Nursing, Accountability and Delegation
Nurses are accountable for their own practice in a number of ways. They are regulated by the Nursing and Midwifery Council and must abide by the standards set in The Code, Professional standards of practice and behaviour for nurses and midwives. Those standards are what patients and members of the public expect from healthcare professionals.
A nurse is accountable for his/her acts and omissions and must be able to justify them to the Nursing and Midwifery Council. Any nurse whose practice falls below the standard expected of a registered nurse may be removed from the register.
A nurse at all times owes a duty to care and must act in the best interests of people under both the civil and criminal law.
A nurse who causes harm to a patient when it was reasonably foreseeable that their act or omission could cause harm may be liable under the civil law of negligence.
Where it is considered that a nurse’s practice amounts to gross negligence a nurse may be liable under the criminal law. Serious acts such as gross negligence manslaughter could result in a prison sentence.
Nurses are also contractually accountable to their employer under their terms of contract. A breach of contract could result in disciplinary proceedings.
In order to remain safe in practice a nurse must ensure that he/she is competent in their role:
The Code, Professional standards of practice and behaviour for nurses and midwives (2015) states:
6 Always practise in line with the best available evidence
To achieve this, you must:
6.1 make sure that any information or advice given is evidence based, including information relating to using any healthcare products or services, and
6.2 maintain the knowledge and skills you need for safe and effective practice.
On 30/11/16 The Nursing and Midwifery Council received a formal request from the Department of Health to be the regulator for the new nursing associate role:
‘The new nursing assistant role is expected to work alongside healthcare assistants and registered nurses to deliver hands-on care, focusing on ensuring patients continue to get the best possible care. Nursing associates will be equipped with the knowledge, skills and behaviours that enable them to support the delivery of nursing care in and across a wide range of health and care settings.’
The NMC’s Chief Executive and Registrar, Jackie Smith responded to the request:
“There is strong support for the nursing associate role and the Department of Health has today decided that it is a role which requires regulation.
“As an organisation we are well equipped to take on the role of the regulator, however, this decision will be made by our Council at its meeting 25 January.”
On 25th January 2017, the NMC decided to take on the regulation of the new nursing associates.
If the NMC take on the role of regulator for the nursing assistant, how will this impact on accountability not only for the nursing assistants, but for the registered nurses?
Nurses are accountable to the NMC for delegating tasks and duties:
11 Be accountable for your decisions to delegate tasks and duties to other people
To achieve this, you must:
11.1 only delegate tasks and duties that are within the other person’s scope of competence, making sure that they fully understand your instructions
11.2 make sure that everyone you delegate tasks to is adequately supervised and supported so they can provide safe and compassionate care, and
11.3 confirm that the outcome of any task you have delegated to someone else meets the required standard.
Any nurse who delegates a duty or a task to any nursing associate must ensure that it is an appropriate delegation.
Delegation has been defined as:
Delegation is the process by which you (the registered nurse) allocate clinical or non-clinical treatment or care to a competent person (the nursing associate). You will remain responsible for the overall management of the service user and accountable for your decision to delegate. You will not be accountable for the decisions and actions of the nursing associate.
To be satisfied that the delegation is appropriate the Royal College of Nursing states the delegation must be:
- In the best interests of the patient,
- There is no clinical risk to the patient if the task/duty is delegated,
- The registered nurse is competent to delegate the task/duty,
- The nursing associate is competent in the skill being delegated,
- The nursing associate is able to take on the extra task/duty,
- The nurse is able to provide supervision and make checks on the outcome of the delegation.
If the nurse is satisfied that the delegation is appropriate then he/she must:
- Ensure that the correct protocol is being followed,
- Explain clearly what is expected and clarify that the nursing associate is clear on what is expected of him/her and the responsibility being taken on,
- Make sure the nursing associate is trained in the delegated task, review training records,
- Evaluate the delegated task.
As a regulated professional the nursing associate will be accountable for his/her actions. Like the registered nurse he/she must not take on a delegated task if he/she is not competent or confident they have the capacity or time to take on the task.
Any delegated task must always be in the best interests of the patient. A nursing associate who is not confident that the delegation is in the best interests of the patient then he/she must refuse to take on the delegated task.
Any acceptance of a task that is beyond the competence of a nursing associate could result in proceedings against both the registered nurse and the nursing associate.
If a nurse or nursing assistant is working within their competence, the employer will be accountable, known as vicarious liability, for those actions.
It is yet to be seen how the nursing associate role will unfold and how the associates will assist the registered nurses or how it will be regulated.
The five R’s of delegation:
- Right activity,
- Right circumstances,
- Right person,
- Right communication,
- Right supervision and evaluation.
Think of this scenario:
- A doctor prescribes incorrectly to a patient being discharged,
- The pharmacist fails to notice the incorrect prescription,
- The registered nurse receives the patient prescription to take home but fails to notice the incorrect prescription,
- The registered nurse delegates to the nursing associate (who is not yet competent in this task),
- The patient is handed the incorrect medication to take home.
This is known as the ‘Swiss Cheese Model.’ (Joseph Reason). At each stage there has been an error which could have been prevented.
Q. Is the nurse responsible for her act/omission? Is the nursing assistant responsible?
A. They are both responsible for their own acts/omissions as regulated professionals. The nurse failed to notice the error and inappropriately delegated the task. The nursing associate failed to refuse the task as she was not competent.
If you require legal advice on any issues concerning nursing, contact Nurses Defence Service on: 0800 01 22 506
Author: Penny Maudsley
