Working Environment

Accountability and delegation case studies

The following case studies provide examples of how the decision making process and the principles of accountability and delegation principles apply in various health and care settings. 

The NMC have also developed some case studies to support working within the Code during COVID-19, see: Maintaining professionalism and trust during the COVID-19 emergency.

The RCN's occupational health resources on record keeping and disclosure of information also includes some useful case studies. 

Justin is a Clinical Nurse Specialist in Palliative Care in the Community setting, he has been to see Mr Jones, Mr Jones is 85-year-old with a diagnosis of Bowel cancer, and metastasis to his liver and lung. Mr Jones is now being nursed in bed as he is declining and is only expected to live for several days. Justin reviews Mr Jones’s symptoms. He prescribes an increase to the medication in the syringe pump and contacts the community nurse to advise of the change and asks them to visit to administer (Justin cannot administer medication he has prescribed), therefore Justin has delegated the administration of the medication to a nurse with appropriate competency within the community team, but remains accountable for the prescribing of the medication. 

On further assessment he discovers that Mr Jones has developed a grade 2 pressure ulcer on his heel, Justin has previously worked as a community nurse where tissue viability was a core component of his role and he has extensive experience and competence in this field. 

As Mr Jones is already receiving wound care he has a range of dressings available in the home. Using his knowledge Justin assesses the wound, cleans and applies an appropriate dressing, he completes a care plan and informs the community nurse of his intervention. Justin delegates the ongoing wound care to the community nursing team in the knowledge that they have the competence to manage this.

The following day Justin calls Mr Jones to check his symptoms and to review the increase in medication he had prescribed. Mr Jones is now more comfortable.

Azizi, a nurse who works on a general medical ward, has been redeployed to the critical care unit to assist with the coronavirus pandemic. He is asked to adjust/administer IV vasopressor medication by the medical team. Azizi is aware this is outside his competency and ability and asks the supervisory nurse for support. This role does not form part of his job description as a ward nurse (responsibility). The critical care nurse would not delegate this activity (authority) to Azizi, given this is outside his competence and job description. 

The critical care nurse retains the professional responsibility of appropriate delegation and Azizi is accountable for his actions.  Azizi knows to escalate this action to his supervising nurse as he is unable to perform the task as it is outside of his scope of practice and not in the best interests of the patient.

Fatima has recently started a job as a general practice nurse. She has previously worked on a general surgical ward for a number of years. To support her induction, Jane the nurse manager is acting as her supervisor. 

As this is a new area of Practice for her, she is eager to learn new skills. Training and education in vaccination and immunisations and cervical cytology have been prioritised. For now, she feels competent to carry out treatment room duties and these form part of her job description.

On starting her clinic one day she sees that a patient requiring travel vaccinations has been added to her list. This role does not form part of her job description and she has not had the appropriate training to undertake the risk assessment required in a travel health consultation. The nurse manager would not delegate this activity as this is outside of Fatima’s competency and job description.

The nurse manager retains the professional responsibility of appropriate delegation and Fatima remains accountable for her actions. Fatima escalates the situation to her supervising nurse as she is unable to conduct the consultation as it is outside of her scope of practice and not in the best interests of the patient.

Seema is a senior registered nurse in a care home which provides care for residents receiving nursing care and others who are in receipt of personal care with nursing interventions provided by the community nursing team. A number of Seema’s colleagues are “sheilding” and some are off sick. Semma is asked by the community nursing staff if she will administer the insulin and undertake the wound care for a resident, John, who normally receives care from the community nursing team. Seema is keen to be supportive to her community nurse colleague but realises a wide range of considerations should be thought through if she accepts this delegated role.

She has a duty of care to the residents to whom she has been delivering nursing care. Seema is accountable residents, the public, her employer and her profession.  She must be sure that any role she undertakes is one in which she is confident and competent. Seema knows she has the skills to manage both the insulin administration and wound management, however she is aware these are not simply mechanistic tasks and that once she has provided those interventions she has a duty of care to the resident to ensure he is not at risk of a hypoglycaemic episode and that his wound needs monitoring for both infection and pain, resulting in revisiting him throughout the day.

