedure specific to delegation and delegated responsibilities eliminates questions from licensed nurses and AP about what can be delegated and how they should be performed. [32]

4. The employer/nurse leader must communicate information about delegation to the licensed nurses and AP and educate them about what responsibilities can be delegated. This information should include the competencies of delegatees who can safely perform a specific nursing responsibility.

• Rationale: Licensed nurses must be aware of the competence level of staff and expectations for delegation (as described within the policies and procedures) to make informed decisions on whether or not delegation is appropriate for the given situahttps://www.nursingworld.org/content-hub/resources/nursing-leadership/delegation-in-nursing/tion. Licensed nurses maintain accountability for the client. However, the delegatee has responsibility for the delegated activity, skill, or procedure.

In summary, delegation is the transfer of the nurse’s responsibility for a task while retaining professional accountability for the client’s overall outcome. The decision to delegate is based on the nurse’s judgment, the act of delegation must be clearly defined by the nurse, and the outcomes of delegation are an extension of the nurse’s guidance and supervision. Delegation, when rooted in mutual respect and trust, is a key component to an effective health care team.

Delegation is an integral skill in the nursing profession to help manage the complexities of the dynamic and ever-changing health care environment. Delegation in nursing has been found to increase employee empowerment, decrease burnout, increase role commitment, and improve job satisfaction. [33] Cultivating delegation skills helps nurses better manage the complexities of their client care role, ensuring that their clients are safely cared for and outcomes are optimized. Delegation skills, like other nursing skills, require purposeful development and do not necessarily come easily when first transitioning into the nursing role. It is important that the new graduate nurse does not mistake delegation for pompous or arrogant behavior. Delegation requires mutual respect between the delegator and delegatee. Delegation is not seen as a sign or weakness and does not reflect one’s desire to shirk their work responsibilities. Instead, delegation reflects strong leadership and organizational skills in which the nurse leader demonstrates that they understand how to leverage their team’s strengths in order to achieve optimal care outcomes.

To help avoid any perception of arrogance in the delegation of an activity, it is important that the new graduate nurse approaches the task of delegation with humility. Clarity in the communication of the delegated responsibility is critical, and the rationale behind the delegation should be communicated to the delegatee. Within the task of delegation, the delegator should express appreciation for the delegatee and their contributions in the collaborative health care environment. Additionally, it is important to understand that no specific nurse delegated task is outside of the “nurse” role. For example, ambulating a client does not to an unlicensed assistive personnel simply because that individual is able to perform that task. Rather, nurses must be willing to perform delegated tasks themselves when necessary. This reflects a team-oriented mindset and helps to reinforce among the care team that all roles are critical to optimizing client care. For new graduate nurses who first transition into a specific health care setting, having the opportunity to shadow individuals in various work roles helps to foster a team mindset. Asking questions of various team members regarding their work role can help a new graduate nurse demonstrate respect and value for other roles.

Examples of helpful questions may include the following:

• “What is the biggest challenge in your typical workday?”
• “What do you most enjoy about your job?”
• “How is it best to communicate with you when the unit is busy?”
• “What do you think people misunderstand most about your role?”

It is important to ensure that the team understands that care is optimized when they function as one collective unit and not in siloed roles. Each team member must feel valued and competent in their role. By understanding and practicing strategic delegation, new graduate nurses can overcome any misconceptions of arrogance and contribute positively to the healthcare team.

Please review the example below to consider variation in approach to task delegation.

Scenario A: Nurse June, a newly graduated nurse, is working in a busy hospital unit. She needs an unlicensed assistive personnel (UAP), Alex, to take vital signs of a patient. Nurse June approaches Alex in the hallway and says in an abrupt tone, “Alex, I need you to take Mr. Smith’s vital signs right now. I’m too busy to do it myself, and besides, that’s what you’re here for. Just get it done quickly.”

Analysis: June’s tone and words suggest she sees Alex’s role as less important and purely as a means to offload her tasks. June does not explain the urgency or importance of the task. June doesn’t acknowledge Alex’s effort or capability, making the request seem like a command rather than a collaborative effort.

Scenario B: Nurse June, a newly graduated nurse, is working in a busy hospital unit. She needs an unlicensed assistive personnel (UAP), Alex, to take vital signs of a patient. Nurse June approaches Alex and says, “Hi Alex, could you please help me by taking Mr. Smith’s vital signs? I’m handling a few urgent matters right now, and it would really help to have your support. I know you’re great at this, and your thoroughness really makes a difference in our patient care. Thank you so much!”

Analysis: June speaks to Alex with courtesy and acknowledges the value of his role. June clearly explains why she needs Alex’s help and the importance of the task. June acknowledges Alex’s competence and expresses gratitude, fostering feelings of value and respect.

• American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www.ncsbn.org/public-files/NGND-PosPaper_06.pdf ↵
• American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation . https://www.ncsbn.org/public-files/NGND-PosPaper_06.pdf ↵
• “Delegation.png” by Meredith Pomietlo for Chippewa Valley Technical College  is licensed under  CC BY 4.0 ↵
• NCSBN. (n.d.). Delegation. https://www.ncsbn.org/1625.htm ↵
• “Delegation Decision Tree.png” by Meredith Pomietlo for Chippewa Valley Technical College  is licensed under  CC BY 4.0 ↵
• ANA. (2023, September 7). Delegation in nursing: How to build a stronger team. Retrieved from https://www.nursingworld.org/content-hub/resources/nursing-leadership/delegation-in-nursing/ ↵

An RN, LPN/VN, or AP who is delegated a nursing responsibility by either an APRN, RN, or LPN/VN (where the state’s Nurse Practice Act allows), is competent to perform the task, and verbally accepts the responsibility.

Allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and not routinely performed.

A nursing activity, skill, or procedure that is transferred from a license nurse to a delegatee.

Being answerable to oneself and others for one’s own choices, decisions, and actions as measured against a standard.

Appropriate monitoring of the delegated activity, evaluation of client outcomes, and follow up with the delegatee at the completion of the activity.

Nursing Management and Professional Concepts Copyright © by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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3.4 Delegation

There has been significant national debate over the difference between assignment and delegation over the past few decades. In 2019 the National Council of State Boards of Nursing (NCSBN) and the American Nurses Association (ANA) published updated joint National Guidelines on Nursing Delegation (NGND). [1] These guidelines apply to all levels of nursing licensure (advanced practice registered nurses [APRN], registered nurses [RN], and licensed practical/vocational nurses [LPN/VN]) when delegating, and there is no specific guidance provided by the state’s Nurse Practice Act (NPA). [2] It is important to note that states have different laws and rules/regulations regarding delegation, so it is the responsibility of all licensed nurses to know what is permitted in their jurisdiction.

The NGND defines a delegatee  as an RN, LPN/VN, or AP who is delegated a nursing responsibility by either an APRN, RN, or LPN/VN (where the state’s Nurse Practice Act allows), is competent to perform the task, and verbally accepts the responsibility. [3] When performing a fundamental skill on the job, the delegatee is considered to be carrying out an “assignment.” Routine care, activities, and procedures are assigned based on what is included in the delegatee’s basic educational program. A licensed nurse is still responsible for ensuring an assignment is carried out completely and correctly. Delegation is defined as allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and not routinely performed. This definition of delegation applies to licensed nurses as well as to assistive personnel. [4]

Delegation is summarized in the NGND as the following: [5]

• A delegatee is allowed to perform a specific nursing activity, skill, or procedure that is outside the traditional role and basic responsibilities of the delegatee’s current job.
• The delegatee has obtained the additional education and training and validated competence to perform the care/delegated responsibility. The context and processes associated with competency validation will be different for each activity, skill, or procedure being delegated. Competency validation should be specific to the knowledge and skill needed to safely perform the delegated responsibility, as well as to the level of the practitioner (e.g., RN, LPN/VN, AP) to whom the activity, skill, or procedure has been delegated. The licensed nurse who delegates the “responsibility” maintains overall accountability for the client. However, the delegatee bears the responsibility for the delegated activity, skill, or procedure.
• The licensed nurse cannot delegate nursing judgment or any activity that will involve nursing judgment or critical decision-making.
• Nursing responsibilities are delegated by someone who has the authority to delegate.
• The delegated responsibility is within the delegator’s scope of practice.
• When delegating to a licensed nurse, the delegated responsibility must be within the parameters of the delegatee’s authorized scope of practice under the NPA. Regardless of how the state/jurisdiction defines delegation, as compared to assignment, appropriate delegation allows for transition of a responsibility in a safe and consistent manner. Clinical reasoning, nursing judgment, and critical decision-making cannot be delegated.

For example, in some agencies, medication administration is delegated to specially trained CNAs. This task is outside the traditional role of a CNA, but the delegatee has received additional training for this delegated responsibility. They have received competency validation in completing this task accurately, but the licensed nurse still maintains accountability for the client. Accountability is defined as being answerable to oneself and others for one’s own choices, decisions, and actions as measured against a standard. If, under the circumstances, a nurse does not feel it is appropriate to delegate a certain responsibility to a delegatee, the delegating nurse should perform the activity themselves. [6]

Another example illustrating the difference between assignment and delegation is evidenced when considering patient assistance with eating. Feeding patients is typically part of the role of assistive personnel. However, if a client has recently experienced a stroke (i.e., cerebrovascular accident) or is otherwise experiencing swallowing difficulties (i.e., dysphagia), this task cannot be assigned to assistive personnel because it is not considered routine care. Instead, the RN should perform this task themselves or delegate it to a specially trained team member.

