Accountability and delegation guide

Accountability

Accountability is the principle that individuals and organisations are responsible for their actions and may be required to explain them to others.

Delegation

Delegation is defined as the transfer to a competent individual, of the authority to perform a specific task in a specified situation.

(Supplementary information to the NMC Code)

Organisational accountability

Does your employer have the appropriate policies, procedures, reporting and governance structures in place?

Team accountability

Is there an appropriate skill mix in your team to ensure effective delegation and to support the delivery of essential care services?

Personal accountability

Are you aware of your responsibilities, your own competence and educational needs?

Accountability in terms of the NMC Code (2018), means being held to account for your actions and being able to explain how you used your professional judgement to make decisions, including decisions to delegate aspects of care.

Under the Code you remain accountable for the decisions made by the people you delegate to.  

The NMC Code (2018) gives clear expectations for individuals on the NMC register when they delegate to others.

The NMC Code states under Practise effectively at section 11:

Be accountable for your decisions to delegate tasks and duties to other people. 

To achieve this, you must:

11.1 Only delegate tasks and duties that are within the other person’s scope of competence, making sure that they fully understand your instructions.

11.2 Make sure that everyone you delegate tasks to is adequately supervised and supported so they can provide safe and compassionate care.

11.3 Confirm that the outcome of any task you have delegated to someone else meets the required standard.

Understanding how to delegate is crucial as delegation needs both accountability and professional judgement. It’s important to recognise when delegation is necessary and most registered nurses delegate expertly every day using their knowledge, skills and experience in order to manage risks.

Points to consider when delegating

• Delegation must always be in the best interests of the service user and not performed simply to save time or money.
• Anyone you delegate to must have been suitably trained to perform the intervention.
• Full records of training given, including dates, should be kept (you may also want to include a record of your decision to delegate to indicate it was the best professional decision possible and that safeguards were in place).
• Evidence that anyone you delegate to is competent and has been assessed. This should be recorded, preferably against recognised standards.
• The role should be within their job description.
• All team members need to be informed that the activity has been delegated.
• The person who delegates the activity must ensure that an appropriate level of supervision is available and that anyone you delegate to has the opportunity for mentorship.
• The level of supervision and feedback required depends on the recorded knowledge and competence, the needs of the service user, setting and the activities assigned.
• Anyone you delegate to must have ongoing development to make sure their competency is maintained.
• The whole process must be assessed to identify any risks.
• Ongoing monitoring and escalation plans as required.
• Commissioning considerations may also need to be taken into account when delegating.
• Delegation must consider the context of every situation rather than focusing on the task alone.
• There should be clear guidelines and protocols in place so that the support worker is not required to make a standalone clinical judgement.

If you are delegating a task to a colleague, ask yourself the following questions:

1. Is delegation in the best interests of the service user?
2. Are there clear guidelines and protocols in place?
3. Have you considered the clinical risk involved in delegating?
4. Do you have authority to delegate the work and the appropriate clinical knowledge?
5. Does your colleague have the skills and knowledge required to undertake the task, including communication and interpersonal skills, as well as clinical competence?
6. Does your colleague have the capacity to take on additional work?
7. Can you provide support and supervision and check that the outcome of the delegation meets the required standard?

If you are being asked to accept the delegated activity, this checklist will assist to determine whether it is appropriate for you to accept it.

1. Has the degree of risk been considered?
2. Are you sure that the activity is not too complex for you to accept?
3. Would you be compromising the service user’s care by accepting it?
4. Does the person delegating have the authority to delegate the work?
5. Are you confident that they hold the appropriate clinical knowledge to delegate the activity to you?
6. Do you have the skills and knowledge required to undertake the task?
7. Are you confident about the communication and interpersonal skills required as well as your clinical competence?
8. Are you sure that accepting the work will not impact on your performance?
9. Do you have the capacity to take on the delegated task?
10. Do you understand what is being asked of you?

Have you answered yes to all of these questions?

If yes, you can accept the delegated activity. If not, say no, accepting it would not be appropriate and in the best interests of the service user.

After accepting the delegated work:

1. Keep your skills and knowledge up to date. Request regular updates with your supervisor if you are not offered them.
2. Work within guidelines: there must be clear and robust protocols in place and these must be reviewed frequently.
3. Regularly check that your job description is accurate and up to date, reflecting the new roles and responsibilities.
4. Do you know what to do if you have any concerns? There must be adequate supervision and access to support when required. You have a duty to let your colleagues know and not to undertake any activities that you do not feel are appropriate at that time.

Delegation must be safe and its aim must be to improve the care of all service users within any given setting.

Nursing Associates (NAs) are an essential part of the care and nursing workforce in England and provide high quality support to registered nurses.

