Which tasks would be most appropriate for the nurse to delegate to the UAP working on a surgical unit?

Although delegating tasks occurs all the time in the workplace, there are often times in which nurses may not effectively delegate to unlicensed personnel. This carries major risk—to the nurse, the staff member, the patients, and the health care facility. Jennifer Flynn, CPHRM, Risk Manager, Nurses Service Organization (NSO), answered our questions about wrongful delegation.

What kinds of tasks could nurses be inappropriately delegating?

Unlicensed Assistive Personnel (UAP) assist registered nurses in the provision of patient care as delegated by and under the supervision of the registered nurse. UAPs assist nurses by performing patient care-related tasks that do not require nursing skill or judgment. Such activities can include the following: activities of daily living (feeding, drinking, ambulating, turning, grooming, toileting, dressing); collecting data (vital signs, weights); collecting simple specimens (stool, urine); transporting patients; restocking supplies; clerical duties; and housekeeping tasks.

To say that another way, a UAP cannot be asked to perform any activities on patients whose status is unstable—activities which require assessment, problem solving, judgment, or evaluation.

Before deciding on whether to assign a task to a UAP, nurses must first determine what your state’s nurse practice act and your facility policies say about task delegation.

What are the risks in delegating to non-nurse personnel?

Improper delegation can negatively impact patient care while also potentially exposing the nurse to liability lawsuits or Board of Nursing complaints. Effective delegation allows the nurse to do what they have been educated to do, that is, make effective judgements about patients and coordinate care. However, the nurse always maintains accountability for the task’s completion and is always accountable for the overall outcome of the patient.

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The American Nurses Association developed the five rights of delegation to assist nurses in making safe decisions:

1. Right Task – Determine which tasks are appropriate for delegation. Some questions to ask include (1) Do your state rules and regulations support delegation? (2) Can I delegate these tasks based on my facility’s policies and procedures?

2. Right Circumstance – Consider the appropriateness of the patient setting and other relevant factors. Some questions to ask include (1) Are there appropriate resources available to perform the task? (2) Does the UAP have the appropriate supervision to accomplish the task? And, (3) Is the situation favorable for delegation? For example, a UAP may be allowed to feed a patient but if a high-risk stroke patient requires feeding, the nurse must first assess if the patient can safely swallow. The UAP can’t make that determination, and the nurses are expected to foresee possible harm to patients before delegating tasks.

3. Right Person – Ensure the right person is delegating the right task to the right person, to be performed on the right patient. Consider the UAP’s knowledge and experience to complete delegated tasks safely. Ask the UAP the following key questions before assigning the task:

• Have you been trained to do this task?
• Have you ever performed this task with a patient?
• Have you ever done this task unsupervised?
• How confident are you about performing this task accurately?
• What problems have you encountered with this task in the past?

Based on these answers, the nurse may decide to delegate, not to delegate, or provide direct supervision while the UAP is performing the task.

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4. Right Supervision – Nurses are required to provide appropriate monitoring, evaluation, intervention, and supervision for all delegated tasks. Remember, nurses are accountable for the outcome of the patient.

5. Right Direction and Communication – Nurses must communicate a clear description of the task, including its objective, limits, and expectations. Consider telling the UAP exactly what you want them to do and by what time to do it. Also request specific feedback about the task at a specific time. Even if you’ve worked with the UAP for a long time, don’t make assumptions about what they may understand. Delegation requires mutual understanding and trust on the part of both the nurse and the UAP. The UAP should be allowed to ask questions, seek clarification, and request additional training.

What kinds of lawsuits/actions from nursing boards could a nurse face by doing this?

If nurses perform activities which are a violation of nursing laws and rules, this may result in either a malpractice lawsuit or even disciplinary action by the Board of Nursing. The most common potential violations related to delegation are failure to supervise over those who practice under the supervision of a nurse, and inappropriate delegation when the nurse may have reason to know the UAP was not qualified to perform the task. In a malpractice lawsuit, your actions or failure to act will be judged against professional practice standards in your state.

Consider this question before deciding to delegate “Would a reasonable prudent person have delegated this task given all aspects of the situation, and under similar circumstances?” If a nurse is unsure of the answer, it is recommended to contact your facility’s risk manager, ask an experienced colleague for advice, practice delegation with written or simulated cases, or request a peer review of your delegation decisions.

Can you give me any real-world examples of wrongful delegation claims?

Some examples of wrongful delegation would include allowing a UAP to feed a high-risk stroke patient without the nurse first assessing the patient’s ability to swallow. You may allow the UAP to report on a patient’s urine output for a determined timeframe, but the UAP shouldn’t report the output is “low” for that requires interpreting assessment date which only the nurse can do.