The delegation process is multifaceted. See Figure 3.2 [7] for an illustration of the intersecting responsibilities of the employer/nurse leader, licensed nurse, and delegatee with two-way communication that protects the safety of the public. “Delegation begins at the administrative/nurse leader level of the organization and includes determining nursing responsibilities that can be delegated, to whom, and under what circumstances; developing delegation policies and procedures; periodically evaluating delegation processes; and promoting a positive culture/work environment. The licensed nurse is responsible for determining client needs and when to delegate, ensuring availability to the delegatee, evaluating outcomes, and maintaining accountability for delegated responsibility. Finally, the delegatee must accept activities based on their competency level, maintain competence for delegated responsibility, and maintain accountability for delegated activity.” [8]

Five Rights of Delegation

How does the RN determine what tasks can be delegated, when, and to whom? According to the National Council of State Boards of Nursing (NCSBN), RNs should use five rights of delegation to ensure proper and appropriate delegation: right task, right circumstance, right person, right directions and communication, and right supervision and evaluation: [9]

• Right task: The activity falls within the delegatee’s job description or is included as part of the established policies and procedures of the nursing practice setting. The facility needs to ensure the policies and procedures describe the expectations and limits of the activity and provide any necessary competency training.
• Right circumstance: The health condition of the client must be stable. If the client’s condition changes, the delegatee must communicate this to the licensed nurse, and the licensed nurse must reassess the situation and the appropriateness of the delegation. [10]
• Right person: The licensed nurse, along with the employer and the delegatee, is responsible for ensuring that the delegatee possesses the appropriate skills and knowledge to perform the activity. [11]
• Right directions and communication: Each delegation situation should be specific to the client, the nurse, and the delegatee. The licensed nurse is expected to communicate specific instructions for the delegated activity to the delegatee; the delegatee, as part of two-way communication, should ask any clarifying questions. This communication includes any data that need to be collected, the method for collecting the data, the time frame for reporting the results to the licensed nurse, and additional information pertinent to the situation. The delegatee must understand the terms of the delegation and must agree to accept the delegated activity. The licensed nurse should ensure the delegatee understands they cannot make any decisions or modifications in carrying out the activity without first consulting the licensed nurse. [12]
• Right supervision and evaluation: The licensed nurse is responsible for monitoring the delegated activity, following up with the delegatee at the completion of the activity, and evaluating client outcomes. The delegatee is responsible for communicating client information to the licensed nurse during the delegation situation. The licensed nurse should be ready and available to intervene as necessary. The licensed nurse should ensure appropriate documentation of the activity is completed. [13]

Simply stated, the licensed nurse determines the right person is assigned the right tasks for the right clients under the right circumstances. When determining what aspects of care can be delegated, the licensed nurse uses clinical judgment while considering the client’s current clinical condition, as well as the abilities of the health care team member. The RN must also consider if the circumstances are appropriate for delegation. For example, although obtaining routine vitals signs on stable clients may be appropriate to delegate to assistive personnel, obtaining vitals signs on an unstable client is not appropriate to delegate.

After the decision has been made to delegate, the nurse assigning the tasks must communicate appropriately with the delegatee and provide the right directions and supervision. Communication is key to successful delegation. Clear, concise, and closed-loop communication is essential to ensure successful completion of the delegated task in a safe manner. During the final step of delegation, also referred to as supervision , the nurse verifies and evaluates that the task was performed correctly, appropriately, safely, and competently. Read more about supervision in the following subsection on “ Supervision .” See Table 3.4 for additional questions to consider for each “right” of delegation.

Table 3.4 Rights of Delegation [14]

Keep in mind that any nursing intervention that requires specific nursing knowledge, clinical judgment, or use of the nursing process can only be delegated to another RN. Examples of these types of tasks include initial preoperative or admission assessments, client teaching, and creation and evaluation of a nursing care plan. See Figure 3.3 [15] for an algorithm based on the 2019 National Guidelines for Nursing Delegation that can be used when deciding if a nursing task can be delegated. [16]

Responsibilities of the Licensed Nurse

The licensed nurse has several responsibilities as part of the delegation process. According to the NGND, any decision to delegate a nursing responsibility must be based on the needs of the client or population, the stability and predictability of the client’s condition, the documented training and competence of the delegatee, and the ability of the licensed nurse to supervise the delegated responsibility and its outcome with consideration to the available staff mix and client acuity. Additionally, the licensed nurse must consider the state Nurse Practice Act regarding delegation and the employer’s policies and procedures prior to making a final decision to delegate. Licensed nurses must be aware that delegation is at the nurse’s discretion, with consideration of the particular situation. The licensed nurse maintains accountability for the client, while the delegatee is responsible for the delegated activity, skill, or procedure.  If, under the circumstances, a nurse does not feel it is appropriate to delegate a certain responsibility to a delegatee, the delegating nurse should perform the activity. [17]

1. The licensed nurse must determine when and what to delegate based on the practice setting, the client’s needs and condition, the state’s/jurisdiction’s provisions for delegation, and the employer’s policies and procedures regarding delegating a specific responsibility. The licensed nurse must determine the needs of the client and whether those needs are matched by the knowledge, skills, and abilities of the delegatee and can be performed safely by the delegatee. The licensed nurse cannot delegate any activity that requires clinical reasoning, nursing judgment, or critical decision-making. The licensed nurse must ultimately make the final decision whether an activity is appropriate to delegate to the delegatee based on the “Five Rights of Delegation.”

• Rationale: The licensed nurse, who is present at the point of care, is in the best position to assess the needs of the client and what can or cannot be delegated in specific situations. [18]

2. The licensed nurse must communicate with the delegatee who will be assisting in providing client care. This should include reviewing the delegatee’s assignment and discussing delegated responsibilities, including information on the client’s condition/stability, any specific information pertaining to a certain client (e.g., no blood draws in the right arm), and any specific information about the client’s condition that should be communicated back to the licensed nurse by the delegatee.

• Rationale: Communication must be a two-way process involving both the licensed nurse delegating the activity and the delegatee being delegated the responsibility. Evidence shows that the better the communication between the nurse and the delegatee, the more optimal the outcome. The licensed nurse must provide information about the client and care requirements. This includes any specific issues related to any delegated responsibilities. These instructions should include any unique client requirements. The licensed nurse must instruct the delegatee to regularly communicate the status of the client. [19]

3. The licensed nurse must be available to the delegatee for guidance and questions, including assisting with the delegated responsibility, if necessary, or performing it themselves if the client’s condition or other circumstances warrant doing so.

• Rationale: Delegation calls for nursing judgment throughout the process. The final decision to delegate rests in the hands of the licensed nurse as they have overall accountability for the client. [20]

4. The licensed nurse must follow up with the delegatee and the client after the delegated responsibility has been completed.

• Rationale: The licensed nurse who delegates the “responsibility” maintains overall accountability for the client, while the delegatee is responsible for the delegated activity, skill, or procedure. [21]

5. The licensed nurse must provide feedback information about the delegation process and any issues regarding delegatee competence level to the nurse leader. Licensed nurses in the facility need to communicate to the nurse leader responsible for delegation any issues arising related to delegation and any individual that they identify as not being competent in a specific responsibility or unable to use good judgment and decision-making.

• Rationale: This will allow the nurse leader responsible for delegation to develop a plan to address the situation. [22]

The decision of whether or not to delegate or assign is based on the RN’s judgment concerning the condition of the client, the competence of the nursing team member, and the degree of supervision that will be required of the RN if a task is delegated. [23]

Responsibilities of the Delegatee

Everyone is responsible for the well-being of clients. While the nurse is ultimately accountable for the overall care provided to a client, the delegatee shares the responsibility for the client and is fully responsible for the delegated activity, skill, or procedure. [24] The delegatee has the following responsibilities:

1. The delegatee must accept only the delegated responsibilities that he or she is appropriately trained and educated to perform and feels comfortable doing given the specific circumstances in the health care setting and client’s condition. The delegatee should confirm acceptance of the responsibility to carry out the delegated activity. If the delegatee does not believe they have the appropriate competency to complete the delegated responsibility, then the delegatee should not accept the delegated responsibility. This includes informing the nursing leadership if they do not feel they have received adequate training to perform the delegated responsibility, is not performing the procedure frequently enough to do it safely, or their knowledge and skills need updating.

• Rationale: The delegatee shares the responsibility to keep clients safe, and this includes only performing activities, skills, or procedures in which they are competent and comfortable doing. [25]

2. The delegatee m ust maintain competency for the delegated responsibility.

• Rationale: Competency is an ongoing process. Even if properly taught, the delegatee may become less competent if they do not frequently perform the procedure. Given that the delegatee shares the responsibility for the client, the delegatee also has a responsibility to maintain competency. [26]

3. The delegatee must communicate with the licensed nurse in charge of the client. This includes any questions related to the delegated responsibility and follow-up on any unusual incidents that may have occurred while the delegatee was performing the delegated responsibility, any concerns about a client’s condition, and any other information important to the client’s care.

• Rationale: The delegatee is a partner in providing client care. They are interacting with the client/family and caring for the client. This information and two-way communication are important for successful delegation and optimal outcomes for the client. [27]

4. Once the delegatee verifies acceptance of the delegated responsibility, the delegatee is accountable for carrying out the delegated responsibility correctly and completing timely and accurate documentation per facility policy. The delegatee cannot delegate to another individual. If the delegatee is unable to complete the responsibility or feels as though they need assistance, the delegatee should inform the licensed nurse immediately so the licensed nurse can assess the situation and provide support. Only the licensed nurse can determine if it is appropriate to delegate the activity to another individual. If at any time the licensed nurse determines they need to perform the delegated responsibility, the delegatee must relinquish responsibility upon request of the licensed nurse.

• Rationale: Only a licensed nurse can delegate. In addition, because they are responsible, they need to provide direction, determine who is going to carry out the delegated responsibility, and assist or perform the responsibility themselves, if they deem that appropriate under the given circumstances. [28]

Responsibilities of the Employer/Nurse Leader

The employer and nurse leaders also have responsibilities related to safe delegation of client care:

1. The employer must identify a nurse leader responsible for oversight of delegated responsibilities for the facility. If there is only one licensed nurse within the practice setting, that licensed nurse must be responsible for oversight of delegated responsibilities for the facility.

• Rationale: The nurse leader has the ability to assess the needs of the facility, understand the type of knowledge and skill needed to perform a specific nursing responsibility, and be accountable for maintaining a safe environment for clients. They are also aware of the knowledge, skill level, and limitations of the licensed nurses and AP. Additionally, the nurse leader is positioned to develop appropriate staffing models that take into consideration the need for delegation. Therefore, the decision to delegate begins with a thorough assessment by a nurse leader designated by the institution to oversee the process. [29]

2. The designated nurse leader responsible for delegation, ideally with a committee (consisting of other nurse leaders) formed for the purposes of addressing delegation, must determine which nursing responsibilities may be delegated, to whom, and under what circumstances. The nurse leader must be aware of the state Nurse Practice Act and the laws/rules and regulations that affect the delegation process and ensure all institutional policies are in accordance with the law.