Seema is aware she will need access to clinical records held by the community team and is likely to need to liaise with them and the Johns family. She feels very uncertain that she will be able provide the time needed to provide the care to a satisfactory standard, she is also aware that she is employed to provide care to “nursing” residents. 

In these circumstances Seema speaks with her employers and the community team and agrees to undertake the delegated role twice a week for three months to provide support within the principles of her code of conduct. The other days will be managed by the community team to ensure there is professional oversight by the team delegating the responsibility. 

Her employer amends her contact to include care of “residential residents”. Johns wound improves considerably and with Seema's input John learns to self-administer his insulin using a new device. 

 

Eve has recently started working in an Early Intervention Service (EIS). Eve has been qualified 5 years as a mental health nurse and has mainly worked in hospital settings. Her case load is made up of young people who are experiencing first onset psychosis. A mother of one of her client's phones to express grave concerns about her son Bob’s welfare. She has not seen him, but reports he is not sleeping or eating properly and has started to smoke cannabis again. All triggers that exacerbated his first admission. Eve had delegated a meeting with Bob to a peer support worker yesterday. The peer support worker reported, they had had a nice chat, that his mental health seemed stable, Bob was feeling much better and, although he was not sleeping was enjoying his new college life and living away from home. Eve, is concerned that the peer support workers impression of Bob, is very different from his mothers. She wants to collaborate with Mum but doesn’t wish to undermine the peer support worker role or breach Bob’s confidence, as he has told her he hasn’t been getting on with his parents in recent months.   

In speaking to Bob’s Mum Eve knows professionals can normally only share information about relatives if this has been agreed. ‘Giving consent’ usually this takes the form of a consent form or an advance statement that explains who patients want to share their information with if they lose mental capacity. In limited situations, Eve can ‘breach confidentiality’ sharing personal information without Bob’s consent, but this is only when it is in the public’s interest or to “preserve safety; Eve has a professional ‘duty of candour’ to raise concerns immediately when coming across situations that put patients or public safety at risk - that is when someone is in extreme danger to themselves or others. For example, Eve with the EIS team may decide to share information with the police if Bob is at risk to other people or when a court or a piece of law says they must. Eve judged this not to be the case in this instance. Eve listened to Bob’s mother’s concerns and, without revealing her source used this information to inform her next meeting with Bob. Working with the peer support worker, Eve role models taking an appraisal of his mental health, she asks him for more detail about his sleeping pattern, eating habits and lifestyle.  From this, she deduced that Mum’s concerns are justified, he is smoking more cannabis and staying up all night to party with his new student friends.  Eve discussed this observation with Bob, and he disclosed that he was finding keeping up with his new life stressful. Working with the peer support worker, Eva and Bob developed a new care plan to focus on healthier coping strategies and are now working on a advance statement to outline how Bob’s family can be involved.   

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 cares for him at home alongside the wider team. 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. 

Daniel works as an Assistant Practitioner supporting community staff to provide continence care for patients based in care homes. His work involves training and advising care staff on how to support residents with continence problems. He works directly with patients where specialist support is required. He visits Mr McCarthy who has a urinary catheter which Mr McCarthy’s main carer helps him with at his local care home. Mr McCarthy knows his regime and understands what works for him and is generally very sociable, talkative and engaging when the nursing staff visit, he also has a very good rapport with his main carer who supports him on a daily basis.

When Daniel visits Mr McCarthy his normal carer is unfortunately off work and Daniel notices that Mr McCarthy is not his normal self. Mr McCarthy informs Daniel that he really isn’t feeling very well and he is in pain, and that he didn’t sleep very well the night before, Daniel also notices that Mr McCarthy is a little confused and not his normal self , has a raised heart rate and not passed his normal urine output. In Daniels role as an AP he has had the appropriate training and education to recognise signs and symptoms of possible infection/sepsis. Daniel knows to raise the alarm and escalates this to the Registered Nurse to enable prompt identification and treatment, in case Mr McCarthy needs to be treated very quickly and within the hour.

Nursing Associates (NA’s) 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 twelve months ago and works on an older people’s 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 for NA’s. 

As an NA she is aware that she is accountable for her actions, and any delegatory arrangements.

For more information, see guidance from the RCN and the Royal Pharmaceutical Society: Professional Guidance on the Administration of Medicines in Healthcare Settings