LessonsManagement of Care

Delegation and who may do what

Decide what may be handed to a licensed practical nurse or to unlicensed assistive personnel, what may never leave the registered nurse, and what the RN still owes after delegating.

The question is judgment, not difficulty

Delegation questions look like they are about how hard a task is. They are not. They turn on whether the task requires a nursing judgment about what findings mean, or only accurate execution of something already decided.

Assessment and evaluation are the two steps of the nursing process that stay with the registered nurse, along with teaching that has not been given before and any decision about a plan of care. Everything in that list requires somebody to decide what something means.

A task can be physically demanding, unpleasant, and entirely delegable. It can also be quick, simple, and not delegable at all. Difficulty is not the test.

What each person may do

Scope varies by state, and the exam tests the common ground rather than any one state's rules. Within that common ground:

  • Unlicensed assistive personnel: measure and record vital signs, intake and output, and weights on stable clients; assist with hygiene, feeding, ambulation and positioning; report what they observe back to the nurse.
  • Licensed practical nurse: give most medications by most routes, change dressings, monitor a stable client, reinforce teaching the registered nurse has already given, and contribute to the care plan.
  • Registered nurse only: the initial and ongoing assessment, the first teaching on any topic, evaluating whether an intervention worked, and any decision about whether the plan should change.

Two extra rules catch most of the remaining questions. An unstable client is not delegated, whatever the task looks like. And intravenous medications are outside the practical nurse's scope in many states, so an exam item that hinges on one usually intends the registered nurse.

The five rights, and the part people forget

  1. The right task: one that may be delegated at all.
  2. The right circumstance: this client, in this condition, right now.
  3. The right person: someone whose competence for this task has actually been established.
  4. The right direction: specific instructions, including what to report and when.
  5. The right supervision: following up, and being available while the task is being done.

The fifth is the one that gets skipped. Delegating a task does not delegate accountability for the outcome — the registered nurse remains answerable for the decision to delegate and for the follow-up. That is why an exam answer that ends with the nurse walking away is almost never correct.

Worth remembering

  • Delegate the task, never the accountability.
  • Assessment, evaluation, first teaching and changes to the plan stay with the registered nurse.
  • An unstable client is not delegated regardless of how simple the task looks.
  • "Right supervision" means the nurse follows up; an answer where the nurse leaves is rarely correct.
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