2.3 Delegation and Supervision
Key Takeaways
- Delegation transfers task performance to the CNA while the nurse keeps accountability for the outcome
- The NCSBN Five Rights are: Right Task, Right Circumstance, Right Person, Right Direction/Communication, Right Supervision/Evaluation
- The CNA is responsible for doing the task correctly; the nurse is accountable for the result
- A CNA must refuse tasks outside scope, beyond competency, unsafe, or for an unstable resident
- Supervision ranges from continuous to available, matched to task risk and CNA experience
What Delegation Is
Delegation is transferring the performance of a task to a qualified person while retaining accountability for the outcome. In long-term care, the licensed nurse delegates to the CNA, who is the unlicensed assistive personnel (UAP). Memorize the split:
- The nurse delegates and stays accountable for the result.
- The CNA performs and is responsible for doing it correctly.
- The task must be within the CNA scope and the CNA's demonstrated competency.
- Delegation cannot transfer nursing judgment — a nurse may delegate taking a blood pressure but never interpreting it or deciding on care.
The National Council of State Boards of Nursing (NCSBN) governs delegation standards nationwide. A nurse who delegates poorly — to the wrong person or for an unstable resident — is liable, which is why the Five Rights exist.
The Five Rights of Delegation (NCSBN)
The nurse must satisfy all five rights before delegating. Exam questions often give a scenario and ask which right was violated.
| Right | The Nurse Asks | Example |
|---|---|---|
| Right Task | Is this task delegable to a CNA at all? | Vital signs — yes; IV push — no |
| Right Circumstance | Is the resident stable and the setting appropriate? | Stable resident vs. one with new chest pain |
| Right Person | Is this CNA trained and competent? | A new CNA may need direct oversight |
| Right Direction/Communication | Were clear, specific instructions given? | "Take Mr. Lee's BP now; tell me if it's over 160" |
| Right Supervision/Evaluation | Will follow-up and feedback occur? | Nurse checks results and is reachable |
A memory hook: T-C-P-D-S ("The Cautious Person Delegates Safely"). Note the modern NCSBN wording pairs communication with direction and evaluation with supervision — watch for either phrasing on the test.
Worked example
A nurse tells a brand-new CNA, "Go check on the residents," with no specifics, while one resident is unstable. Two rights fail: Right Direction/Communication (instructions were vague) and possibly Right Circumstance (an unstable resident is involved). The correct CNA action is to ask for specifics rather than guess.
CNA Duties, Refusing Tasks, and Levels of Supervision
When a task is delegated to you, you must: (1) confirm you understand it, (2) ask questions if anything is unclear, (3) perform it as instructed, (4) report completion and findings, and (5) notify the nurse immediately of any problem. Hiding a mistake is itself a serious error.
When to refuse a delegated task
You should — and legally may — refuse when the task is:
- Outside your scope of practice (you are not authorized)
- Beyond your competency (you were never trained)
- For an unstable resident whose needs exceed CNA care
- Unsafe — missing equipment, no help for a heavy transfer
Refuse respectfully and ask for help: "I haven't been trained to do that. Can you show me, or should the nurse do it?" Refusing an unsafe or out-of-scope task is professional, not insubordinate.
Levels of supervision
| Level | Meaning | When Used |
|---|---|---|
| Continuous | Nurse present throughout | New skill, high-risk task |
| Intermittent | Nurse checks periodically | Routine care, stable resident |
| Available | Nurse reachable if needed | Experienced CNA, low-risk task |
Accountability vs. responsibility
If a CNA records vitals wrong: the CNA is responsible for the error, the nurse is accountable for the resident outcome, and both may face consequences if harm results. This is why prompt, honest reporting protects everyone.
Delegation vs. Assignment, and Reading Exam Scenarios
The exam distinguishes delegation from assignment, and the difference is subtle. An assignment distributes work that is already clearly within a CNA's everyday job description (bathing the residents in rooms 201–208). Delegation transfers a specific task that requires the nurse's clinical judgment about whether it is safe for this CNA and this resident right now. Either way, the nurse keeps accountability and the task must be within CNA scope.
A decision pathway you can apply
When a task lands on you, walk this path:
- In scope? If the task is nurse-only (medications, sterile/invasive work, assessment), refuse regardless of who asked.
- Trained and competent? If you've never been checked off, say so and ask to be shown — never "fake it."
- Resident stable? A new symptom or unstable resident pushes the task back to the nurse.
- Clear instructions? If you don't know what, when, and what to report, ask before acting.
- Backup available? Confirm the nurse is reachable.
Worked example: turning the answer around
Scenario: The nurse says, "The new admission in 210 seems short of breath — go take care of her." A weak CNA guesses. The right move applies the rights: the instruction is vague (Right Direction/Communication) and the resident may be unstable (Right Circumstance), and breathing trouble may exceed CNA care. You report what you see and ask the nurse to assess — you do not independently decide it is "just anxiety."
Common test traps
- A nurse's request can never make an out-of-scope task legal.
- "I was told to" is not a defense for unsafe care; the CNA who performs an unsafe task shares responsibility.
- Refusing an inappropriate delegation is professional, not insubordination — but you must refuse respectfully and offer to get help.
A nurse delegates a complex sterile dressing change to a CNA who has never been trained for it. Which Right of Delegation is most clearly violated?
When a nurse delegates a task to a CNA, who remains accountable for the patient outcome?
Which is NOT one of the NCSBN Five Rights of Delegation?