Delegation in practice

Following on from our recent Advanced Practice article on the principles of delegation and accountability (Practice Nurse, July 2015) we look at the practical implications of delegating to healthcare assistants, and when this is or might not be appropriate

Healthcare assistants (HCAs) are a vital part of the primary care nursing workforce and now provide a great proportion of hands-on care within general practice. Appropriate delegation to HCAs – health care support workers, assistant practitioners and healthcare assistants – is essential in maintaining patient safety and public protection.

However, it is important that practice nurses and other members of the primary health care reach an informed decision before delegating particular activities.

Background

In the wake of recent reports, including the Francis inquiry¹ into failings in Mid-Staffordshire NHS Foundation Trusts, and reports of failings in other hospitals and care homes, there has been a focus on ensuring that unregistered staff in the NHS and social care provide safe and quality care.

The Cavendish Report² and the Shape of Caring Review³ both highlighted the importance of developing the role of the HCA and viewing them as a strategic resource in building the workforce for the future.

The context for health care and support is also changing. Recent NHS publications such as the Five Year Forward View⁴ focus on the importance of prevention and the shift of services from the hospital to primary and community settings, achieved by the development of new models of care, as the key to ensuring that the NHS is fit for the 21st century. This has meant that new roles and responsibilities have been developed and nurses and care staff work in multidisciplinary teams, where individuals have specific tasks and responsibilities, but increasingly they work together as a team to support and care for patients.

The National Nursing strategy⁵ also sets out the shared purpose as nurses, midwives and care staff to deliver high quality, compassionate care, and builds on the enduring values and behaviours, which patients, the public and staff should and will expect.

Delegation of nursing activities must take place in the best interest of the patient and the decision to delegate an aspect of care to the HCA must be based on the assessment of the patient’s needs and must not compromise patient safety.

ACCOUNTABILITY AND RESPONSIBILITY

Registered healthcare practitioners have professional accountability and responsibility. Nurses are regulated by the Nursing & Midwifery Council (NMC), whose role is to protect the public by setting standards to which nurses must commit if they are to remain on the register. The new revised NMC Code⁶ describes the professional standards of practice and behaviour expected of nurses and midwives, and puts the interest of patients first in order to ensure that our practice is safe, effective and promotes trust through professionalism. The code requires registrants to ‘practise effectively’, and ‘be accountable for your decisions to delegate tasks and duties to other people.’

Unlike registered nurses, HCAs are not regulated by a professional body but they have to be accountable for their actions. Both practice nurses and HCAs have social, ethical, legal and contractual accountabilities,⁷ are responsible for the activities they undertake, and must not work beyond their level of competence. It is therefore important that each member of the primary health care team understands their level of accountability and responsibility, and that practice nurses can clearly define their role and boundaries in relation to delegation of activities to HCAs.

PRINCIPLES OF DELEGATION

Registered healthcare practitioners, such as doctors and nurses, use their specific knowledge and clinical judgement to assess patients, prescribe, delegate and supervise care. They are accountable for the assessment, planning and evaluation of standards of care, and for delegating work to HCAs. All patients should expect the same standard of care, whoever delivers it.

The RCN guide on accountability and delegation⁷ summarises the principles clearly:

• HCA role supported by a clear job description
• Education and training of the HCA
• Competent with written evidence of assessment
• Protocols to support practice
• Record keeping and communication of delegated activity to the whole team
• Supervision and mentorship
• Risk assessment/management
• Ongoing development of the HCA

DETERMINING IF DELEGATION IS APPROPRIATE

When considering delegation to an HCA, the practice nurse must determine whether the activity to be delegated is complex, and the plan of care for the patient could change ‘in the moment’, on the basis of clinical judgement. If this is the case, then delegation is not appropriate.

The HCA must not be put in a position where they have to make stand-alone clinical judgement on the care of a patient. The HCA must understand the limitations and scope of practice and must be able to call on the practice nurse if faced with any difficulties.

