Scope of Practice, Delegation, and Chain of Command

Understanding Scope of Practice

Scope of practice defines the procedures, actions, and processes that a healthcare practitioner is permitted to undertake in keeping with the terms of their professional license. For a New Hampshire LNA, this scope is defined by RSA 326-B and the Board of Nursing. Staying within your scope is not merely a suggestion; it is a legal mandate that protects residents from harm and protects you from liability.

The core of the LNA role is providing direct, hands-on care and serving as the eyes and ears of the nursing staff.

Tasks generally WITHIN the LNA scope include:

• Assisting with Activities of Daily Living (ADLs): bathing, dressing, grooming, eating, and toileting.
• Measuring and recording vital signs: temperature, pulse, respirations, blood pressure, and pain levels.
• Measuring intake and output (I&O).
• Assisting with mobility: turning, repositioning, transferring, and ambulating.
• Applying non-sterile dressings or warm/cold compresses (depending on facility policy).
• Observing changes in a resident's physical or mental condition and reporting them promptly.

Tasks strictly OUTSIDE the LNA scope include:

• Administering medications of any kind (including over-the-counter drugs, oxygen, or topical creams), unless the LNA holds an MNA license and is acting under MNA rules.
• Performing sterile procedures, such as inserting Foley catheters or changing sterile surgical dressings.
• Assessing a resident's condition or diagnosing a medical problem.
• Taking verbal or telephone orders from a physician, NP, or PA.
• Discussing a resident's diagnosis, prognosis, or treatment plan with the resident's family.
• Inserting or removing IVs, feeding tubes, or artificial airways.

If you are asked to perform a task outside your scope, you must politely but firmly refuse. Saying 'the nurse told me to do it' will not protect your license if a resident is harmed while you were performing an out-of-scope task.

The Delegation Process

LNAs do not practice independently. Every task you perform for a resident is done under the delegated authority of a licensed nurse (an RN, or in some settings, an LPN). Delegation means that a nurse authorizes a competent LNA to perform a specific nursing task for a specific resident in a specific situation.

While the LNA is responsible for performing the task correctly and safely, the nurse retains ultimate accountability for the outcome. Because of this, nurses use a critical thinking process known as the Five Rights of Delegation before assigning a task:

1. Right Task: Is this task legally within the LNA's scope, and is it appropriate for this specific resident?
2. Right Circumstance: Is the resident's condition stable? (Unstable residents require direct nurse care).
3. Right Person: Has this specific LNA been trained and checked off as competent to perform this task?
4. Right Direction/Communication: Has the nurse provided clear instructions, including what to observe and when to report back?
5. Right Supervision/Evaluation: Will the nurse be available to monitor the outcome and evaluate the results?

As an LNA, you have a reciprocal duty in the delegation process. If a nurse delegates a task that you have not been trained to do, or if you feel the resident's condition has changed making the task unsafe, you have a professional obligation to inform the nurse and refuse the delegation.

The Chain of Command

Healthcare facilities are structured hierarchically to ensure accountability, safety, and clear communication. This structure is known as the Chain of Command. It is the formal line of authority and communication within the organization.

In a typical long-term care facility, the chain of command for an LNA looks like this:

1. LNA (You)
2. Charge Nurse / Staff Nurse (RN or LPN)
3. Nursing Supervisor / Unit Manager
4. Director of Nursing (DON)
5. Facility Administrator
6. Medical Director

The most critical rule regarding the chain of command is that you must follow it step-by-step. Your direct supervisor is the Charge Nurse. All observations, reports of condition changes, resident complaints, or requests for help must go to the Charge Nurse first.

Common Chain of Command Errors:

• Bypassing the nurse: An LNA notices a resident's blood pressure is dangerously high and immediately calls the resident's doctor. This is a severe violation. The LNA must report the vital signs to the Charge Nurse, who will assess the resident and contact the physician.
• Reporting to peers: An LNA tells another LNA that a resident has a new skin tear but forgets to tell the nurse. The nurse cannot update the care plan or apply treatment if they don't know about it.
• Delaying reports: Waiting until the end of a shift to report that a resident vomited or complained of chest pain. Urgent changes must be reported immediately.

If you report a serious issue to your Charge Nurse and they ignore it or take no action, you are then obligated to move one step up the chain (e.g., to the Nursing Supervisor) to ensure the resident's safety. However, always start with your direct supervisor.