The creation of new nursing support roles has blurred the boundaries of registered nurses’ roles and raises questions of accountability and delegation. This article comes with a handout for a journal club discussion
With the emergence of healthcare support staff, the boundaries of the role of registered nurses have been blurred. Often healthcare workers are now allocated tasks that were once the responsibility of qualified nurses. With this change comes a greater need to tackle issues around accountability, responsibility and delegation. When delegating tasks to unregistered support workers, nurses need reassurance that their colleagues are adequately trained, competent and responsible. This is particularly important in community settings, where staff are expected to work autonomously. To ensure the safety and reliability of nursing interventions, there may be a need to standardise the education and continuing professional development of all staff. This article explores the debate around these crucial questions.
Citation: Kendall N (2018) How new nursing roles affect accountability and delegation. Nursing Times [online]; 114: 4, 45-47.
Author: Nyree Kendall is senior lecturer and lead for district nursing, University of Bolton.
In recent years, healthcare support staff have been given increasing responsibilities, as the NHS is trying to meet a rising demand for healthcare services and save money. With the emergence of nursing support roles, the boundaries of qualified nurses’ roles have been blurred. Today, unregistered healthcare workers are often allocated tasks that once were the responsibility of registered nurses. This raises the question of staff’s accountability and responsibility, which according to Maybin et al (2011) have been moved to local levels of authority. It also raises the question of how nursing tasks should be delegated. This article discusses accountability and responsibility in the NHS and nursing generally, and in community and district nursing in particular.
What is accountability?
Accountability is variously described as an “obligation or willingness to accept responsibility or to account for one’s actions” (Merriam-Webster) and the “principle according to which a person or institution is responsible for a set of duties and can be required to give an account of their fulfilment to an authority” (Encyclopaedia Britannica). In nursing, Krautschied (2014) suggests that there is no clear definition of what accountability means and that describing it in practice terms is challenging.
The Royal College of Nursing (2017) links accountability to employees’ contract of duty – staff are accountable to their employers. This can be measured through staff’s adherence to guidance, performance goals and outcome measures. Registered nurses are also accountable to their regulatory body, the Nursing and Midwifery Council. The NMC’s code states that all qualified nurses are accountable for the decisions they make, including the decision to delegate or not delegate tasks to others (NMC, 2015).
In a study of nurses’ perceptions of accountability, Leonenko and Drach-Zahay (2016) found that nurses generally identified it as a critical element of practice and one closely related to responsibility, but were often hindered by a lack of organisational transparency, which is needed to ensure that accountability and responsibility are maintained. When these are not recognised or understood by staff, good governance becomes difficult and the safety and quality of care can be compromised (Bassett, 2012).
To ensure accountability and responsibility, the NHS needs a competent workforce. All staff working in healthcare have a responsibility to perform competently regardless of their role and uncertainty about competence needs to be recognised and reported (RCN, 2017).
What is competence in the healthcare workforce? Definitions include the ability to “do something well or efficiently” (American Heritage, 2007) and the ability to “provide proficient and consistent care” (Miller-Keane and O’Toole, 2006). Competence can also be defined as “a generic quality referring to a person’s overall capacity”, as opposed to competency, which refers to “specific capabilities such as leadership, which are made up of knowledge, attitudes and skills” (King’s College London, 2009).
Cowan et al (2005) tried to extract a definition of competence in nursing practice from the literature, but found that there was little consensus on the subject. They concluded that a combination of factors such as knowledge, skills, performance, values and attitudes needed to be considered.
Another principle that underpins accountability and responsibility is professionalism, which comes from know-ledge applied to practice and can be measured through people’s actions and outcomes (Tilley and Watson, 2004). Scanlon (2011) says that, for people to be professionals, they need to have gained a relevant degree and be recognised by a governing body. It could be argued that some support staff employed by the NHS are not professionally accountable because of a lack of regulation and a lack of recognised and compulsory education.
One group of staff to which this applies is unregistered and unqualified support staff. The Core Skills Training Framework (Skills for Health, 2014) skills passport has somewhat standardised the education of support staff, but it remains basic and mainly meets mandatory training requirements. The training and continuing professional development (CPD) of support staff need to be given more attention to ensure nursing care is delivered safely and reliably.
The Scottish government has identified a lack of consensus regarding the education and CPD of healthcare support workers (NHS Education for Scotland, 2010). To remedy this, we need to use learning needs analysis – which should be the starting point when considering the training and CPD needs of all staff (NHS Digital, 2017). The UK government has issued guidance on how to conduct learning needs analysis (Cabinet Office, 2011), which is considered an essential step towards ensuring staff training, competence and appropriate skill mix.