The adult vaccination programme

It is common practice for HCAs in many settings to administer the influenza and pneumococcal to adults. In 2013, the shingles vaccine was introduced to the routine national immunisation schedule for 70 year olds with a planned catch up programme for those up to the age of 79 years. It would not be in the best interest of the patient for them to be passed to a different health professional for administration of the shingles vaccine. It is therefore entirely appropriate for HCAs to administer the influenza, pneumococcal and shingles vaccines to adults as part of the adult vaccination programme, as long as they are appropriately trained, assessed as competent, and work within set guidelines and protocols. The Royal College of Nursing has provided a useful guidance this as set out below.⁸

Patient safety is paramount, and must not be compromised in any way. There should be a robust framework for the training of the HCA, with clear governance procedures in place.

The following principles set out safe parameters to enable practice nurses and HCAs to practice safely and within acceptable and legal boundaries:

• The HCA must be trained in line with nationally agreed minimum training standards,⁹ assessed as able to demonstrate competence, knowledge of the current evidence-base and understanding of all aspects of immunisation and can safely administer the vaccines.
• The HCA must have adequate support and supervision in administering with the immunisation. They would need to be able to liaise promptly and discuss issues with a registered health professional, who is available on site in a clinic setting.
• The HCA must only administer the immunisation under a Patient Specific Direction (PSD) and may not work under a Patient Group Direction (PGD).
• Adequate indemnity insurance must be arranged for the HCA to perform this activity.

The childhood influenza programme

In 2012 the Joint Committee of Vaccination and Immunisation (JCVI) recommended that the annual influenza vaccination programme should be extended to include all children aged 2, to under 17 years of age. A phased introduction of this extension began in 2013 and is expected to continue until 2016, by which time all children in this age group should have been offered the vaccine.¹⁰

The live attenuated influenza vaccine (LAIV) is administered via the intranasal route rather than by injection.

HCAs have been a vital part of the teams involved in delivering and supporting this programme and have been administering the vaccine to children in some GP surgeries. This practice is appropriate and is supported by the RCN, providing that the HCA is appropriately trained and has the support and supervision of a registered healthcare practitioner within the practice.¹¹

The principles of safe practice for HCAs administering immunisation as outlined above also apply when they have been delegated to administer the LAIV.

The childhood immunisation programme

The immunisation programme in the UK is constantly changing and evolving as research progresses and for this reason, new vaccines are recommended for introduction by the JCVI as and when research identifies better use of the vaccines.

The childhood immunisation programme and its schedules in particular, are complex and change frequently. They also require clinical decision-making that should only be undertaken by a registered healthcare practitioner.

In addition, caring for babies and children can be unpredictable and may require a clinical judgement call from the registered practitioner when faced with a child requiring immunisation.

For this reason it is not recommended that HCAs should administer other vaccines to children, such as the remainder of the childhood immunisation programme.

The view is also supported by the RCN.¹¹

Cervical Sample Taking

Taking samples for cervical screening is seen as part of the overall NHS Cervical Screening Programme¹² (NHSCSP) and is therefore more complex than just ‘sample taking’ in isolation. When undertaking sample taking, there is a need to make judgements and decisions according to the clinical context and condition of the patient, through history taking, visualising the cervix and recognising the variance of normal for a cervix, rather than the ‘task’ to be performed. It should only be undertaken by a qualified practitioner who needs to use their clinical knowledge and judgement to undertake a wider sexual health consultation and be responsive to the patient’s own presentation and circumstances.

This is supported by the Skills for Health standards for sample takers,¹³ which state that those taking samples should be qualified practitioners who have completed a recognised training programme for taking samples for cervical screening.

RAISING AND ADDRESSING CONCERNS

HCAs who have nursing activities delegated to them must be supervised by a registered healthcare practitioner. In the GP practice setting, this should ideally be the practice nurse who delegates activity to the HCA and supervises their work. They should also be involved in the training and assessment of HCA’s competencies, and should make decisions regarding appropriate activities to be delegated to the HCA.

The GP as the employer also has authority to delegate aspects of care to the HCA. If they do so, they must retain responsibility and accountability for that delegation and abide by the principles of delegations as outlined in this paper.

