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Debating delegation

As I predicted, the Francis report on the Mid Staffordshire Hospital Trust has a whole chapter dedicated to nursing. It was uncomfortable reading - appalling practice, low ratios and scant professional accountability. Both The Nursing and Midwifery Council (NMC) as regulator, and the Royal College of Nursing (RCN) representing nurses who broke their professional code, were criticised. Should the 'noise' around nursing practice have made these bodies proactively investigate concerns holding nurse management to account - not individual nurses after the event?

Hindsight provides new eyes. There was 'noise' in the system at Mid Staffs hospital about nursing roles, delegation and numbers. I think there is the same 'noise' increasing in the community setting. I predict the delegation of clinical tasks in the community setting will become an issue sometime soon as we have increasing numbers of patients with complex clinical needs cared for by a decreasing nursing workforce dependant on non-clinical workers.

Today, clinical care that enables patients to be discharged home encompasses giving medicines, including nebulised and injected, nutritional management including percutaneous endoscopic gastrostomy (PEG) feeding, pressure care and simple wound management, continence management including catheter care, and other clinical supports for daily living. Many nurses will recall these as nursing roles. Today, this 'assisted living' is provided by paid non-clinical care workers or family members.

Speedier hospital discharge and avoidance of hospital admission - combined with disposable equipment and technological improvements - means clinical care becomes blurred with social care needs. Do you remember the debate over diabetic care being a nursing task - patients now manage their insulin without nursing support? Ditto catheter care, cytotoxic medication regimes, and numerous others. The threshold for patient self-management has changed. Consequently, family and care workers have stepped into clinical roles.

What has not been satisfactorily clarified is the safe delegation of these roles. Yes, the NMC Code is clear about delegation and where accountability lies.

Indeed, the RCN give excellent practical and extensive illustrations to ensure both the delegator and delegatee are clear about the task, training and consequent accountability. In the real world it is a little more muddy I believe. Where the registered nurse is delegating to a healthcare worker employed by the same employer there is an inherent understanding of the delegation process honed over time with team members that know and trust each other. Yet, do all providers have a policy on delegation from clinician to non-clinician? I suspect not. Many rely on the NMC and RCN guidance; as they employ both delegator and delegatee, accountability and potential litigation is less problematic. Increasingly, relatives are taking on the clinical care of the patient, with delegation coming from the hospital/ community or specialist nurse(s). This involves the transfer of the task, risk and emotion to a relative, making the delegation of clinical duties a bit muddier. It becomes more muddy with the clinical task being delegated by a nurse to a care worker in another organisation, either commissioned in a package of health/social care or pur- chased directly by the patient/client. In this scenario, there is often a significant turnover of care staff; carers attend up to seven times a day, with little continuity, with practical, resource and timing difficulties for nurse delegators reviewing the competency of all the care workers undertaking a clinical task.

Increasingly, the declining nursing workforce relies on care workers to enable patients to manage their clinical condition. Patients rely on nursing to ensure the delegation is appropriate and safe. In this world of increasing safeguarding alerts, rising com- plaints and individual clinical accountability, there is a need for employers to ensure agreed corporate processes are in place to enable their nursing workforce to confidently delegate to those most appropriate to support patients. 

The Mid Staffs inquiry has reminded us that unregulated healthcare workers have variable employment conditions, competencies and attitudes, with nurses and patients increasingly dependent on them. It is an opportune time for nursing to refresh its responsibility in safe delegation and for us to revisit our professional accountability. We have a duty to raise concerns where patient safety may be compromised.

Thanks Robert Francis QC.