Vol. 5 Issue 10
Who's Delegating Here?
For LPNs, it's all a matter of where you work
When it comes to delegation, it may come as a surprise that few LPNs in this region actually have the ability, opportunity and permission to perform this nursing function. Instead, it's their RN counterparts who have the authority to pass specific tasks onto others while maintaining responsibility for outcomes, which is the essence of this term.
ADVANCE has learned, through conversations with nursing board representatives and LPNs working in the region, that delegation is a term that may be misconstrued by nurses but is strictly defined by state boards across the Mid-Atlantic region, in most cases.
States in the region may allow LPNs to "assign," "supervise" or conduct such business through different verbiage, but most do not allow LPNs to delegate.
This isn't necessarily a negative, however. Several sources that ADVANCE spoke with said LPNs shouldn't necessarily view the fact that they're not afforded the chance to delegate as a hindrance. With more authority, comes more responsibility, they say. And with more responsibility comes more accountability and the likelihood that if something detrimental occurs involving a delegated task you'll end up on the hot seat.
Here's a state-by-state look at how regional states view delegation and how LPNs function within these views:
If you're an LPN working in the Mid-Atlantic region and you're longing for the authority to delegate, the Old Line State is the place to be. Chapter 10.27.11, section 3 of the state's nurse practice act states that LPNs may delegate nursing acts to unlicensed individuals who are prepared or qualified to perform such actions.
"We're kind of ahead of the pack in this instance," said Barbara Newman, MS, RN, director of nursing practice for the Maryland Board of Nursing. "I believe there are some states that do allow [LPNs to delegate], but there are many who do not. In Maryland, LPNs have had this authority for at least 12 years."
Within this function, LPNs fully assume responsibility of instructing, directing, and regularly evaluating and supervising the performance of the unlicensed person to whom the tasks are delegated. LPNs are also responsible for rectifying situations where an unlicensed individual performs a delegated function incorrectly, and stopping that person from completing the task.
Like RNs, when Maryland LPNs delegate they hold accountability and responsibility, and must adhere to criteria before passing along a nursing task. This includes, but is not limited to, performing patient assessments before and after the completed task, identifying those on staff who can accept delegation and evaluating the competencies of those receiving the delegation by, for instance, observing the person perform the delegated activity and determining their level of experience.
Kathleen Alascia, LPN, staff nurse at Johns Hopkins Hospital's Harriet Lane Clinic, Baltimore, said LPNs must understand the level of responsibility that goes along with this authority.
"You need to know the competencies of those you're delegating to, be aware of regulations in your practice act and you need to know how your facility follows the practice act," said Alascia, an LPN representative on the Maryland Board of Nursing.
Still, Alascia feels LPNs are up to the task.
"Maryland has always been innovative because of the leadership of our nursing board," she continued. "We delegate here on a routine basis it's part of everyday life. Things wouldn't get done if LPNs couldn't delegate. I also think having the ability to delegate makes life easier for patients, especially in long-term care and assisted living facilities."
Newman said while the LPN's scope allows for delegation, it's ultimately the facility that makes that determination. Furthermore, LPNs have the right to not accept delegated tasks from RNs if uncomfortable with the order and choose not to exercise delegation to others if they desire.
Delegation has a very specific context in New Jersey.
"It is the flow of authority from the professional nurse downward," said Maris Lown, MS, RN, president of the state Board of Nursing.
Though the practice act doesn't explicitly say LPNs cannot delegate, it addresses delegation by RNs to LPNs and unlicensed assistive personnel, said Lown, adding that the regulation and the board's interpretation of the regulation precludes LPNs from having this authority.
"The clarification that the board of nursing makes is that the RN is accountable for all nursing care and, therefore, delegation," Lown said. "Delegation is very fact specific in New Jersey. I think it's important to understand that we are talking about a legal term. When an RN delegates, they are answerable for the outcome."
What LPNs are permitted to do in New Jersey is "assign," Lown said. This is not in any way correlated with delegation because the path of assignment moves laterally, as well as downward. By making assignments, LPNs can instruct other LPNs (not unlicensed professionals) to perform certain jobs. This means that within state regulations, an LPN with authoritative responsibilities can make patient assignments among those tasks that are within the LPN scope of practice. In this scenario, the assigning LPN does not assume further responsibility for the assigned nurse because she is deemed competent per the LPN scope.
This, however, does not relieve anyone from personal accountability, Lown said.
"It's a tenant of English common law that everybody is responsible for their own actions. There are some exceptions, such as minors, but, generally, everyone is accountable for what they do."
Responsibility refers to a one-on-one cause and effect, Lown continued. "If it's an appropriate delegation and something adverse happens, the one delegating may or may not be responsible because there may not be a direct link between the delegation and the adverse event."
This is crucial for LPNs to take note of as it applies to any instance in which they accept delegated tasks from an RN. The LPN may be the one at fault if something goes wrong.
