5.1 CNA Scope of Practice & Delegation

5.1 CNA Scope of Practice & Delegation

Understanding the CNA Scope of Practice

The Certified Nursing Assistant (CNA) plays a foundational role in direct patient care within long-term care facilities, hospitals, assisted living communities, and home health settings across Michigan. In Michigan, the CNA scope of practice is established by state regulations administered through the Department of Licensing and Regulatory Affairs (LARA) in alignment with federal Omnibus Budget Reconciliation Act (OBRA) guidelines. The core focus of the CNA role is executing delegated activities of daily living (ADLs) and routine nursing care under the direct oversight and direction of licensed nursing personnel—specifically Registered Nurses (RNs) and Licensed Practical Nurses (LPNs).

CNAs perform vital supportive duties, but state law establishes rigid boundaries regarding what tasks a nurse aide may legally perform. A CNA must never perform tasks requiring independent clinical judgment, complex decision-making, or invasive clinical skill. Understanding the exact boundary between allowed nursing assistant duties and prohibited licensed nursing actions is essential for maintaining resident safety, avoiding legal liability, and protecting professional certification.

Allowed vs. Prohibited CNA Duties

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The Role of Nurse Supervision and Nursing Judgment

Under Michigan law, nursing assistants do not hold an independent license; they operate as unlicensed assistive personnel (UAP) under the license of the supervising RN or LPN. Delegation is defined as the transfer of authority to perform a specific nursing task from a licensed nurse to a competent nursing assistant, while the delegating nurse retains accountability for the overall outcome.

Nursing care relies heavily on nursing judgment—the complex clinical reasoning process involving assessment, diagnosis, care planning, and evaluation. While a CNA collects valuable objective data (such as measuring a blood pressure reading of 160/98 mmHg), the CNA cannot diagnose hypertension or decide to withhold a medication. The CNA must immediately report objective findings to the supervising nurse, who then applies nursing judgment to analyze the data and modify the resident's care plan.

Legal Responsibility & Accountability

When a task is delegated, dual accountability exists:

1. The Licensed Nurse is accountable for assessing the resident, determining task appropriateness, verifying CNA competency, providing direction, and evaluating resident outcomes.
2. The CNA is accountable for executing the delegated task correctly according to established standards of care, recognizing personal limitations, and reporting changes or completion back to the nurse.

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The Five Rights of Delegation

To ensure resident safety, all delegation decisions must adhere to the Five Rights of Delegation. Both the supervising nurse and the CNA must understand these five principles before care is delivered.

1. Right Task: The task delegated must be within the CNA scope of practice, routine, predictable, non-invasive, and requiring no clinical assessment or nursing judgment (e.g., measuring routine vital signs or assisting with a bed bath).
2. Right Circumstance: The resident's condition must be stable. If a resident is experiencing acute chest pain or respiratory distress, delegating routine hygiene to a CNA is inappropriate; immediate licensed nurse assessment is required.
3. Right Person: The nurse must delegate to a CNA who has completed approved training and demonstrated competency for that specific task. Additionally, the task must be performed on the correct resident.
4. Right Direction and Communication: The delegating nurse must provide clear, concise instructions including specific parameters (e.g., "Please take Mr. Davis's blood pressure while he is seated and report to me immediately if the systolic is over 140").
5. Right Supervision and Evaluation: The nurse must provide appropriate oversight, remain available for guidance, monitor performance, and evaluate the resident's condition after task completion.

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How to Safely Decline or Clarify an Unsafe Delegation

A CNA has a legal, professional, and ethical obligation to decline a delegated task if performing it would compromise resident safety or violate state law. Refusing an unsafe assignment is not insubordination when handled professionally.

Step-by-Step Guide for Declining an Assignment

• Step 1: Evaluate the Request: Ask yourself: Is this in my job description? Was I trained to do this? Is the resident stable? Is it legal for a CNA in Michigan?
• Step 2: Communicate Calmly & Respectfully: Address the delegating nurse directly in private. State clearly that you cannot perform the task and explain the specific reason (e.g., "Nurse Sarah, I have not received clinical training on tracheostomy care, and it is outside the CNA scope of practice").
• Step 3: Offer a Safe Alternative: Reaffirm your commitment to resident care by offering an authorized task (e.g., "I am happy to assist you by holding the resident's shoulders while you perform the tracheostomy care").
• Step 4: Escalate If Necessary: If the nurse pressures or threatens you to perform an illegal or untrained procedure, report the situation immediately to the Charge Nurse, Nurse Supervisor, or Director of Nursing (DON).

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Clinical Scenarios & Real-World Application

Scenario A: Improper Delegation Request

Situation: During a busy morning shift, Nurse Bob hands CNA Marcus a bottle of eye drops and says, "Mrs. Adams needs her prescription glaucoma drops right now. Please instill 2 drops in her left eye while I finish this dressing change." Analysis: In Michigan long-term care facilities, CNAs are prohibited from administering prescription medications, including medicated eye drops. Marcus must politely inform Nurse Bob: "Nurse Bob, medication administration is outside the CNA scope of practice. I cannot give Mrs. Adams her eye drops, but I can assist her with getting dressed while you administer them."

Scenario B: Proper Delegation & Timely Reporting

Situation: Nurse Elena delegates routine 08:00 vital signs for resident Mr. Jenkins to CNA Maya. While measuring Mr. Jenkins's radial pulse, Maya counts 112 beats per minute (tachycardia) and notices Mr. Jenkins is sweating and complaining of feeling dizzy. Analysis: Maya performed a delegated task within her scope (taking vital signs). Recognizing abnormal findings and acute physical symptoms, Maya immediately reports the pulse rate of 112 bpm, diaphoresis, and dizziness to Nurse Elena. Nurse Elena promptly assesses Mr. Jenkins. Maya followed perfect protocol by collecting data within scope and escalating immediately to the licensed nurse.