178. CCA Study Notes: Assigning, Delegation, and Support Worker Responsibilities

The Big Picture

Support workers receive tasks as part of client care. Some tasks fall within the support worker’s usual role. Other tasks normally belong to a regulated health care provider and require delegation before a support worker performs them.

The key difference involves authority. Assignment gives a worker responsibility for a task already within the worker’s role. Delegation transfers authority for certain tasks under specific conditions.

Support workers remain responsible for their own actions. They must understand the task, stay within their role, ask for help when needed, and raise concerns when a task does not seem appropriate.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

What Assigning Means

Assigning means appointing someone to take responsibility for providing a task or part of client care. The assigned task must fall within the person’s scope of practice, the agency’s job description, and the scope of employment.

A task is a function, procedure, or activity that a support worker assists the client with or performs for the client.

A supervisor might assign daily tasks through an assignment sheet. Assigned support worker tasks do not require the education and professional judgement of a nurse.

Examples of tasks that might form part of a support worker’s assignment include:

• activities of daily living, or ADLs, such as dressing, personal hygiene, mobility, feeding, and toileting
• instrumental activities of daily living, or IADLs, such as handling finances, managing medications, transportation, shopping, meal preparation, communication devices, housework, and basic home maintenance
• social and recreational activities
• household management, including housecleaning and meal preparation
• basic support care tasks, including measuring height, weight, and vital signs

A support worker should never receive an assignment outside the agency’s job description and the worker’s scope of employment.

Controlled Acts and Authority

Authority means the legal right to do something.

Some health care tasks require special legal authority because an unqualified person might cause harm while performing them. These tasks are called controlled acts.

Examples given for controlled acts include inserting catheters and giving insulin.

Different provinces and territories use different terms and rules. The regulated professional organizations in each jurisdiction identify acts that require authorization and determine when delegation is permitted.

Different provinces use different terms for authorized acts and delegation:

• British Columbia uses reserved acts and calls delegation transfer of function.
• Alberta uses the term restricted activities.
• Ontario uses the term controlled acts.
• Legislation ⓘ also regulates health professions and nursing practice in Nova Scotia.

Examples of authorized procedures described include:

• performing a procedure below the skin or a mucous membrane, such as cleaning and dressing an open wound
• administering a substance by injection or inhalation
• inserting an instrument, hand, or finger into certain body openings, including the bladder, esophagus, trachea, nose, ears, bloodstream, or surgically created openings

Unregulated health care workers, including support workers, do not normally have authority to perform these acts.

A properly delegated act is different. When legislation, employer policy, and the worker’s job description permit delegation, the nurse transfers the required authority to the unregulated worker for that task.

What Delegation Means

Delegation is the process through which a nurse authorizes another health care provider to perform certain tasks. It includes some tasks that normally require a regulated health care provider.

Transfer of function is another term for this process.

A controlled act might be delegated to:

• a member of the client’s household
• a family member
• a support worker
• another unregulated care provider

Specific conditions, called exceptions, must apply before delegation to someone outside a regulated health profession is permitted.

The nurse keeps the authority to delegate. The support worker does not gain authority to delegate tasks to other people.

When a Task Is Suitable for Delegation

Each client’s situation requires its own decision.

Before delegation, the nurse determines whether the task and circumstances make delegation appropriate. The nurse must feel confident that the support worker:

1. understands the responsibilities involved
2. knows when and from whom to request help
3. knows when, how, and to whom to report the task outcome

Tasks delegated to support workers must meet important conditions. They must be routine, have predictable outcomes, require little supervision ⓘ, and involve stable clients.

A procedure that counts as a routine activity for one client does not automatically count as routine for another client.

Examples of tasks identified as possible delegated tasks include:

• suctioning a permanent tracheostomy
• in-and-out catheterization
• glucometer-related tasks
• dressings
• tube feedings
• medication

Only some nursing tasks qualify for delegation. Employer policies, employer guidelines, job descriptions, and provincial or territorial legislation determine which tasks qualify and how delegation occurs.