Beyond the need to analyse the training needs of staff, Chappell and Ford (2014) argue that it is also important to assess their clinical abilities and recognise their skills. However, assessing clinical competence is a complex process requiring valid and reliable frameworks appropriate to the practice setting (Wass et al, 2001).
Marcus (2015) adds that it is essential to ensure employees are aware of the needs of their organisations and feel accountable to them, which can be achieved through outcome management and personal development plans. This is reinforced by Garber et al (2012), who suggest that setting objectives for employees increases their sense of responsibility and accountability. Giving staff responsibility for adhering to the organisation’s values and meeting its objectives, alongside their own, fosters self-awareness and accountability.
Griffith and Tengnah (2017) say that the key functions of accountability are to protect, deter, regulate and educate to prevent negligence and ensure high standards of care provision. There are misconceptions about the levels of accountability of newly qualified nurses and delegation because they are insufficiently prepared to make clinical judgements when they complete their training (Gerrish, 2000; Magnusson et al, 2017). Delegating to other team members is questionable. If competence and professionalism cannot be ascertained through a certain level of education and through recognition by the profession, then the ability of the unregistered workforce to accept accountability can be questioned.
The appropriateness of delegation is often questioned by qualified staff when they allocate work to unqualified colleagues as they think it raises issues of accountability, ability and governance (Harrison, 2007). However, healthcare support staff should be accountable for their actions and omissions, and strive to maintain and improve the care they provide through CPD; in addition, all healthcare workers should be aware of their ability to do their job in a competent manner (Lovegrove et al, 2013).
Although they are not accountable to a professional organisation, support staff do have a responsibility towards their employer. To sustain and manage that responsibility, the RCN recommends that employers keep a fitness-to-practise register. However, this is not a statutory requirement, so there is no centralised register, and if registers exist they are rarely transferable between settings (RCN, 2007).
In community and district nursing services, care is usually provided in the patient’s home by a member of staff on working alone, so staff are expected to work autonomously and make decisions (HEE, 2015). To delegate effectively and safely to healthcare support staff, nurses need reassurance that relevant training and CPD have been provided and that staff are confident and competent in delivering care (RCN, 2017).
The NMC has recently issued guidance on professionalism in nursing care provision (NMC, 2017). The key themes, which are outlined in Box 1, lead to autonomous working and to enabling others to work to their full scope of practice (NMC, 2017).
Box 1. Themes in NMC guidance on professionalism
- Accountability through safe practice
- Advocating for others
- Promoting professionalism and trust through effective leadership
- Evidencing competency through critical thinking and inquiry
Registered and unregistered roles
Initially, the associate practitioner (AP) role was meant to be a supervised one in which responsibility and accountability would have been de facto limited (Lovegrove et al, 2009). However, since the introduction of APs, there has been a blurring of roles and responsibilities. APs often work without direct supervision and are often delegated tasks traditionally undertaken by registered nurses (Wakefield et al, 2010).
Nursing associates (NAs), on the other hand, will be registered with the NMC, so they will be obliged to ensure that their own standards of practice are aligned with those of first-level nurses and will be accountable for their actions, including delegation to others (NMC).
There has been much discussion on the role and function of NAs. Unions have expressed concerns that their introduction could reduce the number of fully registered nurses, which could negatively affect patient safety (Dean, 2016). Health Education England emphasises that NAs are not being introduced to replace nurses but to enhance the workforce and therefore improve patient outcomes and safety, as well as to create a career pathway for support staff (HEE, 2016). However, within organisations, there is often a lack of clarity about the responsibilities of different roles, so accountability in relation to delegation of tasks can be a grey area (Spilsbury et al, 2011).
In all areas of nursing, including district and community nursing, accountability and responsibility are fundamental to ensure the public is protected and situations such as those described in the Francis, Winterbourne View and Berwick reports do not happen again (Griffith, 2015).
The introduction of the AP role has meant that more responsibility and accountability can be transferred from qualified nurses to support staff, but there are concerns about standards of, and variability in, training and CPD, and therefore the delegation of some nursing responsibilities. This should be given some thought, and standardising the education of support staff should be considered, as it would provide reassurance about competence and accountability.
The discussions around the role of NAs indicate that many in healthcare think support staff should be regulated to ensure accountability and responsibility. It will be interesting to observe the impact of the introduction of NAs in terms of accountability and responsibility, as they will be registered with and monitored by the NMC, whereas APs are not. It will also be interesting to observe how the structure of community nursing teams will evolve in the future in light of these developments.
- With the emergence of support roles, the boundaries of qualified nurses’ roles have been blurred
- Staff are accountable to their employers but nurses are also accountable to their regulatory body
- Accountability around delegation of tasks can be a grey area
- To delegate tasks to support staff, nurses need reassurance that they are well-trained and competent
- Standardising the education of lower-level support staff would provide reassurance about competence and accountability
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