• Rationale: A systematic approach to the delegation process fosters communication and consistency of the process throughout the facility. [30]

3. Policies and procedures for delegation must be developed. The employer/nurse leader must outline specific responsibilities that can be delegated and to whom these responsibilities can be delegated. The policies and procedures should also indicate what may not be delegated. The employer must periodically review the policies and procedures for delegation to ensure they remain consistent with current nursing practice trends and that they are consistent with the state Nurse Practice Act. (Institution/employer policies can be more restrictive, but not less restrictive.)

• Rationale: Policies and procedures standardize the appropriate method of care and ensure safe practices. Having a policy and procedure specific to delegation and delegated responsibilities eliminate questions from licensed nurses and AP about what can be delegated and how they should be performed. [31]

4. The employer/nurse leader must communicate information about delegation to the licensed nurses and AP and educate them about what responsibilities can be delegated. This information should include the competencies of delegatees who can safely perform a specific nursing responsibility.

• Rationale: Licensed nurses must be aware of the competence level of staff and expectations for delegation (as described within the policies and procedures) to make informed decisions on whether or not delegation is appropriate for the given situation. Licensed nurses maintain accountability for the client. However, the delegatee has responsibility for the delegated activity, skill, or procedure.

In summary, delegation is the transfer of the nurse’s responsibility for a task while retaining professional accountability for the client’s overall outcome. The decision to delegate is based on the nurse’s judgment, the act of delegation must be clearly defined by the nurse, and the outcomes of delegation are an extension of the nurse’s guidance and supervision. Delegation, when rooted in mutual respect and trust, is a key component to an effective health care team.

• American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation. https://www.ncsbn.org/NGND-PosPaper_06.pdf ↵
• American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation . https://www.ncsbn.org/NGND-PosPaper_06.pdf ↵
• “Delegation.png” by Meredith Pomietlo for Chippewa Valley Technical College  is licensed under  CC BY 4.0 ↵
• NCSBN. (n.d.). Delegation. https://www.ncsbn.org/1625.htm ↵
• "Delegation Decision Tree.png" by Meredith Pomietlo for  Chippewa Valley Technical College  is licensed under  CC BY 4.0 ↵

An RN, LPN/VN, or AP who is delegated a nursing responsibility by either an APRN, RN, or LPN/VN (where the state’s Nurse Practice Act allows), is competent to perform the task, and verbally accepts the responsibility.

Allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and not routinely performed.

Being answerable to oneself and others for one’s own choices, decisions, and actions as measured against a standard.

Leadership and Management of Nursing Care Copyright © 2022 by Kim Belcik and Open Resources for Nursing is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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• OJIN Homepage
• Table of Contents
• Volume 15 - 2010
• Number 2: May 2010
• Delegation Skills

Developing Delegation Skills

Ms. Weydt has more than thirty years of experience working in acute care settings and leading nursing and interdisciplinary teams in a variety of acute care settings. As she has worked to improve patient care processes and outcomes, she has focused considerable attention on developing healthy interpersonal relationships and delivery systems that span the care continuum. She currently serves as Director of Patient Care Services at Arcadia Medical Center, Arcadia, WI, and adjunct faculty with Creative Health Care Management. She earned her Master’s degree in Healthcare Administration from Cardinal Stritch University, Milwaukee, WI, and her BSN from Montana State University. Alice is also a graduate of the University of Minnesota Independent Study Program in Patient Care Administration.

One of the most complex nursing skills is that of delegation. It requires sophisticated clinical judgment and final accountability for patient care. Effective delegation is based on one’s state nurse practice act and an understanding of the concepts of responsibility, authority, and accountability. Work Complexity Assessment, a program that defines and quantifies various levels of care complexity based on the knowledge and skill required to perform the work, has demonstrated that methods of patient assignment and staff scheduling that support consistency increase what could be delegated to ancillary personnel by using the more effective assignment patterns. The author begins this article by discussing delegation and the related concepts of responsibility, accountability, and authority. Next factors to consider in the delegation process, namely nursing judgment , interpersonal relationships , and assignment patterns are presented. The author concludes by sharing how to develop delegation skills .

Key words: accountability, authority, delegation, delegation potential, pairing and partnering scenarios, patient assignments, professional practice, relationship management, responsibility, simulation, staff schedule, state nurse practice act, unit-based, Work Complexity Assessment

Registered Nurses (RNs) are brokers of patient care resources. RNs synthesize data collected by nurses and other healthcare professionals so as to coordinate the patient’s safe, individualized care and to best address patient and family needs in a way that maximizes available resources. RNs decide what patient care interventions are necessary and how, when, and by whom these interventions need to be provided. These decisions are made in a clinical environment in which shrinking resources and increased demands for services heighten the need for nurses to delegate care based on professional guidelines and their state nurse practice acts. The author begins this article by discussing delegation and the related concepts of responsibility, accountability, and authority. Next factors to consider in the delegation process, namely nursing judgment, interpersonal relationships, and assignment patterns are presented. The author concludes by sharing how delegation skills can be taught and strengthened.

Delegation and Related Concepts

Delegation is an important skill that influences clinical and financial outcomes... Perhaps one of the most difficult responsibilities an RN has is that of effective delegation. RNs are required to understand what patients and families need and then engage the appropriate care givers in the plan of care in order to achieve desired patient outcomes while maximizing the available resources on the patient’s behalf. Delegation is an important skill that influences clinical and financial outcomes; yet, an RN’s delegation skills often are not evaluated in the same manner as other clinical skills, even though a number of nurses continue to need help in delegating appropriately.

The following scenario is a typical situation that RNs frequently describe when sharing their need for more staff:

...the RN performed work that others could have completed. Near the end of her shift, the RN finds that the LPN and nursing assistant have all their work completed and are sitting in the nursing station waiting for the next shift to arrive. The RN has been running all evening trying to juggle competing patient needs, such as administering blood and initiating IV antibiotics for patients assigned to the LPN and nursing assistant, in addition to answering a pharmacist’s questions about a patient’s lab results and performing requests made by team members from other services, all while trying to complete the care needed for her patients. The RN is struck by how overwhelmed she feels and questions the LPN and nursing assistant about why they did not help her. The LPN and nursing assistant respond that had the RN asked them to help, they would have, adding, “but we can’t read your mind.” The RN responded, “I didn’t have time ask. Couldn’t you see I was busy?”

There is no doubt that this RN needed help. The RN’s challenge, however, was not related to a lack of available personnel. Rather the situation developed because the RN performed work that others could have completed. Almost all RNs can benefit from strengthening their delegation skills so as to maximize the available resources.

Delegation is a complex process in professional practice requiring sophisticated clinical judgment and final accountability for patients’ care ( National Council of State Boards of Nursing [NCSBN], 2005 ). The variability and complexity of each patient situation requires RN assessment to determine what is appropriate for the LPN, nursing assistant, and/or other assistive personnel, or even another RN, to perform. In the delegation process, RNs need to match the skills of the staff with the needs of the patient and family. Matching staff skill to patient and family needs highlights the difference between delegation and assignment. The NCSBN defines delegation as “giving someone a task from the delegator’s practice” ( NCSBN, 1995, p.1 ). This task, however, needs to be one that the person accepting the assignment is qualified to perform. Assignment is defined as “giving someone else a task within his/her own practice and is based on job descriptions and policies” ( NCSBN, 1995, p.1 ). Clarifying the difference between delegation and assignment helps staff members understand why one cannot develop a simple laundry list of what can be delegated to others.

Perhaps one of the most difficult responsibilities an RN has is that of effective delegation. Delegation belongs to the practice of registered nurses, but often it is not well understood or practiced. Ebright, Patterson, Chalko, & Render ( 2003 ) have stated that innovations, such as work redesign, have contributed to increased complexity affecting how delegation occurs. Work redesign has relied heavily on assistive personnel, sometimes called nurse extenders; however, many tasks cannot be delegated to these assistants because they exceed the scope of practice of these personnel ( Ebright, et al. )

In the scenario provided above, the RN was the person directing the work of others. However, the RN did not communicated with the LPN and nursing assistant about what needed to be done. In addition, the RN accepted the responsibility to perform additional activities requested by other departments rather than redirecting some of them. This behavior is not uncommon. A study of 170,000 healthcare workers found that RNs often performed inappropriate work or work that others could have done, thus contributing to a loss of the professional components of nursing ( Murphy, Ruch, Pepicello, & Murphy, 1997 ).

Nurses are stewards of healthcare resources. They promote cost containment for healthcare organizations ( NCSBN & American Nurses Association [ANA], 2006 ). Delegation is a skill that maximizes the available resources in the interest of patient care. Professional nurses need to work effectively with assistive personnel because of the escalating shortage of RNs, rising patient acuity, and increased therapy complexity ( NCSBN & ANA ). RNs are responsible for the care they provide and for determining what care can be appropriately delegated to others. LPNs and assistive personnel have technical expertise that can be maximized when RNs become skilled delegators who understand the concepts of responsibility, accountability, and authority, and grasp how these concepts influence what activities RNs can delegate to others ( Forte, Forstrum, & Lindquist, 199 8).

Responsibility

Frequently when discussing delegation, RNs will comment: If I am responsible for someone else’s work, I would rather do it myself. This statement infers that one is liable or has to answer for the actions of another. The ANA has stated that responsibility involves liability with the performance of duties in a specific role ( ANA Code of Ethics, 2001 ). Responsibility is a two-way process that is both allocated and accepted ( Creative Health Care Management, 2008 ). Assistive personnel accept responsibility when they agree to perform an activity delegated to them.

Accountability

Accountability involves a retrospective review which includes critical thinking to determine if the action was appropriate and giving an answer for what has occurred. RNs demonstrate accountability when they answer both for themselves and for others regarding their actions ( ANA Code of Ethics, 2001 ). RNs assure appropriate accountability by verifying that the receiving person accepts the delegation and accompanying responsibility ( NCSBN and ANA, 2006 ).