The practice nurse has a duty under the NMC Code to preserve safety and must therefore intervene if they feel that the delegated activity is inappropriate or unsafe. They must do this by ‘…raising concerns immediately whenever you come across situations that put patients or public safety at risk. You must take necessary action to deal with any concerns where appropriate’.⁶

The practice nurse must communicate clearly what their concerns are, first and foremost to the registered practitioner who delegated the activity to the HCA, and should try to resolve this locally as the Code requires registrants to ‘deal with differences of professional opinion with colleagues by discussion and informed debate, respecting their views and behaviours and behaving in a professional way’. However, if they are still concerned then they must seek advice and take the appropriate action to maintain patient safety.

In accordance with the National Nursing Strategy,⁵ if practice nurses are to provide high quality, safe and effective care, they must have the commitment to care with compassion, ensure all care staff are competent, and have the courage to communicate effectively in order to challenge poor practice.

CONCLUSION

In summary, HCAs are valuable members of the practice team, and practice nurses will frequently find themselves in a position of delegating routine tasks to them. However, it is important to recognise that not all tasks are suitable for delegation, and also to be aware of your professional duty to raise concerns where tasks are delegated inappropriately.

REFERENCES

1. Francis R. The Mid Staffordshire NHS Foundation Trust Public Inquiry, 2013. http://www.midstaffspublicinquiry.com/

2. Cavendish C . An Independent Review into Healthcare Assistants and Support Workers in the NHS and Social Care Settings, 2013. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/236212/Cavendish_Review.pdf

3. Health Education England, Lord Willis (Independent Chair). Raising the Bar – Shape of Caring: A Review of the Future Education and Training of Registered Nurses and Care Assistants, 2014. http://hee.nhs.uk/wp-content/blogs.dir/321/files/2015/03/2348-Shape-of-caring-review-FINAL.pdf

4. NHS England. NHS Five Year Forward View. October 2014. http://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

5. NHS England. Compassion in practice: Two years on, 2014. http://www.england.nhs.uk/wp-content/uploads/2014/12/nhs-cip-2yo.pdf

6. Nursing and Midwifery Council. The Code: Professional standards of practice and behaviour for nurses and midwives. London 2015. Available at: http://www.nmc-uk.org/Documents/NMC-Publications/revised-new-NMC-Code.pdf

7. Royal College of Nursing. Accountability and delegation – What you need to know: The principles of accountability and delegation for nurses, students, health care assistants and assistant practitioners, 2011. https://www.rcn.org.uk/__data/assets/pdf_file/0003/381720/003942.pdf

8. Royal College of Nursing. HCSW and Adult Vaccination, 2014. Available at: http://www.rcn.org.uk/__data/assets/pdf_file/0008/597860/Final_HCSW_Adult_immunisation_paper_revised_Oct2014_V3_2.pdf

9. Public Health England. National Minimum Standards and Core Curriculum for Immunisation Training of Healthcare Support Workers. 2012. https://www.gov.uk/government/publications/immunisation-training-of-healthcare-support-workers-national-minimum-standards-and-core-curriculum

10. Public Health England. The national childhood flu immunisation programme 2014/15 - Information for healthcare practitioners, 2014. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/394070/PHE__Childhood_influenza_programme_2014_15_FINAL_v2_CO.pdf

11. Royal College of Nursing. HCSW and Live Attenuated Influenza Vaccination (LAIV) to CYP http://www.rcn.org.uk/__data/assets/pdf_file/0009/618318/LAIV-HCSW-paper-revised-2015_final.pdf

12. NHS Cancer Screening Programme (NHSCSP) Publication 23. Taking Samples for Cervical Screening: A Resource Pack for Trainers. NHSCSP Publication No 23, April 2006 http://www.cancerscreening.nhs.uk/cervical/publications/nhscsp23.pdf

13. Skills for Health Toolkit: CHS37 Obtain cervical cytology samples from individuals. Available at: https://tools.skillsforhealth.org.uk/competence/show/html/id/1030/