Delegation, scope of practice and a short-staffed night
It is 02:00 on a 24-bed surgical ward. You are the only registered nurse; the HCSW is a bank worker on her second shift, and there is no ward manager or coordinator on site. You have 24 patients, including two with complex wound care due at 06:00, one patient on hourly neuro observations after a head injury, and a post-op patient with a PCA who is due a set of observations. A patient presses the call bell with new chest pain. The HCSW asks you to 'just sign off' the fluid balance charts and observations she has not done because she is 'run off her feet'.
1. How do you prioritise and delegate safely in the next hour?
Read the worked answer
Prioritise by clinical risk; delegate only what is within the HCSW's competence and your accountability.
Immediate:
- Chest pain - assess now (ABCDE, pain score, ECG if trained/available, vital signs, escalate to the on-call doctor). This is the highest priority: possible cardiac event.
- Hourly neuro observations - do not let these lapse; a deteriorating head-injury patient is time-critical. Ask the HCSW to do the set of observations on the post-op PCA patient only if she is competent and has been shown; otherwise do them yourself in between.
- PCA observations - essential; respiratory depression is a risk. Do not delegate if the HCSW is not trained.
- Wound care at 06:00 - can wait; plan for after the immediate risks are managed.
Delegation principles (NMC Code):
- You remain accountable for the delegation. Delegate tasks, not responsibility.
- Only delegate to someone competent for that task; a second-shift bank HCSW may not be competent for complex observations or fluid balance interpretation.
- Give clear instructions, a time frame, and the boundaries of what to report back.
- Do not sign off care you did not do or verify. Falsifying records is a serious professional breach.
Escalate: call the nurse in charge/on-call manager about staffing; use the escalation policy. Document the staffing level and the actions taken.
2. The HCSW asks you to sign off charts she has not completed. How do you respond, and what are the professional issues?
Read the worked answer
Refuse clearly and kindly; offer a safe alternative.
- Do not sign. 'I can't sign for care that hasn't been done - it's not safe and it's not honest. Let's work out what we can do now.'
- Explore why - is she overwhelmed, unclear about the task, or not trained? Offer support, show her how, or reprioritise.
- Make a plan - identify which charts are outstanding, do the essential ones together, and document what was actually done and any gaps.
- Report the staffing and the gap to the nurse in charge/manager and via incident reporting if patient safety was compromised.
- If she has already falsified a record, escalate immediately - this is a fitness-to-practise concern for her and a patient safety risk.
Professional issues:
- Accountability - you are accountable for your own record-keeping and for what you delegate. Signing off false records is dishonest and could harm patients.
- NMC Code - be open and honest, keep clear and accurate records, and act without delay if you believe there is a risk to safety.
- Scope of practice - do not ask an HCSW to do tasks outside her competence; provide training and supervision.
- Record-keeping - records must be a true account of the care given.
Judgement: short staffing is a system problem, not a licence to falsify; escalate and document.