RNs, by virtue of their professional licensure, have the authority to transfer a selected nursing activity in a specific situation to a competent individual ( NCSBN, 1995 ). Authority is the right to act in areas where one is given and accepts responsibility ( Creative Health Care Management, 2008 ). RNs have authority, or legitimate power, to analyze assessments, plan nursing care, evaluate nursing care, and exercise nursing judgment ( NCSBN ) which includes delegation. In the scenario at the beginning of the article, the RN had the authority, but did not exercise this authority, to delegate to the LPN and/or nursing assistant.  Summary LPNs are accountable for the quality of their performance... In the delegation process accountability rests within the decision to delegate, while responsibility rests within the performance of the task. LPNs are accountable for the quality of their performance and responsible for caring out the activities assigned to them. When a RN delegates an activity, such as medication administration, to an LPN, the LPN is accountable for safely performing this medication administration according to established regulations and standards, and responsible for completing this activity. The RN is then accountable to follow up with the LPN to review the outcome. This intentional reflection on the delegated activity directs future efforts and promotes learning ( Creative Health Care Management, 2008 ). Understanding the difference between responsibility and accountability helps to clarify how RNs can delegate work to another without being held responsible for their actions.

Delegation and Nursing Judgment

The ANA Code of Ethics ( 2001 ) notes that delegation is based on the RN’s judgment concerning a patient’s condition, the competence of all members of the nursing team, and the degree of supervision required. This statement coincides with the Five Rights of Delegation developed by the NCSBN ( 1995 ). These Rights of Delegation include: (a) the right task, (b) the right circumstance, (c) the right person, (d) the right direction/communication, and (e) the right supervision.

Additionally, four guidelines for effective delegation have been identified by Koloroutis ( 2004, p. 136 ). They include the following:

• Delegation requires RNs to make decisions based on patient needs, complexity of the work, competency of the individual accepting the delegation, and the time that the work is done.
• Delegation requires that timely information regarding the individual patient be shared, defines specific expectations, clarifies any adaptation of the work in the context of the individual patient situation, and provides needed guidance and support by the RN.
• Ultimate accountability for process and outcomes of care – even those he or she has delegated - is retained by the RN.
• RNs make assignments and the care provider accepts responsibility, authority, and accountability for the work assigned.

Delegation decisions are sometimes made based on a list of tasks found in a job description, such as taking vital signs, bathing, or ambulating patients. In these cases the RN is really assigning tasks rather than using professional judgment to match the staff member’s skills to patient needs. Assigning nursing assistants to perform all the baths or take all the vital signs for a group of patients indicates that the delegation is task based rather than judgment based. Making assignments based on a list of tasks in a job description short-circuits the critical thinking skills of the RN because the RN’s judgment is not utilized. Matching the staff member’s expertise to patient needs is essential for sound delegation decisions.

An example of this matching would be an RN’s decision that an LPN with five years of long term care experience prior to working in orthopedics is a more qualified care giver for a 91 year old post operative arthroplasty patient than an LPN who is also available but who has less background in caring for geriatric patients. It is the understanding of the geriatric patient’s needs at this point in time that would lead the RN to intentionally select the LPN with long term care experience.  In this situation, the RN would still assume the responsibility of first assessing the patient before delegating the care to the LPN, and the responsibility of clarifying expectations of the care to be given in order to meet the desired outcomes.  The RN would periodically assess the patient’s status and not hesitate to instruct the LPN about what to monitor and direct specific interventions.  In this example, the matching of patient need to the nurse skills would be very intentional, relying on the RN’s professional judgment.

Although delegation is a skill that requires knowledge and practice, delegation is not commonly identified as an RN competency. Understanding and applying the delegation guidelines presented above provides a foundation for effective delegation.

Delegation and Interpersonal Relationships

The manner in which a team member is asked to perform care by the delegating RN influences the team member’s willingness to respond. Another important factor in delegation is the relationship between the RN and the LPN, nursing assistant, and/or other team member(s). Each member of the healthcare team has a valuable contribution to make to patient care ( Creative Health Care Management, 2006 ). This contribution is magnified when the RN has a healthy interpersonal relationship with the team providing care. Delegation is the invitation for participation. The manner in which a team member is asked to perform care by the delegating RN influences the team member’s willingness to respond. Communication style influences teamwork and relationships. Engaging in direct, open, and honest communication is a characteristic of good teamwork. Thus the ability to delegate and the quality of the delegation is influenced by healthy interpersonal relationships, the manner in which the activity is delegated, and the openness of the communication.

In contrast, in the scenario at the beginning of this article, comments made by various team members set the stage for blaming. The LPN and nursing assistant stated that they would have helped, had the RN asked them to do so, thus blaming the RN. One can wonder why the LPN and nursing assistant did not offer help or take initiative on their own to do more. Had the RN, LPN, and nursing assistant had a better relationship, the LPN and/or assistant might have had a greater desire to see their team provide the best care possible and have taken the initiative to perform the care that was within their scope of practice. Then the RN could have better managed what needed to be done and better patient care could have been provided.

In the ideal situation, the RN, LPN, and nursing assistant would have been active partners in care and shared the work. The RN, anticipating what would need to be done while she was busy with other activities, would have discussed openly, directly, and honestly with the LPN and assistant the additional care she needed to ask them to manage. Healthy interpersonal relationships among all personnel on the shift promote a synergy between team members, enabling them to work together more effectively. Although there is a connection between healthy relationships among team member and quality care, positive interactions among all staff members on a given shift are not always demonstrated in practice.

Healthy interpersonal relationships among all personnel on the shift promote a synergy between team members, enabling them to work together more effectively. Trust is an important element in developing healthy team relationships. Kolorouits ( 2004 ) has noted that effective delegation is based on both trust and an understanding of professional practice. When RNs state that they are reluctant to delegate care when they do not know their team member’s skill level, they are likely saying that they avoid delegation because they don’t trust their other team members. Trust, a critical factor in relationships, is based on knowledge of one another’s capabilities and confidence in these abilities. Caregiver consistency, which builds trust, is achieved by staffing schedules and methods of patient assignment which directly impact how work is delegated. The staffing schedule and patient assignment methods that promote consistency among caregivers and between caregivers and their patients become the foundation for enhancing the quality of work relationships ( Koloroutis, 2004 ) as described below.

Delegation and Assignment Patterns

The correlation between consistency of care givers and delegation potential (the amount of nursing care that can legally and safely be assigned to a non-professional staff member) is explored in the Work Complexity Assessment (WCA) Program. WCA is a consultant-led process, developed by Tom Ingalls and licensed through Creative Health Care Management; it helps define and quantify various levels of care complexity based on the knowledge and skill required to perform the work. The delegation potential is based on what could be delegated rather than on traditional delegation practices that are often task based. WCA uses the three scenarios (three different ways of assigning personnel) to determine the delegation potential and examine the impact of staffing schedules and methods of patient assignment on delegation. The three scenarios, namely unit based, pairing, and partnering, vary in the amount of time in which nurses and other personnel work the same shifts and care for the same patients ( Koloroutis, 2004 ). Each scenario is described below.

Unit-Based Scenarios

In the unit-based scenario, assistive personnel, such as the ward secretary and nursing assistant, serve the unit. The nursing assistant works off a task list usually found in the job description, and has minimal direction from, or interaction with the RNs. The nursing assistant is often left to prioritize the multiple tasks given by differing RNs who are unaware of one another’s requests of the assistant. This lack of communication can cause conflicts. The RNs do not know what their fellow RNs have also asked the assistant to do and the assistant has no way of knowing to which RN they are ultimately accountable. Nursing assistants express frustration with conflicts and work expectations that cannot be negotiated. RNs express frustration about not knowing the nursing assistants whereabouts or what they are doing.

An example of the unit based scenario is assigning a nursing assistant to take all the vitals signs or bathe all the patients. The nursing assistant understands what is expected, but may be interrupted in completing the vital signs and baths and asked to ambulate a patient by one RN, who does not know that another RN has just requested the nursing assistant to help with a dressing change. Meanwhile, the nursing assistant is trying to complete the bathes and take all patients’ vital signs, while the RNs are questioning why the nursing assistant hasn’t responded to their requests for help. In these scenarios the emphasis is on completing tasks of care, rather than focusing on the care process. It is difficult to develop healthy relationships and trust under these conditions.

Pairing is the second scenario in which one RN works with an LPN and/or a nursing assistant for the shift ( Koloroutis, Felgen, Person, & Wessel, 2007 ). However, the RN and LPN and/or assistant are not intentionally scheduled to work the same shift each day. Although they may all work the same shift on the next day, they may not be paired on the next day to care for the same patients. For a given shift, however, they work together, or are paired, and care for the same group of patients. Delegation usually increases with pairing. In this scenario, the RN and the LPN or nursing assistant discuss how care is to be prioritized and how it is to be done, and identify expected individualized outcomes for the shift. For instance, a patient’s therapeutic goal for the shift might be for the patient to ambulate the length of the hall 30 minutes after the pain medication has been administered, with a pain rating no greater than 2 on a scale of 1 to 10 at the end of the walk. The nursing assistant would report observations and the pain scale rating to the RN who would then determine if the plan for pain control is adequate. Pairing increases the delegation potential and promotes healthy relationships.

The third scenario is partnering ( Koloroutis, Felgen, Person, & Wessel, 2007 ). In partnering, one RN and one LPN and/or nursing assistant are consistently scheduled to work together, making a commitment to maintain healthy interpersonal relationships, trust each other, and advance each other’s knowledge. It is recognized that the RN has the authority to make the delegation decisions. In this model, the LPN, nursing assistant, and RN know one another well enough to anticipate what is going to be needed for patient care. The LPN or nursing assistant who works in a partnership with the RN knows that the RN will want a specific patient to ambulate and to achieve pain control by a certain time within a eight hour shift and/or will need a particular piece of equipment or certain supplies at a certain time. This knowledge enables the assistant to have the information or equipment available even before the RN asks for it. Compared to the assistant in the paired assignment, the assistant who is partnered could anticipate that the RN will want the patient walked within a given timeframe after a pain medication has been administered, and could plan to be available to walk the patient at the appropriate time. Together the RN and the LPN or nursing assistant care for “our patients” rather than “your patients” and “my patients.” This reflects a major shift in thinking and in the method assignments are made. Had partnering been used in the scenario at the beginning of the article, the staff involved would have known each other’s needs and expectations and would have been able to coordinate their efforts more effectively.