How could this become even worse with the continuing nursing shortage?

Nursing shortages and increases in patient complexity have driven the need for delegation to be a necessary component of today’s health care environment. In response to various economic and business pressures, the health care industry has sought to increase the utilization of UAPs to refocus the role of nurses on patient care and coordination. Both the ANA and the National Council of State Boards of Nursing have provided insight and direction to address this process, so that nurses can practice safely. Nurses who are familiar with their state’s practice act, applicable state rules and regulations, their facility policies and procedures, and the ethics of the profession will be well positioned to appropriately use UAPs in delivering safe patient care. A clear understanding of these guidelines is a nurse’s best protection against inappropriate delegation and reducing the likelihood of a malpractice lawsuit or disciplinary action.

PRACTICE TEST QUESTIONS Downloaded from FILIPINO NURSES CENTRAL {www.nursescentral.ning.com} Question Number 1 of 25 A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed assistive personnel (UAP)? The correct response is "D". A) Teach the client how to cough up secretions B) Changes the tracheostomy trach ties C) Monitor if client has shortness of breath D) Perform routine tracheostomy dressing care Your response was "A". The correct answer is D: Perform routine tracheostomy dressing care Unlicensed assistive personnel should be able to perform routine tracheostomy care. Question Number 2 of 25 Which one of these tasks can be safely delegated to a PN? The correct response is "C". A) Assess the function of a newly created ileoostomy B) Care for a client with a recent complicated double barrel colostomy C) Provide stoma care for a client with a well functioning ostomy D) Teach ostomy care to a client and their family members Your response was "C". The correct answer is C: Provide stoma care for a client with a well functioning ostomy. Question Number 3 of 25 During the interview of a prospective employee who just completed the agency orientation, which approach would be the best for the nurse manager to use to assess competence? The correct response is "B". What degree of supervision for basic care do you think you A) need? B) Let’s review your skills check-list for type and level of skill. C) Are you comfortable working independently? D) What client care tasks or assignments do you prefer? Your response was "B". The correct answer is B: Let’s review your skills check-list for type and level of skill. d to a PN. This client has minimal risk of instability of the situation. Question Number 4 of 25 A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements? The correct response is "C". I will arrange for a conference with you and the UAP within the A) next week. B) I can assure you that I will look into the matter. C) I would like for you to approach the UAP about the problem the next time it occurs. D) I will add this concern to the agenda for the next unit meeting. Your response was "B". The correct answer is C: Suggest that the nurse approach the assistant about the problem Helping staff manage conflict is part of the manager''s role. It is appropriate to urge the nurse to confront the other staff member to work out problems without a manager''s intervention when possible Question Number 5 of 25 The charge nurse on a cardiac step-down unit makes assignments for the team consisting of an RN, a PN, and an unlicensed assistive person. Which client should be assigned to the PN? The correct response is "B". A 49 year-old with new onset atrial fibrillation with a rapid A) ventricular response B) A 58 year-old hypertensive with possible angina. C) A 35 year-old scheduled for cardiac catheterization. A 65 year-old for discharge after angioplasty and stent placement. Your response was "B". D) The correct answer is B: A 58 year-old hypertensive with possible angina. This is the most stable client. The clients in options C and D require initial teaching. The client in option A is considered unstable since the dysrhythmia is a new onset. Question Number 6 of 25 The RN delegates the task of taking vital signs of all the clients on the medical-surgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a postmastectomy client’s blood pressure on the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on that client’s left arm. Which of these statements is most accurate? The correct response is "D". A) The RN is accountable for this situation. B) The RN did not delegate appropriately. C) The UAP is covered by the RN’s license. D) The UAP is responsible for following instructions. Your response was "D". The correct answer is D: The UAP is responsible for following instructions. The UAP is responsible for carrying out the activity correctly once directions have been clearly communicated especially if given verbally and in writing. Question Number 7 of 25 A practical nurse (PN) from the pediatric unit is assigned to work in a critical care unit. Which client assignment would be appropriate? The correct response is "D". A client admitted with multiple trauma with a history of a newly A) implanted pacemaker A new admission with left-sided weakness from a stroke and B) mild confusion A 53 year-old client diagnosed with cardiac arrest from a C) suspected myocardial infarction A 35 year-old client in balanced traction admitted 6 days ago D) after a motor vehicle accident Your response was "D". The correct answer is D: A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accident This client is the most stable with a predictable outcome Question Number 8 of 25 Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)? The correct response is "B". A) Document skin turgor and color changes