Running head: RN ACCOUNTABILITY IN THE DELEGATION OF TASKS 1

RN Accountability in the Delegation of Tasks to UAP: An Ethical Analysis

Shaolin K. Mosely

James Madison University

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RN Accountability in the Delegation of Tasks to UAP: An Ethical Analysis

Introduction

In the hospital setting, registered nurses have the authority to delegate tasks to unlicensed

assistive personnel (UAP). Nurses work closely with UAP to take care of patients and often

assign them duties such as monitoring intake and output, documenting vital signs, and assisting

with ADLs. Because a nurse’s most important role in healthcare is the promotion of health and

prevention of illness, a nurse should never allow an UAP to complete a task improperly because

it poses a risk for patient harm. Though it has been delegated to the UAP, the registered nurse is

ultimately accountable for the task and its outcome. According to Dohmann, “Accountability

arises out of one’s… strong personal commitment to ensuring that a result is achieved” (2009).

This is an important aspect of nursing care because accountability is the foundation of safe

nursing practice and is crucial to the congruence between nursing actions and standards that are

associated with quality healthcare (Krautscheid, 2014).

Background

During my first semester of clinical rotation, I was involved in an ethically challenging

situation that displayed a lack of accountability of nursing staff. I was caring for a patient who

was status post an ischemic stroke. She suffered from resulting aphasia and was unable to

verbally express herself. While in the hospital, she had multiple instances of urinary retention, so

the doctor ordered a Foley catheter. We told her that the Foley would alleviate her discomfort,

but she made us aware that she was unhappy and nervous. An RN and I calmly reassured her and

I began the catherization. After a few unsuccessful attempts, the nurse called on a UAP and

another RN for help. At this point, the four of us were in the patient’s room trying to finish up
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this process so the patient could rest. Though she was unable to verbalize her feelings, she was

experiencing pain and increasing anxiety while we continued to attempt insertion.

The UAP claimed she had performed catheter insertion on this patient before and was

confident in her ability to do so, so we stepped back to let her proceed. My catheter kit was still

good to use, but I handed her a new pair of sterile gloves. After neglecting to wash or sanitize her

hands, she rolled her eyes and incorrectly applied the sterile gloves. Her carelessness was made

clear when she responded to our judging eyes with the comment, “You got your way of doing

things and I’ve got mine”. She did not attempt to keep the sterile catheter away from contact with

the bed and other nonsterile surfaces. In the end, the other RN successfully inserted a catheter

from a new box, but the patient had already been potentially contaminated at this point. The

situation was never directly addressed afterward.

We did not stop the CNA or say anything to her during or immediately after the offense. I

was in a situation of moral distress because I wanted to speak up and I knew that I should have,

but I felt unable to do so. I felt restricted in my role as a nursing student and was uncomfortable

with my new role as a professional. I did not want to violate the integrity of the UAP, though she

had already done so herself. I also did not want the patient to hear us critiquing the UAP when

she already felt so vulnerable, because it is important to maintain trust between the patient and

all of the staff members. One of us nurses could have politely said “You seem to be having some

trouble, why don’t you stop there and I’ll try it”. Then, we should have had a more serious

conversation in private to discuss the issue and its implications. If these attempts were

ineffective, we could have taken up the situation to someone that would have more power.
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Methods & Findings

The Madison Collaborative of James Madison University developed The Eight Key

Questions as a prompt for ethical reasoning in difficult situations. This guide outlines eight

questions that may arise from an ethically challenging situation and allows one to assess the

moral implications of a situation (The Madison Collaborative, 2013). I will use this framework to

analyze the aforementioned situation. The only Key Question that does not apply to this situation

is the question of liberty. In this case, the patient’s freedom and personal autonomy was not

affected and there was not an issue of consent.

The most important ethical considerations in this situation are our responsibilities as

nurses, the outcomes of our inaction, and the rights of the patient. The unsafe technique of the

UAP implies dangers to the unit when considering short and long-term outcomes. Failing to

maintain sterile technique during catheterization poses a high risk for a catheter-associated

urinary tract infection (CAUTI). A CAUTI in this patient would be particularly dangerous

because UTIs can cause confusion in the elderly, adding to their risk for falls and medication

noncompliance. In the long-term, multiple incidences of CAUTI and other hospital-associated

infections affect patient satisfaction, hospital reputation, and even the costs of the hospital.

Furthermore, registered nurses are ultimately responsible for the tasks that they delegate to UAP,

and it is important to take accountability when the tasks are done incorrectly to reduce medical

risks. This moment as an could have been an teaching opportunity to show the UAP the proper

way to insert a catheter, and discuss the importance of a sterile field. Because we did not do this

and were instead very passive in the situation, we denied the patient her right to safe healthcare.

Next, I will analyze this situation and its implications of fairness to all players in the

situation, the reflection of character of the nurses and our ability to empathize. When I decided
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not to speak up, I was selfish in my interest of my reputation. I was afraid that speaking up

would negatively impact my relationship with the UAP staff. However, the patient’s safety is

more important. None of us nurses acted equitably because we neglected the opportunity for

advocating for a vulnerable person in a less powerful position. When I reflect on this situation

personally, I realize that my inaction was a poor example of the nurse I wanted to become and

did not represent the values I want to uphold. Though all of us nurses care about our patients and

want to treat them well, perhaps we would have intervened in the situation if we personally knew

the patient and thus empathized more. I have heard that nurses have many unpleasant

experiences in their careers and eventually become exhausted and simply give up in their pursuit

to be leaders.

Our actions could have been guided if we had acknowledged what authorities would have

expected in the situation. A very important authority to nurses is the Code of Ethics of the

American Nurses Association, a professional organization that represents and guides registered

nurses in the US (American Nurses Association, 2015). Provision 4 of the Code of Ethics is

interpreted as: The nurse has authority, accountability, and responsibility for nursing practice;

makes decisions; and takes actions consistent with the obligation to promote health and to

provide optimal care. This would have provided us guidance in taking action.

Conclusion

This analysis should serve as a reminder of the importance of proper task delegation.

While it was not best practice for us to be passive in the situation, our response does not make us

“bad nurses”. It does however show a weakness in our practice that we must work on in order to

better ourselves as nurses. In the future, we will reflect on why it is ethically important to

advocate for patients in even challenging situations.

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References

American Nurses Association (2015). Code of ethics for nurses with interpretive statements.

Retrieved from http://nursingworld.org/DocumentVault/Ethics-1/Code-of-Ethics-for-

Nurses.html

Dohmann, E. L. (2009). Accountability in nursing: six strategies to build and maintain a culture

of commitment. Marblehead, MA: HCPro.

Krautscheid, L. C. (2014). Defining Professional Nursing Accountability: A Literature Review.

Journal of Professional Nursing, 30(1), 43-47. doi:10.1016/j.profnurs.2013.06.008

The Madison Collaborative. (2013). The eight key questions handbook. Retrieved from

https://www.jmu.edu/mc/Docs/131101%208KQ%20Handout%20Revision.pdf