Partnering is supported by a staffing schedule that is developed so as to consistently have care givers working together and by the method of patient assignments that ensures the same staff cares for the same group of patients for their length of stay. Partnering reflects a philosophy of care that values continuity and relationships, with management and staff honoring the partnership. The delegation potential is generally highest when staff partner with each other because consistent relationships over time enhance knowledge about capabilities and help to foster trust between members of the nursing staff.

Thus staffing schedules and patient assignments impact the delegation potential. When this connection is understood and valued, staff members see how work can be done differently. This becomes especially effective when staff at the point of care take ownership of a staffing schedule that promotes continuity of care and when the patient assignment matches the talents of the caregivers to the needs of the patient and family.

...the amount of work delegated can be expanded when direct care givers work together consistently. Because the depth of expertise varies within roles, including the RN role, delegation is more difficult when the assistant is not known by the RN. Pairing and partnering increase delegation because trust is developed, relationships are fostered, and growth is supported. In partnering, there is increased commitment to one another and confidence that complex situations can be managed. The partnership enables RNs to perfect their delegation skills more fully.

Some staff members have shared with me that having limited nursing assistants or LPNs available with whom they can partner poses a challenge to implementing this partnering scenario. Creativity is needed to make this scenario work using existing resources. For example, in situations with predominately RN staff, more experienced RNs could mentor new RNs using pairing or partnering, thus enhancing care and helping the new RNs to grow professionally.

Work Complexity Assessment consultants have demonstrated that the amount of work delegated can be expanded when direct care givers work together consistently. Delegation potentials are significantly higher when caregivers are paired or partnered, with the partnered scenario generally having the highest delegation potential. In analyzing the findings from delegation potential studies, RNs frequently cite trust with their co-workers as a key factor when delegating. They state that delegation requires an understanding of one another’s knowledge and skills. Direct care givers who work together consistently have been found to experience the following gains in the work setting:  (a) more knowledge about each other’s competence and continued growth in competence; (b) increased commitment to each other and ability to deal with more complex situations; and (c) increased efficiency in getting the work done through natural synergy ( Weydt, 2009, p. 11 ). The Table compares the description, outcomes, and challenges of the unit-based, pairing, and partnering assignment patterns.

...role clarification becomes increasingly important as new positions develop to address...complex patient care needs. Delegation is a multifaceted skill set that begins with understanding one’s state nurse practice act which outlines nursing’s legal responsibility, authority, and accountability for patient care. RNs are encouraged to conduct ongoing reviews of their state practice act with special attention given to delegation. The review often prompts discussion about organizational policies and procedures as well as clarifying roles, such as that of the LPN or technical support staff. The role clarification becomes increasingly important as new positions develop to address the variety of complex patient care needs. Understanding the role expectations as well as knowing the expertise of the staff to whom care is delegated influences what the RN delegates.

Delegation skills can be strengthened when:

• RNs understand the nurse state practice act
• Nursing education and nursing service support students and RNs as they continually expand their knowledge about delegation
• Simulation exercises using scenarios found in daily practice are used to teach and demonstrate delegation competency
• Pairing and/or partnering is utilized and supported by the staff schedule and method of patient assignment
• Delegation is viewed as competency that is based on a skill set and that requires ongoing development

Developing delegation skills is indeed a multifaceted activity. Developing delegation skills begins during pre-licensure nursing education. It is important that educators and organizations provide clinical experiences for students to see delegation as a skill set that has to be practiced in order for it to be perfected. Developing practice environments that foster students’ learning of delegation skills reinforces the authority of all RNs to delegate to LPNs and nursing assistants who may see the student as inexperienced. As new RNs enter professional practice, they need ongoing support and education to perfect this skill.

Delegation skills can also be developed using simulation to create practice scenarios reflecting daily practice.  Delegation skills can also be developed using simulation to create practice scenarios reflecting daily practice. Both clinical aspects of care and delegation skills can be evaluated during the simulation. Simulation creates the opportunity for feedback and analysis of how pre-licensure students and/or RNs directed the work of others during the simulation, with an emphasis on the effect that the simulated delegation would have had on clinical and financial outcomes. RNs can evaluate their interpersonal skills used during the simulation, as well as review the work performed, asking how the work could have been done differently and considering who else might have been in a position to do this work.

Simulation might be used, for example to improve both the skill of delegation and that of administering blood for a post-operative patient. In the simulation scenario, the required technical skills of blood administration could be evaluated as well as the RN’s ability to appropriately delegate, during the procedure, some responsibilities for patient care to either the LPN or nursing assistant. The post-simulation discussion (debriefing) could include an evaluation of both the blood-administration procedure and also the quality of the delegation with a focus on the RN’s communication skills. The LPN and nursing assistant could provide feedback as to their perception of the RN’s delegating skills.

It is important that educators and organizations provide clinical experiences for students to see delegation as a skill set that has to be practiced in order for it to be perfected. Delegation is a complex professional skill requiring sophisticated clinical judgment and final accountability for patients’ care. Effective delegation is based on one’s state nurse practice act; it serves to maximize patient care resources. Concepts of responsibility, accountability, and authority are integral to each RN’s understanding of professional nursing practice, which includes properly assuming authority for the decisions and outcomes associated with patient care, sharing the process of patient care with other responsible members of the nursing team, and holding all members of the nursing team accountable for their responsibilities. Delegation requires RNs to use critical thinking skills in order to match staff expertise with patient and family needs. Staff relationships also influence the delegation potential and the delegation process. Three assignment scenarios are used in Work Complexity Assessment, namely unit based, pairing, and partnering, to determine the delegation potential for a specific patient care unit/service. Staffing schedules and consistent patient assignments that support pairing and partnering enable staff members to increase knowledge about each other and help to foster a strong sense of trust, thus increasing the delegation potential.

When RNs do not effectively delegate to others, quality of care can be lessened and valuable resources can be mismanaged. Resources will surely continue to shrink and care demands will surely continue to rise, thus increasing the risks of inappropriate delegation. Having clarity about what can be delegated helps to define quality professional practice not only for nurses but also for other team members, patients, and families.

Alice Weyd t, RN, MS E-mail: [email protected]

© 2010 OJIN: The Online Journal of Issues in Nursing Article published May 31, 2010

American Nurses Association. (2001). Code of ethics for nurses with interpretive statements an independent study module. Author: Washington DC.

American Nurses Association. (2010). Nurse–related principles for delegation . Retrieved 24, 2010 from www.safestaffingsaveslives.org/WhatisSafeStaffing/SafeStaffingPrinciples/PrinciplesforDelegationhtml.aspx#Nurse

Creative Health Care Management. (2007). Leading an empowered organization manual . Minneapolis: Author.

Ebright , P., Patterson, E., Chalko, B., & Render, L. (2003). Understanding the complexity of registered nurse work in acute care setting, JONA, 33, (12), 630-638.

Forte , P., Forstrom, S., & Lindquist, L. (1998). Work complexity assessment: Notes from the field. Journal of Nursing Administration, 28(7/8), 39-44.

Koloroutis , M. (2004). Relationship-based care: A model for transforming practice. Minneapolis, MN: Creative Health Care Management, Inc.

Koloroutis , M., Felgen, J., Person, C., & Wessel, S. (2007). Field guide: Relationship-based care visions, strategies, tools and exemplars for transforming practice. Minneapolis, MN: Creative Health Care Management, Inc.

Murphy , E., Ruch, S., Pepicello, J., & Murphy, M. (1997). Managing an increasingly complex system. Nursing Management, 28 (10), 33-38.

National Council of State Boards of Nurses. (1995). Concepts and decision-making process . National Council position paper . Retrieved July 29, 2009, from www.ncsbn.org/323.htm

National Council of State Boards of Nurses and American Nurses Association. (2006) NSCBN and ANA issue joint statement on nursing delegation. Retrieved January 14, 2010 from www.ncsbn.org/pdfs/Joint_statement.pdf

Weydt , A. (2009). Defining, analyzing, and quantifying work complexity. Creative Nursing, 15 (1), 7-14.

May 31, 2010

DOI : 10.3912/OJIN.Vol15No02Man01

https://doi.org/10.3912/OJIN.Vol15No02Man01

Citation: Weydt, A., (May 31, 2010) "Developing Delegation Skills" OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 2, Manuscript 1.

• Article May 31, 2010 When Does Delegating Make You a Supervisor? Jennifer Matthews, PhD, RN, ACNS-BC
• Article May 31, 2010 Delegation in Long-Term Care: Scope of Practice or Job Description? Kirsten N. Corazzini, PhD ; Ruth A. Anderson, PhD, RN, FAAN ; Carla Gene Rapp, PhD, RN, CRRN ; Christine Mueller, PhD, RN, BC, NEA-BC, FAAN ; Eleanor S. McConnell, PhD, RN, GCNS, BC ; Deborah Lekan, MSN, RNC
• Article May 31, 2010 Delegation in the School Setting: Is it a Safe Practice? Cheryl Resha, EdD, MSN, RN
• Article May 31, 2010 Mindful Communication: A Novel Approach to Improving Delegation and Increasing Patient Safety Mary K. Anthony, PhD, RN, CS; Kathleen Vidal RN MSN
• Article May 31, 2010 Nursing Delegation in the United Kingdom Patricia Gillen, PhD, RN, RM, RNT, MSc, BSc ; Sean Graffin, RN, RMN, RNT, BSc

Prioritization, Delegation, and Assignment in Nursing NCLEX Practice Questions (100 Items)

In this NCLEX guide , we’ll help you review and prepare for prioritization, delegation, and assignment in your nursing exams. For this nursing test bank , improve your prioritization, delegation , and patient assignment skills by exercising with these practice questions. We will also be teaching you test-taking tips and strategies so you can tackle these questions in the NCLEX with ease. The goal of these practice quizzes and reviewers is to help student nurses establish a foundation of knowledge and skills on prioritization, delegation, and assignment.

