The relationship between a Registered Nurse (RN) and a Certified Nursing Assistant (CNA) is foundational to effective patient care delivery. The RN holds the license and the ultimate responsibility for the patient’s overall care, while the CNA provides direct support for routine patient needs. Delegation is the professional process through which the RN transfers the authority to perform a specific nursing task to the CNA. This transfer is necessary for efficiently managing the nursing workload, allowing the RN to focus on complex clinical issues requiring specialized judgment.
Legal Framework Governing Delegation
The legal authority for a Registered Nurse (RN) to delegate tasks originates from the State Nurse Practice Act (NPA) and is governed by the State Board of Nursing (BON). The NPA defines the legal scope of practice for licensed nurses and establishes the parameters for delegation to unlicensed assistive personnel like CNAs. Since these laws are state-specific, the exact tasks a CNA can perform vary, requiring the RN to know the specific regulations of their jurisdiction.
The central concept is that the RN delegates the task but retains accountability for the outcome. Delegation transfers the responsibility for performing the activity, but the professional liability for overall patient care remains with the delegating nurse. The RN must ensure the task was delegated appropriately and executed safely, holding the RN responsible for the decision to delegate.
Understanding the Five Rights of Delegation
The decision to delegate is a clinical judgment guided by the structured framework known as the Five Rights of Delegation. These rights must be considered before any task is assigned to ensure patient safety and quality of care.
- Right Task: The activity must be delegable according to the state’s NPA and facility policies, typically being a routine, non-invasive task with predictable results.
- Right Circumstance: Requires evaluating the patient’s condition and the setting. A task appropriate for a stable patient may be unsafe for an unstable patient.
- Right Person: The RN must confirm the CNA possesses the necessary education, training, and documented competence to perform the specific task safely.
- Right Direction/Communication: The RN must provide clear, concise, and specific instructions, including the objective, limits, expected outcome, and reporting time frame.
- Right Supervision/Evaluation: The RN must provide appropriate monitoring, assistance, and follow-up, ensuring the CNA reports any unexpected findings or changes immediately.
Tasks Commonly Delegated to CNAs
Activities of Daily Living (ADLs)
CNAs are primarily responsible for assisting patients with Activities of Daily Living (ADLs), which are routine personal care tasks that do not require clinical judgment. This includes helping patients with bathing, dressing, and grooming to maintain hygiene and comfort. CNAs also assist with patient feeding, provided the patient does not have a swallowing impairment or high aspiration risk. Toileting and providing peri-care are standard functions essential for patient dignity and skin integrity.
Basic Patient Care Procedures
Basic procedures involve routine tasks following a standardized sequence of steps. This includes providing basic skin care, such as applying non-medicated lotions to intact skin to prevent breakdown. CNAs may also collect routine, non-sterile specimens, such as urine or stool samples. Depending on facility policy, CNAs might assist with simple, non-sterile dressing changes on chronic wounds with predictable healing patterns.
Monitoring and Recording Data
The collection of objective data is a common and appropriate delegated task, involving measurement rather than interpretation. CNAs routinely measure and record a patient’s vital signs (temperature, pulse, respiration, and blood pressure) on stable patients. They are also responsible for accurately measuring and documenting patient weight and calculating intake and output (I&O) of fluids. While the CNA collects the data, the RN is solely responsible for analyzing and interpreting these findings to identify trends or potential problems.
Support and Mobility
Assisting patients with movement and positioning is routinely delegated to CNAs. This involves ambulation, helping patients walk to maintain strength and prevent complications from immobility. CNAs also manage patient transfers, such as moving a patient from the bed to a chair or wheelchair using proper body mechanics and assistive devices. Repositioning bedridden patients every two hours is performed by CNAs to prevent pressure injuries.
Tasks That Cannot Be Delegated
A fundamental principle of delegation is that the Registered Nurse cannot transfer any task that requires professional nursing judgment or complex problem-solving. This includes the initial, comprehensive patient assessment that establishes the patient’s baseline status upon admission or the start of a shift. Furthermore, the formulation of a nursing diagnosis, the development of the patient’s nursing care plan, and the subsequent evaluation of care plan effectiveness must remain with the RN.
Medication administration is generally non-delegable to CNAs, especially intravenous (IV) medications, injections, and narcotics. Patient teaching of new information, such as education about a new diagnosis or medication, is also prohibited, although CNAs may reinforce teaching the RN has already initiated. Tasks involving invasive procedures, such as inserting a urinary catheter, performing sterile dressing changes, or providing nasogastric tube feedings, are strictly prohibited from delegation.
The Nurse’s Ongoing Accountability and Supervision
The act of delegation initiates a continuous process of supervision and evaluation for which the Registered Nurse remains fully accountable. The RN must maintain ongoing oversight of the CNA’s performance of the delegated task, ensuring that it is completed correctly and within the expected timeframe. This supervision includes direct observation, checking documentation, and confirming that the patient’s response to the care is consistent with the expected outcome.
A crucial part of this accountability is ensuring the CNA understands the necessity of immediate and accurate reporting of any deviation from the patient’s baseline condition. The RN must be readily available to provide guidance and intervene if the patient’s condition changes or if the CNA encounters an unexpected issue. If a negative patient outcome occurs, the RN may be held accountable if it is determined that the initial delegation violated one of the Five Rights. The RN’s professional responsibility is not discharged until the delegated task is completed, the outcome is evaluated, and the patient remains safe.