Emma qualified as a NA 12 months ago and works on an older peoples’ inpatient ward. She is part of the multidisciplinary team that provides care to older adults, some of whom live with a long-term condition. She is responsible for looking after several patients and she works collaboratively with other nursing colleagues which include a registered nurse (RN) and a health care assistant (HCA). 

Mr Allen is an inpatient and requires his subcutaneous injection which Emma knows she can administer and is within her scope of practice. She has done this before with the RN and recognises and understands her role in relation to medicines management practices. 

She has been educated and trained to correctly undertake delegated, relevant administration of medicines safely and in a timely manner and acts in accordance with the Nursing and Midwifery Council (NMC) standards and codes of practice. 

The individual NHS Trust also has clear local protocols and instructions which define the circumstances in which medications should be administered by NAs. 

As an NA she is aware that she is accountable for her actions, and any delegatory arrangements. See: Standards of proficiency for registered nursing associates

RN1 is employed as a Band 5 Registered Nurse. They worked a night shift alongside RN2. RN2 took a break from 4am to 6am. RN1 was left responsible for RN2’s patients’ care and it is alleged that RN1 failed to carry out observations and provide appropriate patient care while RN2 was on their break. 

When RN2 returned from their break, they found Patient B unresponsive and asked RN1 to review the patient with them. RN1 alerted the crash team and, despite their efforts, the patient was pronounced dead. 

Both RN1 and RN2 were referred to the NMC. The concerns relating to their nursing practice related to:

• observation and patient care
• delegation
• communication
• responding to an emergency.

In relation to RN1, it was alleged that they failed to ensure that they received an adequate handover from RN2. In mitigation, RN1 stated that she had delegated the observations of Patient B to a Health Care Support Worker (HCSW).

The NMC was unimpressed with the conduct of both RN1 and RN2. The Fitness to Practise panel found that there were significant and serious breaches of the Code, including “Be accountable for your decisions to delegate tasks and duties to other people” and “Confirm that the outcome of any task you have delegated to someone else meets the required standard”.  

The panel found that RN1 took no steps to ensure that the HCSW conducted observations during RN2’s break. This raised a fundamental question about their professionalism and showed little regard for the wellbeing and safety of the service users in their care.

The HCSW admitted in interview that, in addition to not conducting observations on Patient B during RN2’s break, they had not carried out any observations on Patient B as requested by RN2 earlier that night or the nightshift before.

The NMC’s Fitness to Practise panel determined, in relation to RN2, that they had failed to ensure delegated tasks were carried out. In addition to this failure they had dishonestly recorded that vital signs for Patient B had been monitored when they had not.

Both RN1 and RN2 were struck off the nursing register. 

Jenny is a district nurse (D/N) managing a caseload in the community setting, and has been to see her patient, Miss Williams, accompanied by Jo, a Community Health Care Support Worker (HCSW). Miss Williams is a 71 year-old who lives alone, with a diagnosis of lower leg ulcers and a medical history of chronic anxiety and agoraphobia. She also has a history of poor sleep hygiene and often sleeps in her chair. She has also recently been admitted to the caseload.

During the first scheduled visit, Jenny assesses and develops in partnership with Miss Williams the overall person-centred care plan. Jenny explains her decision-making process to Jo. Upon completion of the holistic assessment, it was found that Miss Williams was not using her compression hosiery correctly and that she was struggling to follow the instructions given to her because of associated chronic health conditions, poor mobility issues and sleep hygiene patterns. 

Jo observed how Jenny discussed leg care management with Miss Williams which included the importance of:

• Skin assessment - the importance of checking her skin including her feet which would include skin discolouration and nail integrity.
• Circulatory assessment - the importance of checking for varicose veins, dry skin, discoloration, history of cramp and overall mobility.
• Wound assessment - Jenny visually checked Miss Williams leg using the leg assessment tool used by the district nursing team. Consent was also obtained prior to undertake a *Doppler assessment (NICE, 2023) to measure Miss Williams ankle-brachial pressure index (ABPI). This would enable compression hosiery to be worn.
• Jenny also discussed at length with Miss Williams her activities of daily living which included the medications that she uses.
• On further assessment Jenny discovers that Miss Williams has not been managing her medication correctly and has run out of her medication for anxiety management. Consent was gained from Miss Williams and Jenny made a referral to the mental health outreach team and General Practitioner (GP).
• During the assessment Jenny ensured that she adopted the Make Every Contact Count framework (MECC).

The delegated action arising from this episode of care which was assigned to the HCSW was a weekly application of compression hosiery and skin integrity check.

Jenny, as the Registered District Nurse, ensured that the delegated activity given to Jo, (HCSW) was clearly explained and understood. The delegated follow up visit to check skin and apply compression hosiery for Miss Williams was appropriate and in line with the skills and competency of the HCSW within the community team. Jenny also understands that she is still accountable for the prescribed action and care plan and that it is her responsibility to oversee care plan interventions.