Quiz Guidelines

Before you start, here are some examination guidelines and reminders you must read:

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Prioritization, Delegation, and Assignment Practice Quiz

This section contains the practice questions to exercise your knowledge on nursing prioritization, delegation, and assignment. As with other quizzes, be sure to read and understand the question carefully. For prioritization, delegation, and assignment questions, read each choice carefully before deciding on your answer. Good luck and answer these questions at your own pace. You are here to learn.

Quizzes included in this guide are:

Nursing Prioritization, Delegation and Assignment Reviewer for Nurses

This is your guide to help you answer NCLEX priority, delegation, and assignment style questions.

NCLEX Tips for Nursing Prioritization, Delegation, and Assignment questions:

Here are six tips and strategies to help you ace NCLEX questions about delegation, assignment, and prioritization.

1. Do not make decisions based on resolutions

Do not make decisions concerning the management of care issues based on resolutions you may have witnessed during your clinical experience in the hospital or clinic setting. As a student nurse , you are constantly reminded that NCLEX questions are to be solved and responded to in the context of “Ivory Tower Nursing.” That is, if you only had one patient at a time, loads of assistive personnel, countless supplies, and equipment. This is what people mean when they refer to “ textbook nursing .” But when you’re in the real world without the time and resources, you adjust. Your clinical rotation in management may have been less than ideal but remember that in NCLEX, the answers to the questions are seen in nursing textbooks or journals. Always bear in mind, “Is this textbook nursing care?”

2. Never delegate the functions of assessment, evaluation and nursing judgment.

Throughout your nursing education , you learned that assessments, nursing diagnosis , establishing expected outcomes, evaluating care and any other tasks and aspects of care including but not limited to those that entail sterile technique, critical thinking, professional judgment, and professional knowledge are the responsibilities of the registered professional nurse. You cannot give these responsibilities to nonprofessional, unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and personal care aides.

3. Identify tasks for delegation based on the client’s needs.

Delegate activities for stable patients because some of these needs are relatively predictable and more frequently encountered. These are somewhat routinized and without the need for high levels of professional judgment and skill. But if the patient is unstable, the needs are acute and become unpredictable, ever-changing, and rarely encountered based on the patient’s changing status. These needs should not be delegated.

4. Ensure the appropriate education, skills, and experience of personnel performing delegated tasks.

Delegate activities that involve standard, consistent, and unchanged systems and procedures. The care of a patient with chest tubes and chest drainage can be delegated to either another RN or a licensed practical nurse. Therefore, the authorizing RN must ensure that the nurse is qualified, skilled, and competent to perform this intricate task, observe the patient’s response to this treatment, and ensure that the equipment is operating suitably and accurately.

The care of a stable chronically ill patient who is comparatively stable and more anticipated than a seriously ill and unstable acute patient can be assigned to the licensed practical nurse, and assistance with the activities of daily living and basic hygiene and comfort care can be assigned and delegated to an unlicensed assistive staff member like a nursing assistant or a patient care technician. Activities that frequently occur in daily patient care can be delegated. Bathing, feeding , dressing , and transferring patients are examples.

Procedures that are complex or complicated should not be delegated, especially if the patient is highly unstable.

5. Remember priorities!

Recall and understand Maslow’s Hierarchy of Needs , the ABCs (Airway, Breathing, Circulation ), and stable versus unstable. It is necessary to know and understand the priorities when deciding which patient the RN should attend to first. Remember that you can see only one patient or perform one activity when answering questions that require you to establish priorities.

Always keep in mind that improper and inappropriate assignments can lead to inadequate quality of care, unexpected care outcomes, the jeopardization of client safety, and even legal consequences. Right assignment of care to others, including nursing assistants, licensed practical nurses, and other registered nurses, is certainly one of the most significant daily decisions nurses make.

6. Additional Test Taking Tips and Strategies

• Questions using keywords such as “ best ,” “ essential ,” “ highest priority ,” “ primary ,” “ immediate ,” “ first ,” or “ initial response ” are asking for your prioritizing skills.
• Know the patient’s purpose of care, current clinical condition, and outcome of care in order to determine and plan priorities.
• Identify the priority patient based on the following: patient’s age, day of admission/ surgery , or the number of body systems involved.
• Unlicensed assistive personnel (UAP) such as nurses’ aides, certified nursing assistants, attendants, health aides are not allowed to delegate. Only a registered nurse can delegate tasks. 
• In some states, Licensed Practical Nurses ( LPN ) may delegate to a UAP depending on the state nursing practice .   
• Ensure the appropriate knowledge, skills, and experience of personnel performing the delegated tasks.
• Do not delegate teaching, assessment , planning , evaluating, and nursing judgment to an unlicensed nurse.
• A client with an unstable and unpredictable condition cannot be delegated to a UAP’s or LPNs.
• Delegate tasks that involve standard, simple procedures such as bathing , dressing , feeding , and transferring patients.
• Student nurses, float nurses, personal assistants, and other personnel may require levels of guidance and supervision.

Nursing Prioritization

Prioritization is deciding which needs or problems require immediate action and which ones could be delayed until later because they are not urgent. In the NCLEX, you will encounter questions that require you to use the skill of prioritizing nursing actions. These nursing prioritization questions are often presented using the multiple-choice format or via ordered-response format. For a review, in an ordered-response question format , you’ll be asked to use the computer mouse to drag and drop your nursing actions in order or priority. Based on the information presented, determine what you’ll do first, second, third, and so forth. Directions are provided with the question. To help you answer nursing prioritization questions, remember the three principles commonly used:

1. Remember ABC’s (airway, breathing, and circulation).

Patients with obvious respiratory problems or interventions to provide airway management are given priority.

2. Maslow’s Hierarchy of Needs

Use Maslow’s hierarchy of needs as a guide to prioritize by determining the order of priority by addressing the physiological needs first.

There are five different levels of Maslow’s hierarchy of needs:

• Physiological Needs. The basic physiological needs have the highest priority and must be met first. Some examples of physiological needs include oxygen, food, fluid, nutrition , shelter, sleep , clothing, and reproduction.
• Safety Needs. Safety can be divided into physical and physiological. These include health, property, employment, security of the environment, and resources.
• Social Needs. These include love, family, friendship, and intimacy.
• Esteem. These include confidence, self-esteem , respect, and achievement.
• Self-actualization. These include creativity, morality, and problem-solving.

3. Using the Nursing Process

The nursing process is a systematic approach to assess and give care to patients. Assessment should always be done first before planning or providing interventions.

Delegation in Nursing

Delegation is the transference of responsibility and authority for an activity to other health care members who are competent to do so. The “delegate” assumes responsibility for the actual performance of the task and procedure. The nurse (delegator) maintains accountability for the decision to delegate and for the appropriateness of nursing care rendered to the patient. The role of a registered nurse also includes delegating care, assigning tasks, organizing and managing care, supervising care delivered by other health care providers while effectively managing time! The NCLEX includes questions related to this unique nursing role of delegation.

5 Rights of Delegation in Nursing

The following are the five rights of delegation in nursing:

• Right Person. The licensed nurse and the employer and the delegatee are responsible for ensuring that the delegatee possesses the appropriate skills and knowledge to perform the activity.
• Right Tasks. The activity falls within the delegatees’ job description or is included as part of the nursing practice settings established written policies and procedures. The facility needs to ensure the policies and procedures describe the expectations and limits of the activity and provide any necessary competency training.
• Each delegation situation should be specific to the patient, the licensed nurse, and the delegatee.
• The licensed nurse is expected to communicate specific instructions for the delegated activity to the delegatee; the delegatee should ask any clarifying questions as part of two-way communication . This communication includes any data that needs to be collected, the method for collecting the data, the time frame for reporting the results to the licensed nurse, and additional information pertinent to the situation.
• The delegatee must understand the terms of the delegation and must agree to accept the delegated activity.
• The licensed nurse should ensure that the delegatee understands that she or he cannot make any decisions or modifications in carrying out the activity without first consulting the licensed nurse.
• Right Circumstances. The health condition of the patient must be stable. If the patient’s condition changes, the delegatee must communicate this to the licensed nurse, and the licensed nurse must reassess the situation and the appropriateness of the delegation.
• The licensed nurse is responsible for monitoring the delegated activity, following up with the delegatee at the completion of the activity, and evaluating patient outcomes . The delegatee is responsible for communicating patient information to the licensed nurse during the delegation situation. The licensed nurse should be ready and available to intervene as necessary.
• The licensed nurse should ensure appropriate documentation of the activity is completed.

Recommended Resources

Recommended books and resources for your NCLEX success:

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

Saunders Comprehensive Review for the NCLEX-RN Saunders Comprehensive Review for the NCLEX-RN Examination is often referred to as the best nursing exam review book ever. More than 5,700 practice questions are available in the text. Detailed test-taking strategies are provided for each question, with hints for analyzing and uncovering the correct answer option.

Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items Next Generation NCLEX®-style practice questions of all types are illustrated through stand-alone case studies and unfolding case studies. NCSBN Clinical Judgment Measurement Model (NCJMM) is included throughout with case scenarios that integrate the six clinical judgment cognitive skills.

Saunders Q & A Review for the NCLEX-RN® Examination This edition contains over 6,000 practice questions with each question containing a test-taking strategy and justifications for correct and incorrect answers to enhance review. Questions are organized according to the most recent NCLEX-RN test blueprint Client Needs and Integrated Processes. Questions are written at higher cognitive levels (applying, analyzing, synthesizing, evaluating, and creating) than those on the test itself.

NCLEX-RN Prep Plus by Kaplan The NCLEX-RN Prep Plus from Kaplan employs expert critical thinking techniques and targeted sample questions. This edition identifies seven types of NGN questions and explains in detail how to approach and answer each type. In addition, it provides 10 critical thinking pathways for analyzing exam questions.

Illustrated Study Guide for the NCLEX-RN® Exam The 10th edition of the Illustrated Study Guide for the NCLEX-RN Exam, 10th Edition. This study guide gives you a robust, visual, less-intimidating way to remember key facts. 2,500 review questions are now included on the Evolve companion website. 25 additional illustrations and mnemonics make the book more appealing than ever.

NCLEX RN Examination Prep Flashcards (2023 Edition) NCLEX RN Exam Review FlashCards Study Guide with Practice Test Questions [Full-Color Cards] from Test Prep Books. These flashcards are ready for use, allowing you to begin studying immediately. Each flash card is color-coded for easy subject identification.