Routine Activities of Living

An unregulated health care worker, including a support worker, can be assigned an authorized act when the task is a routine activity of living.

A routine activity of living has two characteristics:

• the client needs the activity regularly
• a nurse has previously performed it for the client with consistent and safe results

The same procedure might therefore receive different decisions for different clients.

For example, one client might need regular enemas as a predictable part of care. Another client might need an enema for the first time before surgery. The first situation might qualify as routine, while the second does not.

The support worker does not decide when an authorized act should occur. The worker receives an assignment or delegation when appropriate.

Who Delegates a Task

Depending on provincial or territorial legislation, a regulated health care provider holds responsibility for delegation to support workers.

Examples include:

• registered nurses, or RNs
• registered practical nurses, or RPNs
• licensed practical nurses, or LPNs

In some workplace settings, another regulated health care provider, such as a social worker, might delegate a task.

The regulated health care provider must protect the client’s health and safety while making the delegation decision.

The delegating provider remains accountable for properly following the delegation process. The support worker also remains accountable to the employer and client for personal actions and for performing the accepted task correctly.

You must understand the delegation rules that apply in your province or territory and in your facility or agency.

Accountability

Accountability means accepting responsibility and being prepared to explain your actions, decisions, intentions, and things you did or failed to do.

Delegation does not remove the support worker’s accountability.

Once you accept a delegated task, you remain responsible for performing it safely and correctly.

The Delegation Process

Delegation follows a process based on the client’s needs, the task, and the support worker’s knowledge and skills.

1. Assessment of Needs

The nurse gathers information about:

• the person’s needs
• the support worker’s knowledge
• the support worker’s skills

The nurse then decides whether delegation is safe.

2. Communication

The nurse and support worker discuss the task.

The support worker agrees to perform it after receiving proper instruction. The nurse makes sure the worker understands the directions.

The support worker communicates questions, concerns, and progress to the nurse as needed.

The support worker reports and records the care provided according to employer policy.

3. Guidance and Assistance

The nurse observes the care and checks that the task is completed correctly.

The nurse also monitors the person’s response and follows up when problems or concerns occur.

4. Follow-Up and Feedback

The nurse decides whether the delegation was successful.

The nurse makes decisions about possible changes in the person’s care and gives the support worker feedback about task performance.

What the Nurse Considers Before Delegating

Before delegation, the nurse considers the legal and workplace limits surrounding the support worker.

The nurse needs to know:

• which tasks the province or territory permits support workers to perform
• which tasks appear in the worker’s job description
• what the worker learned during training
• which skills the worker learned and how those skills were evaluated
• the worker’s previous experience

A task does not automatically qualify for assignment or delegation because it appears in the job description or because the worker has performed it before.

The client’s circumstances, needs, the task, and the individual support worker must all support the decision.

When a client’s needs and the task require a nurse’s knowledge, judgement, and skill, the nurse performs the task. The support worker might assist when asked.

Factors Affecting the Nurse’s Delegation Decision

Before delegating a task, the nurse considers questions such as:

1. Does the client’s condition, the risk involved, and the available environmental support make the task appropriate for a support worker?
2. Will the support worker perform the task often enough to maintain competence ⓘ?
3. Is adequate supervision available in that setting?
4. Is a nurse available if the client’s condition changes or a problem occurs?
5. Does the task qualify for delegation, and does the worker’s job description include it?

The client’s circumstances remain central to the decision.

Before You Accept a Delegated Task

The support worker has responsibilities before agreeing to delegation.