B) Test stool for occult blood and urine for glucose C) Suggest foods high in iron and those easily consumed D) Report mental status changes and the degree of mental clarity Your response was "C". The correct answer is B: Test stool for occult blood and urine for glucose The UAP can do standard, unchanging procedures that require no decision making. Question Number 9 of 25 The care of which of the following clients can the nurse safely delegate to an unlicensed assistive personnel (UAP)? The correct response is "A". A client with peripheral vascular disease and an ulceration of A) the lower leg. A pre-operative client awaiting adrenalectomy with a history of B) asthma An elderly client with hypertension and self-reported nonC) compliance A new admission with a history of transient ischemic attacks D) and dizziness Your response was "A". The correct answer is A: A client with peripheral vascular disease and an ulceration of the lower leg. This client is stable with no risk of instability as compared to the other clients. And this client has a chronic condition, with needs of supportive care. Question Number 10 of 25 An RN from the women’s health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would be most appropriate for this nurse? The correct response is "B". A newly diagnosed client with type 2 diabetes mellitus who is A) learning foot care A client from a motor vehicle accident with an external fixation B) device on the leg C) A client admitted for a barium swallow after a transient ischemic attack D) A newly admitted client with a diagnosis of pancreatic cancer Your response was "A". The correct answer is B: A motor vehicle accident (MVA) client with an external fixation device on the leg This client is the most stable, requires basic safety measures and has a predictable outcome. Question Number 11 of 25 Which client data should the nurse act upon when a home health aide calls the nurse from the client's home to report these items? The correct response is "C". A) The client has complaints of not sleeping well for the past week. The family wants to discontinue the home meal service, meals on wheels. The urine in the urinary catheter bag is of a deeper amber, C) almost brown color. B) D) The partner says the client has slower days every other day. Your response was "C". The correct answer is C: The urine in the urinary catheter bag is of a deeper amber almost brown color. Home health aides need to report diverse information to nurses through phone calls and documentation. The nurse who develops the plan of care for a specific client, and supervises the aide, must identify potential danger signs which require immediate action and follow-up. The color of the urine requires follow-up evaluation Question Number 12 of 25 A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which o staff members should the charge nurse assign the client? The correct response is "D". A) Unlicensed assistive personnel (UAP) B) Senior nursing student C) PN D) RN Your response was "D". The correct answer is D: An RN The RN is responsible for teaching and assessment associated with discharge and these activities can not be delegated to the other listed persons. Question Number 13 of 25 The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client? The correct response is "B". A) Ask the client and family if they are satisfied with the care given Determine if the home health aide's care is consistent with the plan of care Investigate if the home health aide is prompt and stays an C) appropriate length of time for care Check the documentation of the aide for appropriateness and D) comprehensiveness Your response was "B". B) The correct answer is B: Determine if the home health aide is following the plan of care Although the nurse must complete all of the above responsibilities, evaluation of an adherence to the plan of care is the first priority. The plan of care is based on the reason for referral, health care providers’ orders, the initial nursing assessment, the client’s responses to the planned interventions, and the client''s and family''s feedback or inquires. Question Number 14 of 25 The nurse in the same day surgery unit assigns the unlicensed assistive personnel (UAP) to give a 1000 ml soap solution enema (SSE) to a client scheduled for an abdominal hysterectomy. Which statement by the nurse is most appropriate? The correct response is "D". A) "Administer enemas until the results are clear." B) "Give 3 enemas before surgery." C) "Let me know the results of the enema." D) "Slow the flow of the solution if cramping occurs." Your response was "A". The correct answer is D: "Slow the flow of the solution if cramping occurs." The professional nurse can delegate tasks with an expected outcome. The UAP is given adequate information about the procedure. Question Number 15 of 25 A charge nurse working in a long term care facility is making out assignments. Which assignment to an unlicensed assistive personnel (UAP), if made by the nurse, requires intervention by the supervisor? The correct response is "D". A) Provide decubitus ulcer care and apply a dry dressing B) Bathe and feed a client on bed rest C) Oral suctioning of an unresponsive elderly client Teaching a family intermittent (bolus) feedings via G-tube before discharge Your response was "D". D) The correct answer is D: Teaching a family intermittent (bolus) feedings via G-tube before discharge Initial teaching can not be delegated to a UAP or a PN and must be done by RNs. Question Number 17 of 25 A client is receiving an intravenous (IV) infusion for pain control. When caring for this client, which one of these actions can the RN safely assign to an unlicensed assistive personnel (UAP)? The correct response is "D". Ask the client the degree of relief and document the client’s A) response B) Decrease the set rate on