Scope of Practice, Duties, and Limitations

Scope of Practice, Duties, and Limitations

On the Delaware Prometric written exam and in every long-term care facility regulated by the Division of Health Care Quality (DHCQ), the role of the nurse aide is one of the highest-weighted domains. Domain I (Role of the Nurse Aide) accounts for about 18% of the 60-question written test—roughly eleven questions. Many of those items test whether you know the legal boundary between what a Certified Nurse Aide (CNA) may do and what only a licensed nurse or other licensed professional may do.

Working Under Licensed Nurse Supervision

A Delaware CNA does not practice independently. You provide nursing-related care under the direction and supervision of a licensed nurse—typically a Registered Nurse (RN) or Licensed Practical Nurse (LPN/LVN), depending on the facility’s staffing model. Supervision means a licensed nurse has assigned work that is within your training and legal scope, remains available for questions and problems, and retains responsibility for overall nursing care.

This structure exists for resident safety. The nurse assesses, plans, and evaluates; the nurse aide implements assigned portions of that plan and reports back what was observed. If you are asked to perform a task you were never trained for, or a task that clearly belongs to licensed practice, you must refuse the task politely and immediately notify the charge nurse—not improvise.

Duties Commonly Within CNA Scope

Within training, facility policy, and the care plan, Delaware CNAs commonly:

1. Activities of Daily Living (ADLs) — Bathing, perineal care, oral hygiene and denture care, grooming, dressing and undressing, toileting assistance, and help with eating and drinking.
2. Vital signs and basic measurements — Temperature, pulse, respirations, blood pressure (when trained and assigned), height, weight, and intake and output (I&O) recording.
3. Observation and reporting — Watching for changes in skin, mobility, appetite, elimination, mood, pain behavior, or mental status, then reporting those changes to the licensed nurse in a timely way.
4. Mobility and positioning — Turning and repositioning, transfers with a gait belt or mechanical lift as trained, wheelchair transport, ambulation assistance, and range-of-motion exercises when ordered in the care plan.
5. Comfort and environment — Bed making, tidy room care, hydration encouragement, answering call lights promptly, and supporting rest, privacy, and dignity.
6. Infection control basics — Hand hygiene, personal protective equipment (PPE) as required, and keeping resident care equipment clean according to facility procedure.

These tasks sound routine, but they are skilled work. Doing them safely and respectfully is the core of the nurse aide role on both the written exam and the clinical skills evaluation.

Limitations: What CNAs Never Do

Prometric and Delaware training programs emphasize hard stop lines. Unless your state registry, training, and facility specifically authorize a task (most Delaware nurse aide jobs do not), CNAs do not:

• Administer medications — including pills, injections, eye drops, patches, or oxygen titration by order. Even “just this once” is outside scope.
• Perform sterile procedures — such as sterile wound packing, urinary catheter insertion, or tracheostomy suctioning as an independent sterile task.
• Take physician orders — You do not accept telephone or verbal medical orders from a physician, nurse practitioner, or physician assistant. Route the caller to a licensed nurse.
• Diagnose or prescribe — You may report signs (“Resident’s left ankle is swollen and warm”), but you do not name a disease or recommend a drug.
• Change the care plan independently — You may suggest observations to the nurse; you do not rewrite goals, discontinue therapies, or invent new treatments.
• Perform invasive assessments reserved for licensed staff — deep wound assessment, IV management, and similar licensed functions stay with the nurse.

If a co-worker or family member pressures you outside scope, the correct response is always: stop, explain the limit, and notify the licensed nurse. Scope violations can end a career and harm residents.

Chain of Command in Delaware Nursing Facilities

Delaware nursing homes and similar facilities organize clinical decision-making so problems escalate efficiently. For day-to-day care questions, the nurse aide’s first clinical contact is usually the charge nurse or assigned RN/LPN. That person can reassign tasks, clarify the care plan, assess the resident, call the provider, or escalate to the unit manager or Director of Nursing.

A practical chain for clinical issues often looks like:

1. You (CNA) observe and act within assignment.
2. Charge nurse / licensed nurse receives report and directs next steps.
3. Unit manager / supervisor handles unresolved unit-level problems.
4. Director of Nursing (DON) and facility administration address systemic or serious safety issues.
5. Outside the facility, DHCQ and the long-term care ombudsman address regulatory and rights concerns through formal channels.

Do not skip the licensed nurse for clinical changes simply because a family member is insistent or another department is convenient. Skipping chain of command delays care and confuses accountability. Non-clinical issues (supplies, schedules) may go to a different supervisor, but resident condition always goes to nursing first.

The Care Plan Is the Law of the Assignment

Every resident has an individualized care plan developed by the interdisciplinary team and driven by nursing assessment. For the CNA, the care plan answers: What assistance level? Which diet? Fall risk? Transfer method? Preferred bath time? Communication needs? When the written assignment and the care plan conflict with a casual verbal request, follow the care plan and ask the nurse to resolve the conflict.

Examples of care-plan-driven decisions:

• A resident is “stand-pivot with gait belt and one assist”—you do not switch to a full mechanical lift alone without nursing direction.
• A resident is NPO for a procedure—you do not give water “because they asked.”
• A resident prefers a female aide for perineal care—you honor that preference whenever staffing allows and report barriers.

When you are unsure, the exam-safe and practice-safe rule is: ask before you act. Uncertainty is not a failure; guessing outside the plan is.

Personal Responsibility: Body Mechanics and Self-Care

Scope includes protecting yourself so you can protect others. Delaware skills testing and workplace safety both expect:

• Body mechanics — Bend at the hips and knees, keep the load close, avoid twisting, raise the bed to a working height, and use friction-reducing devices and mechanical lifts when indicated.
• Team lifts — Get help rather than forcing a transfer that risks a fall or a back injury.
• Self-care — Sleep, hydration, appropriate footwear, and reporting your own injury or illness that could impair safe care.
• Injury prevention culture — Use gait belts correctly, lock wheels, clear pathways, and never sacrifice technique for speed.

A CNA with a preventable back injury cannot answer call lights. Personal responsibility is professional responsibility.

Putting Scope Into Everyday Practice

A strong Delaware CNA starts the shift by reviewing assignments and care-plan notes, completes ADLs and vitals as ordered, watches for change, documents and reports accurately, and stays inside legal limits even under time pressure. On the Prometric exam, choose the option that keeps the resident safe, follows the nurse’s direction and care plan, and refuses illegal or untrained tasks. That pattern is the heart of Domain I.