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

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