the pump by 2 ml/minute C) Check the IV site for drainage and loose tape D) Assist the client with ambulation and a gown change Your response was "D". The correct answer is D: Assist the client with ambulation and a gown change When directing the UAP, communicate clearly and specifically what the task is and what should be reported to the nurse. Implementation of routine tasks should be delegated since they do not require independent judgment. Question Number 18 of 25 The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to? The correct response is "C". A) Practical nurse (PN) B) Registered Nurse (RN) C) Unlicensed assistive personnel (UAP) D) Volunteer Your response was "C". The correct answer is C: Unlicensed assistive personnel (UAP) The measurement and recording of vital signs may be delegated to UAP. this falls under the umbrella of routine task with stable clients. Other considerations for delegation of care to UAP would be: who is capable and is the least expensive worker to do each task? Question Number 19 of 25 When walking past a client’s room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention? The correct response is "B". "If we work together we can get all of the client care A) completed." "Since I am late for lunch, would you do this one client's B) glucose test?" C) "This client seems confused, we need to watch monitor closely." D) "I’ll come back and make the bed after I go to the lab." Your response was "B". The correct answer is B: "Since I am late for lunch, would you do this one client''s glucose test?" Only the RN and PN can delegate to UAPs. One UAP can not delegate a task to another UAP. The RN or PN is legally accountable for the nursing care. Question Number 20 of 25 As the RN responsible for a client in isolation, which can be delegated to the PN? The correct response is "A". A) Reinforcement of isolation precautions B) Assessment of the client's attitude about infection control C) Evaluation of staffs' compliance with control measures D) Observation of the client's total environment for risks Your response was "A". The correct answer is A: Reinforcement of isolation precautions PNs and UAPs can reinforce information that was originally given by the RN. Question Number 21 of 25 Which of these clients would be most appropriate to assign to a PN? The correct response is "C". A trauma victim with quadriplegia and a client 1 day post-op A) radical neck dissection A client with newly diagnosed type 2 diabetes mellitus and a B) client with a history of AIDS admitted for pneumonia A client with hemiplegia is fed by a nasogastric tube and client C) with a left leg amputation in rehabilitation A client with a history of schizophrenia in alcohol withdrawal D) and a client with chronic renal failure Your response was "C". The correct answer is C: A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitation This client requires supportive care and interventions within the scope of practice of a PN. This client is stable with little risk of complications or instability. Question Number 22 of 25 Which of these clients would be appropriate to assign to a PN? The correct response is "B". A trauma victim with multiple lacerations and requires complex A) dressings. An elderly client with cystitis and an indwelling urethral B) catheter. A confused client whose family complains about the nursing C) care 2 days after surgery. A client admitted for possible transient ischemic attack with D) unstable neuro signs. Your response was "B". The correct answer is B: An elderly client with cystitis and an indwelling urethral catheter. This is a stable client, with predictable outcome and care and minimal risk for complications. Question Number 23 of 25 Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP? The correct response is "B". A) Assist with plans for any clients discharged B) Provide basic hygiene care to all clients on the unit C) Assess a client after an acute myocardial infarction D) Gather the vital signs of all clients on the unit Your response was "B". The correct answer is B: Providing basic hygiene care to all clients on the unit. Basic client care, which is routine, should be delegated to a UAP since the unit is short on help. The vital signs would be done by the RN and PN as they made rounds since this data is more critical to make decisions about the care of the clients Question Number 24 of 25 An unlicensed assistive personnel (UAP), who usually works in pediatrics is assigned to work on a medical-surgical unit. Which one of the questions by the charge nurse would be most appropriate prior to making delegation decisions? The correct response is "C". A) "How long have you been a UAP?” B) "What type of care did you give in pediatrics?” C) "Do you have your competency checklist that we can review?” D) "How comfortable are you to care for adult clients?” Your response was "A". The correct answer is C: "Do you have your competency checklist that we can review?” The UAP must be competent to accept the delegated task. Further assessment of the qualifications of the UAP is important in order to assign the right task. Question Number 25 of 25 The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP? The correct response is "B". A) Report signs of redness overlying a joint B) Monitor the client's response to ambulatory activity C) Encouragement for the independence in self-care D) Assist the client to transfer from a bed to a chair Your response was "D". The correct answer is B: Monitor the client''s response to ambulatory activity Monitoring the client’s response to interventions requires assessment, a task to be performed by an RN.

What activities would be appropriate to delegate to the UAP?

Which task could a staff nurse delegate to a UAP?

What tasks can a UAP perform?

What are three tasks that a registered nurse may assign to a UAP?