Recommended Links

An investment in knowledge pays the best interest. Keep up the pace and continue learning with these practice quizzes:

• Nursing Test Bank: Free Practice Questions UPDATED ! Our most comprehenisve and updated nursing test bank that includes over 3,500 practice questions covering a wide range of nursing topics that are absolutely free!
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11 thoughts on “Prioritization, Delegation, and Assignment in Nursing NCLEX Practice Questions (100 Items)”

Very helpful. A LPN graduate who has taken the nclex four times. It gives me a quick overview. Thanks

Love it!!! These made me think. They up there with ReMar and uWorld.

Very helpful thanks

In which order will the nurse perform the following actions as she prepares to leave the room of a client with airborne precautions after performing oral suctioning?

please your order for this question is wrong

I have learned a lot from the NursesLabs. Love it!

Nurse Pietro receives an 11-month old child with a fracture of the left femur on the pediatric unit. Which action is important for the nurse to take FIRST? First- Speak with parents as to how injury occurred??? Yes, this is going to take place but this the first thing to do? Perhaps the wording needs to change as I have been “textbook” taught, treat first, then question in cases of suspected abuse.

good questions which test your analyzing and critical thinking skils

Thank you for making this free. It is my additional resources. This has been very helpful. I really appreciate that you are helping all future nurses to be at their best .

I’m really grateful for this excercise which aids in preparing for the NCLEX. Thanks

This has help me pass my nclex !! Thanks

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Assignment and Delegation: Guidelines for Nurses

We developed Assignment and Delegation: Guidelines for Nurses to provide a framework for nurses when assigning or delegating to unregulated care providers (UCPs) or other members of the healthcare team. These guidelines outline the differences between assignment and delegation as well as the accountabilities and consideration for nurses prior to assigning or delegating care to UCPs. 

If you have any questions about the Assignment and Delegation: Guidelines for Nurses , please reach out to us at [email protected] . 

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• The Official Publication of the Georgia Nurses Foundation (GNF)

Delegating vs. Assigning: What You Need to Know

Cynthia Saver and Georgia Reiner

Georgia Nursing April 2024

This article appears on page 10 of

Registered nurses (RNs) often delegate to other RNs, licensed practical nurses/vocational nurses (LPN/LVNs), and assistive personnel (AP). (In some states or jurisdictions, LPN/LVNs may be allowed to delegate, so “licensed nurses” will be used in this article.) Delegating appropriately protects patients and reduces the risk of legal liability, yet the parameters of delegation often are not fully understood.

One common area of misunderstanding is delegation vs. assignment. Knowing the differences between the two is essential to ensure you delegate appropriately. The primary difference relates to scope of practice and where the clinician learned the activities to be carried out.

Assignment According to national guidelines for nursing delegation from the National Council of State Boards of Nursing (NCSBN) and American Nurses Association (ANA), an assignment refers to the “routine care, activities, and procedures that are within the authorized scope of practice of the RN or LPN/VN or part of the routine functions of the AP.” This definition covers fundamental skills that the assignee would have learned in a basic education program. A licensed nurse is still responsible for ensuring the assignment is carried out correctly.

Delegation According to the NCSBN/ANA guideline, delegation applies when the delegatee is performing a “specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and not routinely performed.” As opposed to work that is part of an assignment, the work associated with delegation was not learned in a basic education program. Therefore, the delegatee must have obtained additional education and have verified competence in the delegated area for which they will be responsible. The licensed nurse maintains overall accountability for the patient, but the delegatee is responsible for the delegated activity, skill, or procedure.

Licensed nurses can’t delegate activities that involve clinical reasoning, nursing judgment, or critical decision making, and the delegated responsibility has to be within the delegator’s scope of practice under the state’s or jurisdiction’s nurse practice act (NPA).

Responsibilities Organizational administrators, the delegator, and the delegatee each have responsibilities when an activity, skill, or procedure is delegated.

Professionals who work at the administrative or managerial level of the organization set the cultural tone for the nursing work environment and are responsible for managing the delegation processes. Those at the administrative level within an organization define what nursing responsibilities may be delegated, to whom, and under what set(s) of circumstances. They are also responsible for developing and maintaining policies and procedures associated with delegation, periodically evaluating the efficacy and safety of delegation processes, and training and educating staff.

The delegator is responsible for determining the needs of the patient, when delegation is appropriate, and if the delegatee is competent to complete the delegated task. Delegators must follow delegation guidelines in the NPA and relevant organizational policies and procedures. Clear communication is key, and the delegator must be available as a resource to the delegatee. Delegators also need to evaluate outcomes as they maintain overall accountability for the patient. Delegators must be prepared to step in at any point if it appears the delegatee is not handling the assignment appropriately. Any problems should be reported to nursing leadership.

The delegatee is responsible for only accepting activities that fall within their competence and that they feel comfortable completing safely. Delegatees must communicate with the delegator, particularly if the patient’s condition changes, and complete the activity correctly, including fulfilling any documentation requirements. Delegatees maintain accountability for the delegated activity and need to notify the delegator immediately if they have difficulty completing the task. 

One special case NCSBN notes that in some cases, APs are taught how to perform skills that were previously thought to be exclusively RN and LPN/LVN responsibilities, such as certified medical assistants administering injections. In these cases, it’s best to consider such tasks as being delegated and, therefore, validate competency.

Keeping patients safe Knowing the differences between assigning and delegating helps protect patients and avoid legal action should an error occur. Assignments involve routine tasks learned in basic education and that fall under designated scope of practice, while delegation involves tasks that were learned through additional education and for which competency has been determined.

Good communication and an understanding of the responsibilities of delegators and delegatees is essential to avoid misunderstanding. Remember, the licensed nurse remains accountable for the patient, but the delegatee is responsible for the delegated task.

Five rights of delegation The NCSBN outlines five rights of delegation. In the case of a lawsuit, a key component would be whether you adhered to these rights: 

• Right task. The task needs to fall within the delegatee’s job description or is part of organizational policies and procedures. 
• Right circumstance. The patient must be stable. 
• Right person. The delegatee must have the appropriate skills and knowledge to perform the task. 
• Right directions and communication. Clear directions need to be given, with the delegator verifying understanding by the delegatee. Communication must be two-way, with the delegatee asking questions as needed. 
• Right supervision and evaluation. The delegator needs to monitor the delegated activity, including evaluating patient outcomes. 

Article by: Cynthia Saver, MS, RN, President of CLS Development, Inc., in Columbia, Md and Georgia Reiner, MS, CPHRM, Risk Analyst, NSO

References National Council of State Boards of Nursing. National guidelines for nursing delegation. J Nurs Reg. 2016;7(1):5- 12.

NCSBN, ANA. National guidelines for nursing delegation. 2019.

Disclaimer: The information offered within this article reflects general principles only and does not constitute legal advice by Nurses Service Organization (NSO) or establish appropriate or acceptable standards of professional conduct. Readers should consult with an attorney if they have specific concerns. Neither Affinity Insurance Services, Inc. nor NSO assumes any liability for how this information is applied in practice or for the accuracy of this information. Please note that Internet hyperlinks cited herein are active as of the date of publication but may be subject to change or discontinuation.

This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. The individual professional liability insurance policy administered through NSO is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to [email protected] or call 1-800-247-1500. www.nso.com .

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What is the Difference Between the Assignment and the Delegation of Nursing Care?

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National Guidelines for Nursing Delegation

• National Council of State Boards of Nursing
• evidence-based
• nursing assignment
• • Understand evidence-based, state-of-the-art standards for delegation.
• • Explain the differences between assignment and delegation and the responsibilities of the employer, nurse leader, delegating nurse, and delegatee in the process of delegation.

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Delegation Versus Assignment

• • A delegatee is allowed to perform a specific nursing activity, skill, or procedure that is outside the traditional role and basic responsibilities of the delegatee’s current job.
• • The delegatee has obtained the additional education and training, and validated competence to perform the care/delegated responsibility. The context and processes associated with competency validation will be different for each activity, skill, or procedure being delegated. Competency validation should be specific to the knowledge and skill needed to safely perform the delegated responsibility as well as to the level of practitioner (i.e., RN, LPN/VN, UAP) to whom the activity, skill, or procedure has been delegated.
• • The licensed nurse who delegates the “responsibility” maintains overall accountability for the patient. However, the delegatee bears the responsibility for the delegated activity, skill, or procedure.
• • The licensed nurse cannot delegate nursing judgment or any activity that will involve nursing judgment or critical decision making.
• • Nursing responsibilities are delegated by someone who has the authority to delegate.
• • The delegated responsibility is within the delegator’s scope of practice.
• • When delegating to a licensed nurse, the delegated responsibility must be within the parameters of the delegatee’s authorized scope of practice under the NPA.
• • The routine care, activities, and procedures that are within the authorized scope of practice of the RN or LPN/VN or part of the routine functions of the UAP
• • The above are included in the coursework taught in the delegatee’s basic educational program.
• • Certified medication aides taught to pass out medications
• • Certified medical assistants taught to give injections.