At the next follow up visit to Miss Williams, Jo the Community (HCSW) delivered and applied the newly prescribed hosiery in line with agreed guidance and care plan developed by Jenny (D/N). Jo reported back to Jenny on her visit to Miss Williams.

Support for a complex health care needs child in mainstream education

James is a registered nurse working within a community service for children and young people. He is the responsible nurse for Ada who has been supported by the service as she has multiple complex healthcare needs. Currently there is a full-time care package of staff managed by the community service James is employed by and he is the responsible nurse who delegates the care Ada receives.

Ada is fully ventilated via a tracheostomy and requires 24-hour care from a mixture of staff and parents. Ada has restricted physical mobility in that they are able to move their eyes to communicate via an Eyegaze software package or through Picture Exchange Communication System (PECS) and can mouth some vocabulary, this is the extent of their ability to move. Ada has good cognitive function and can communicate well through the tools available.

Parents and the local Education department have agreed that Ada’s educational needs would be best met by attending initially a mainstream nursery and now a mainstream school. They are supported to attend by a team of Registered Nurses and Health Care Support Workers provided by our service. Whilst at school one of our team is supported by an Education provided Pupil Support Assistant to provide care for Ada. Education Staff are not trained to support ventilation but can assist NHS staff with tracheostomy care and emergency care. There are three allocated Pupil Support Assistants who are trained and supervised to provide this support. James reviews Ada’s care plan regularly and ensures that the delegation remains appropriate and safe.  

The education team within our service provides the required healthcare training, supervision and annual updates in tracheostomy care including suctioning and emergency tracheostomy care. Education staff also have training in moving and handling and basic life support provided through their own employer.

Training has also been provided to both NHS staff and Education staff on how to use a Tobi eyegaze and on the use of PECS.

Ada enjoys being at school and learning, she can read and do maths questions and puzzles via her eyegaze as well as communicate with staff and her peers.

Frances works in a small care home for young people with learning disabilities. She has recently qualified as a learning disability nurse and is a new staff member to this particular care facility. She has had lots of experience including voluntary work, in learning disability settings prior to undertaking her learning disability nurse training. 

Frances is keen ‘to make a good impression’ in the nursing team and to be seen as supportive and coping well in her role. James has been at the care home for a week and is allocated to her care. James’ behaviour includes frequently falling to the floor and he wears head protection to help prevent serious injury to his head during these falls. Frances is concerned that the care plan does not detail the care James needs and how to best manage his falls. As the nurse allocated to his care, she is concerned about meeting James’ needs safely.

Frances asks the nurse handing over to work with her and James to build on the existing plan of care so that it better reflects James’ safety and behaviour management needs. They work with James and his mother, who regularly collaborates with the team to design and review care plans. The new care plan is agreed with a review date.

Frances also asks the nurse handing over to work alongside her and James briefly so they can get to know each other. Frances uses this time under supervision to ask questions and support James’ needs whilst working alongside the other nurse. This provides assurance for ongoing supervision and support from other members of the nursing team, during the time that she is caring for James.

Frances has demonstrated her professional accountability by identifying limitations to her practice and raising a concern about patient safety. She also addressed her record keeping responsibilities by working collaboratively to update James’ records so that his plan of care met his needs more comprehensively, ensuring that she and others could provide continuity of care. 

She also took steps to ensure that her skills and confidence to provide individualised care to James were addressed, by asking for and receiving some direct supervision. This also respected James’ needs by supporting him to become familiar with her whilst he feels safe with other team members, he has already built a trusting rapport with.

References and further resources

England

Nursing and Midwifery Council (NMC): The Code: Professional standards of practice and behaviour for nurses, midwives, and nursing associates

NMC: Read the code online

NMC: Standards of proficiency for registered nursing associates

Skills for Health: Information Hub - Standards and frameworks

Northern Ireland

NIPEC. Delegation. Accountability and Delegation ( development resource) for Norther Ireland

Scotland

NHS Scotland

NHS Education for Scotland (NES). Making delegation safe and effective : a learning resource for nurses, midwives, allied health professionals and health care support workers

NES. Development and Education Framework for level 2-4 NMAHP Healthcare Support Workers

NES. Framework for the administration of medicines by level 3 and level 4 Healthcare Support Workers in Scotland

Social care 

Care Inspectorate. Prompting, assisting and administration of medication in a care setting: guidance for professionals

Care Inspectorate. Guidance about medication personal plans, review, monitoring and record keeping in residential care services (PDF)

Scottish Government. Clinical and Care Governance Framework 

Scottish Social Services Council (SSSC). The SSSC Codes of Practice

Wales

Health Education and Improvement Wales (HEIW). All Wales Delegation Guidelines

Videos

NMC. Let's talk about delegation. Caring with Confidence: The Code in Action

NMS. Let's talk about accountability. Caring with Confidence: The Code in Action