"Fault is always determined by the facts of a particular situation," Lown added. "But in all cases, the registered professional nurse shall be available for supervision."
Lown said the subject of LPN delegation remains a recurring topic of discussion among board members.
Delaware also does not allow its LPNs to delegate. However, "LPNs can assign to any unlicensed person those tasks related to activities of daily living that are included in the unlicensed individual's scope of practice," said Iva Boardman, MSN, RN, Delaware Board of Nursing executive director.
In other words, LPNs have the ability to tell an unlicensed person, "If you are allowed to do it, I can assign you to do this or that," Boardman said.
Though this may mimic the delegation function in that it permits LPNs to give assignments in downward fashion, this doesn't qualify as delegation because no responsibility carries over.
"The basic difference is that the LPN doesn't have to know whether or not the unlicensed person knows how to do the task those functions are already recognized by their respective scope of practice," Boardman said.
While the Delaware Nurse Practice Act doesn't specifically state that LPNs can't delegate, chapter 10.4.2.1 describes unprofessional conduct as the performing of any act beyond the "authorized" scope of the level of nursing practice for which the individual is licensed, Boardman said. In Delaware, LPNs are authorized to assign, per state rules and regulations, not delegate, she added.
LPNs can not delegate nursing tasks while working in the Old Dominion State, where delegation is defined as transferring "the authorization of an RN to an unlicensed person to perform selected nursing tasks and procedures."
Yet, LPNs do have the power to "supervise" nursing aides and "assign" them tasks that are already within their scope of practice.
"The distinction between delegation and assignment is key," said Jay Douglas, MS, RN, executive director, Virginia Board of Nursing. "Assignment means designating nursing activities to another that are consistent with their scope of practice or role description; whereas, delegation is the transferring of a nurse's authority to perform certain tasks or procedures to someone that would otherwise be beyond their scope of practice or role description."
While no clear-cut definition of supervision exists within the state's description of LPN practice, it is defined within the RN's role of delegation as the "guidance or direction of a delegated nursing task" while providing periodic observation and evaluation of performances. State regulations do state that nurse's aides work under, among others, the supervision of LPNs.
Douglas said that while delegation applies strictly to RNs, LPNs can report to RNs those observations they make regarding aide performances within their roles. However, there are no regulations regarding proper LPN supervision over others currently in place, as this may be more of an employment, rather than licensure, issue.
"It would be prudent practice to handle each instance of proposed delegation carefully, but each possible scenario is not addressed or defined in our law or regulations of practice," Douglas said. "The board believes the regulations in place are appropriate in providing the general criteria for appropriate delegation and supervision for the RN to determine on a case-by-case basis."
Carol King, LPN, a staff nurse at Norfolk Senior Center and a former board of nursing member, accepts not having the right to delegate, but takes her responsibility of supervising very seriously.
"I'm responsible for the patients," she said. "I have to know that the aides are able to carry out what's within the standards of their practice."
If you're looking for a clear answer on LPN delegation tasks in the Keystone State you're out of luck. The laws and regulations regarding delegation are "silent," said Laurette Keiser, MSN, RN, executive secretary, section chief, Pennsylvania State Board of Nursing.
"There isn't any language there," Keiser continued. "But the concept of delegation is that it would be both permissible for RNs and LPNs if we had that language in the statute."
This can appear to give all nurses authority to delegate, but it can also leave all nurses in a bind based on the fact that if a patient were to suffer an unforeseen circumstance, numerous parties could come into question in the event that the board decided to investigate a claim or occurrence. Basically, there's no precedent here as there is in other states in the Mid-Atlantic region.
"It's important for the board to have something on this because it would provide some parameters," Keiser added. "We're here for safe care and that's what it's all about. But the board has [delegation] on its list of issues that it plans to discuss.
"[LPNs] may also be able to operate more safely and effectively in today's healthcare arena by being permitted to delegate," Keiser said. "Though, there will be the added responsibility and accountability for whatever is delegated."
Similar to Pennsylvania, the DC regulations are silent as they pertain to LPN delegation, said Karen Skinner, MSN, RN, executive director of the district's board of nursing. However, the board recognizes the LPN's right to delegate and expects them to refer to the delegation decision-making tree that RNs often use when delegating tasks.
However, the board is currently revising its regulations and plans to add delegation language relatable to LPNs in upcoming proposals that are scheduled to be considered at the board's next meeting (Oct. 5), Skinner said.
"We realize that LPNs do delegate, and we think it's important to give LPNs the guidance they need when making a delegatory decision," she explained.
If those proposals gain approval from the board's legal counsel, they could be sent to the DC register for public review sometime this winter. Once there, the general population will have 30 days to view and comment on the proposed regs before they are officially written as nursing law.
Joe Darrah is assistant editor at ADVANCE.