Additional Key Definitions

• Google Scholar

Literature Review

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Guidelines for Delegation

• • APRNs when delegating to RNs, LPN/VNs, and UAP
• • RNs when delegating to LPN/VNs and UAP
• • LPN/VNs (as allowed by their state/jurisdiction) when delegating to UAP.
• Agency for Healthcare Research and Quality

Employer/Nurse Leader Responsibilities

• 1. The employer must identify a nurse leader responsible for oversight of delegated responsibilities for the facility . If there is only one licensed nurse within the practice setting, that licensed nurse must be responsible for oversight of delegated responsibilities for the facility.
• 2. The designated nurse leader responsible for delegation, ideally with a committee (consisting of other nurse leaders) formed for the purposes of addressing delegation, must determine which nursing responsibilities may be delegated, to whom, and under what circumstances . The nurse leader must be aware of the state/jurisdiction’s NPA and the laws/rules and regulations that affect the delegation process and ensure all institution policies are in accordance with the law.
• 3. Policies and procedures for delegation must be developed . The employer/nurse leader must outline specific responsibilities that can be delegated and to whom these responsibilities can be delegated. The policies and procedures should also indicate what may not be delegated. The employer must periodically review the policies and procedures for delegation to ensure they remain consistent with current nursing practice trends and that they are consistent with the state/jurisdiction’s NPA (institution/employer policies can be more restrictive, but not less restrictive).
• 4. The employer/nurse leader must communicate information about delegation to the licensed nurses and UAP and educate them about what responsibilities can be delegated . This information should include the competencies of delegatees who can safely perform a specific nursing responsibility.
• 5. All delegatees must demonstrate knowledge and competency on how to perform a delegated responsibility . Therefore, the employer/nurse leader is responsible for providing access to training and education specific to the delegated responsibilities. This applies to all RNs, LPN/VNs, and UAP who will be delegatees. Competency validation should follow education and competency testing should be kept on file. Competency must be periodically evaluated to ensure continued competency. The context and processes associated with competency validation will be different for each activity, skill, or procedure being delegated. Competency validation should be specific to the knowledge and skill needed to safely perform the delegated responsibility as well as to the level of practitioner (i.e., RN, LPN/VN, UAP) to whom the activity, skill, or procedure has been delegated.
• 6. The nurse leader responsible for delegation, along with other nurse leaders and administrators within the facility, must periodically evaluate the delegation process . The licensed nurse and/or his or her manager (if applicable) must report any incidences to the nurse leader responsible for delegation. A decision should be made about corrective action, including whether further education and training are needed or whether that individual should not be allowed to perform a specific delegated responsibility.
• 7. The employer/nurse leader must promote a positive culture and work environment for delegation.

Licensed Nurse Responsibilities

• Open table in a new tab
• 2. The licensed nurse must communicate with the delegatee who will be assisting in providing patient care . This should include reviewing the delegatee’s assignment and discussing delegated responsibilities, including information on the patient’s condition/stability, any specific information pertaining to a certain patient (e.g., no blood draws in the right arm), and any specific information about the patient’s condition that should be communicated back to the licensed nurse by the delegatee.
• 3. The licensed nurse must be available to the delegatee for guidance and questions, including assisting with the delegated responsibility, if necessary, or performing it him/herself if the patient’s condition or other circumstances warrant doing so .
• 4. The licensed nurse must follow up with the delegatee and the patient after the delegated responsibility has been completed .
• 5. The licensed nurse must provide feedback information about the delegation process and any issues regarding delegatee competence level to the nurse leader . Licensed nurses in the facility need to communicate, to the nurse leader responsible for delegation, any issues arising related to delegation and any individual that they identify as not being competent in a specific responsibility or unable to use good judgment and decision making.

Delegatee Responsibilities

• 1. The delegatee must accept only the delegated responsibilities that he or she is appropriately trained and educated to perform and feels comfortable doing given the specific circumstances in the health care setting and patient’s condition . The delegatee should confirm acceptance of the responsibility to carry out the delegated activity. If the delegatee does not believe he or she has the appropriate competency to complete the delegated responsibility, then the delegatee should not accept the delegated responsibility. This includes informing the hospital leadership if he or she does not feel he or she has received adequate training to perform the delegated responsibility, is not performing the procedure frequently enough to do it safely, or his or her knowledge and skills need updating.
• 2. The delegatee must maintain competency for the delegated responsibility .
• 3. The delegatee must communicate with the licensed nurse in charge of the patient . This includes any questions related to the delegated responsibility and follow-up on any unusual incidents that may have occurred while the delegatee was performing the delegated responsibility, any concerns about a patient’s condition, and any other information important to the patient’s care.
• 4. Once the delegatee verifies acceptance of the delegated responsibility, the delegatee is accountable for carrying out the delegated responsibility correctly and completing timely and accurate documentation per facility policy . The delegatee cannot delegate to another individual. If the delegatee is unable to complete the responsibility or feels as though he or she needs assistance, the delegatee should inform the licensed nurse immediately so the licensed nurse can assess the situation and provide support. Only the licensed nurse can determine if it is appropriate to delegate the activity to another individual. If at any time the licensed nurse determines he or she needs to perform the delegated responsibility, the delegatee must relinquish responsibility upon request of the licensed nurse.

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Provider accreditation

• a. Nurses are accountable for predicting adverse outcomes.
• b. Unlicensed assistive personnel (UAP) must accept any delegated nursing activity.
• c. UAP work under the license of the delegating nurse.
• d. Nurses cannot delegate any element of the nursing process.
• a. Right reason
• b. Right person
• c. Right task
• d. Right communication
• a. Communication and collaboration
• b. Licensure and experience
• c. Training and authorization
• d. Certification and endorsement
• a. Any licensed nurse can delegate and supervise unlicensed assistive personnel (UAP).
• b. Only registered nurses can delegate and supervise UAP.
• c. All states prohibit licensed practical/vocational nurses (LPN/VNs) from delegating and supervising.
• d. Some states prohibit LPN/VNs from delegating and supervising UAP
• a. Shortage of training programs for unlicensed assistive personnel (UAP)
• b. Variation in roles and responsibilities of UAP
• c. Inconsistent use of a decision tree for delegation
• d. Lack of standardized patient handoffs
• a. Unlicensed assistive personnel (UAP) can delegate to other UAP
• b. Licensed practical/vocational nurses (LPN/VNs) can delegate to registered nurses (RNs) and UAP
• c. RNs can delegate to advanced practice registered nurses (APRNs), LPN/VNs, and UAP.
• d. APRNs can delegate to RNs, LPN/VNs, and UAP.
• a. Supervision
• b. Delegation
• c. Responsibility
• d. Accountability
• a. Delegation
• b. Supervision
• c. Assignment
• d. Authorization
• a. The health care provider
• b. The health care employer
• c. The nurse leader
• d. The nurse who delegates the activity
• a. Ensuring appropriate policies and procedures regarding delegation are in place
• b. Ensuring adequate staffing
• c. Establishing scope of practice guidelines for unlicensed assistive personnel
• d. Promoting and maintaining a positive culture
• a. Ask the UAP to observe and learn how to perform the skill
• b. Perform the activity himself or herself
• c. Contact the nursing supervisor
• d. Consult another nurse
• a. By observing the delegatee perform the activity
• b. By encouraging autonomy, creativity, and self-discipline
• c. By providing support, guidance, and instructions
• d. By assessing the staff member’s knowledge, skills, and abilities

Article info

After being developed, the guidelines were vetted by the state boards of nursing and national nursing leaders across the United States. They were approved by the NCSBN Board of Directors.

Identification

DOI: https://doi.org/10.1016/S2155-8256(16)31035-3

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Assignment vs. Delegation

Nursing Students General Students

Published Feb 12, 2017

I have a quick question regarding assignments vs. delegation to LPNs.

I understand that delegation is the transfer of responsibility for a certain task but that accountability remains with the delegator. Assignment is the transfer of both responsibility and accountability among RNs (per my book). My book does not address assigning in regards to LPNs.

So my question is, can an RN assign an LPN to complete an aspect of patient care and, if so, is accountability transferred to the LPN as well as responsibility?

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Short answers, an RN can assign pt care to an LPN or CNA. On an administrative level, and LPN can assign an RN , too. Delegation is different. My emphasis below. Suggest you go to the links and read them both, which might help.

Caveat, this is from MA. Your state probably has similar resources at your DPH website; they are likely to be very similar if not identical, but others may respond c different info.

From my state BoN regs:

Five Rights of Delegation

The Licensed Practical Nurse in the Charge or Supervisor Nurse Role

It is within LPN scope of practice to function in the charge or supervisor nurse role. This role may include, but is not limited to: making patient care assignments; creating schedules; contributing to personnel evaluations; budgetary management; and educating others to organizational policy and procedure. To make a patient care assignment” means to appoint or designate a Registered Nurse ( RN ), LPN or unlicensed person (UP) the responsibility to implement an established nursing care planfor a designated group of patients for a designated period of work time. The patient care assignment must be consistent with the assignee's scope of practice and/or competency, the assignee's job description, and the employing agency's policies. The job description of charge nurse or supervisor must include the duties and responsibilities of its administrative role. The charge nurse or supervisor directs nursing service personnel to comply with the organization's policies and procedures.

The non-clinical, administrative functions of the supervisor or charge nurse roles, such as making a patient care assignment, differs from the clinical function of delegation (see Table 1).

[TABLE=width: 680]

[TD=width: 151] [/TD]

[TD=width: 276] Making a Patient Care Assignment [/TD]

[TD=width: 253] Delegation [/TD]

[TD=width: 151]Definition[/TD]

[TD=width: 276]Distribution of work that each RN , LPN or UP is responsible for during a given period of work time [1] [/TD]

[TD=width: 253]The authorization by a licensed nurse to a UP to provide selected nursing services [2] [/TD]

[TD=width: 151]Who may initiate[/TD]

[TD=width: 276] RN or LPN[/TD]

[TD=width: 253] RN or LPN[/TD]

[TD=width: 151]Who is recipient[/TD]

[TD=width: 276] RN , LPN or UP[/TD]

[TD=width: 253]UP[/TD]

[TD=width: 151]Functional area[/TD]

[TD=width: 276]Administrative[/TD]

[TD=width: 253]Clinical[/TD]

Delegation is the authorization by a RN or LPN to an UP to provide selected nursing activities. The licensed nurse retains responsibility and accountability for these delegated activities. Neither LPNs nor RNs delegate nursing activities to other licensed nurses. (my emphasis)

All nurses are responsible and accountable for their individual clinical assessments (determining care needs based on data), nursing judgments (reaching a clinical decision based upon analysis of the evidence or data), performance of nursing activities, and competency [3] . Respectful collaboration is encouraged to coordinate nursing services, ensuring that the patient's total plan of care is maintained.

The job description of charge nurse or supervisor must include the duties and responsibilities of its administrative role.

Concurrent with administrative duties and responsibilities, the LPN in the charge or supervisor role may also provide nursing care to a designated group of patients for a designated period of work time.

Determining supervision for purposes of administrative oversight is an employer prerogative and not within the authority of the Board.

[1] Adapted from the American Nurses Association and the National Council of State Boards of Nursing Joint Statement on Delegation

[2] 244 CMR 3.05(1)

[3] the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by the Board and for the delivery of safe nursing care in accordance with accepted standards of practice – 244 CMR 9.02 Competency