Ask yourself:

1. Does my job description and my agency’s written care policies include this task?
2. Does the task fall within my scope of practice?
3. Is the task part of the client’s ADLs or IADLs?
4. Do I know how the client usually responds to the task, and do I know enough to compare the usual response with today’s response?
5. Is the task appropriate considering the client’s current condition?
6. Do I understand the risks related to the task?
7. Is the client or representative able to direct the client’s care and allow me to perform the task?
8. If I am learning, will I receive enough supervision to perform the task correctly and protect the client, and will I perform it often enough to maintain competence?
9. Is an appropriate health care provider available if the client’s condition changes or a problem develops?
10. If I was judged competent in the past, do I still remember all the steps required to perform the task safely?
11. Am I able to refuse if I do not feel competent enough to perform the task with the supervision available?

These questions help the support worker decide whether accepting the delegation is appropriate.

Delegation Does Not Automatically Transfer Between Clients

In some provinces, delegation for one client does not transfer to another client.

Learning to perform a delegated task for one client does not automatically authorize you to perform the same task for another client.

The regulated health care provider decides whether a task taught to a support worker applies to more than one client. When the provider delegates the task for several clients, the delegation requirements apply separately to each client.

Teaching and Monitoring a Delegated Task

The regulated health professional who delegates a task must have the knowledge, skill, and judgement needed to perform it competently.

The delegating professional must also:

• have the knowledge, skill, judgement, communication skills, and patience needed to teach the task
• accept responsibility for teaching the task
• consider the risks and benefits of teaching it and predict the expected outcome
• assess the support worker’s performance
• determine that the support worker performs the task correctly
• decide whether the taught task applies to more than one client
• monitor the support worker over time to make sure performance remains correct and safe

Policies must address when communication is necessary. The nurse and support worker also need a way to communicate in a timely manner when necessary.

Support Workers Do Not Assign or Delegate

A support worker does not have authority to assign or delegate tasks.

You must not authorize another person to perform a task that someone assigned or delegated to you.

A co-worker might help with tasks assigned to you. A delegated act is different. Only the worker who received that delegation performs the delegated act.

Delegation in Community Care

In community care, the nurse supervising health care needs often works in another location.

As part of teaching a delegated controlled act, the nurse should give the support worker written instructions covering:

• how to perform the task
• the predicted outcome
• what the worker needs to record

The nurse teaches the task, assesses the worker’s performance, and explains when to request help and what information to record.

The nurse continues monitoring performance. The support worker must have timely access to assistance when needed.

Some agencies offer educational programs or workshops for specific ADL tasks. A support worker completes this type of program only after the nurse determines that the worker performs the task safely and competently. The agency monitors performance over time.

When a Client or Caregiver Requests a Task at Home

A client or caregiver might ask a support worker to perform a task when no other health care provider is present.

You must never perform a task beyond your scope of practice.

If the requested task requires supervisor authorization, explain that you are not allowed to perform it without that authorization. Contact your supervisor and discuss the situation.

When Another Professional Requests an Unusual Task

Especially in community settings, a professional who is not your nurse or supervisor might ask you to perform a task that you do not normally perform.

Before taking on the task, consider your agency’s policies and use your judgement. Contact your supervisor when you need clarification.

A simple, noninvasive task that you have done for the client before is usually something you can do. Tell the professional when:

• you have concerns about your ability to perform the task
• the task falls beyond your scope of practice
• the client’s condition changes

Accepting a Delegated Task

When you accept a task, you become accountable for your own actions.

You must complete the task safely. Ask for help whenever you feel unsure or have questions.

Always report what you did and what you observed.

Refusing a Delegated Task

You have the right to refuse a delegated task when you have a sound reason. When a sound reason exists, refusing the task is both your right and your duty.

If you believe you lack the competence or available supervision needed to perform the task safely, refusing the task protects the client and respects your responsibility for your own actions.

You must not ignore an order or request. Communicate your concerns to the nurse who delegated the task.

If the problem continues, speak with your supervisor, instructor, or another professional who assists with resolving the concern.

You must not refuse a delegated task simply because you dislike the task or do not want to perform it. A refusal requires a sound reason. Refusing without a sound reason puts the client at risk for harm and puts your job at risk.