Test Delegation in Practice: A Governance Framework for Nurses and Midwives

This Delegation in Practice Framework is designed to support the nurses/midwives to practically apply existing professional guidance within multiprofessional, cross‑agency teams. It also seeks to strengthen partnership working with the person receiving care and support, promoting a risk‑enabled, empowering approach that enhances their choice, control, and involvement in decision‑making.

This Framework for nursing and midwifery delegation will:

• satisfy the requirements of the NMC Code;
• support risk enablement in the delivery of person-centred outcomes for people drawing on care and support;
• work in primary, secondary and community care contexts;
• support practice delegated to staff working within an employed capacity e.g. domiciliary, healthcare support staff, classroom education support staff and Personal Assistants;
• utilise an approach that informs effective and consistent decision making; and
• support co-ordination of care across professions, teams and agencies in partnership with the person receiving health care interventions.

Delegation for the purposes of this framework, is defined as the process by which a nurse or midwife (delegator) allocates clinical or non-clinical tasks and duties to a competent person (delegatee). The delegator remains accountable for the overall management of practice, for example, in a clinical context: the plan of care for a service user, and accountable for the decision to delegate. The delegator will not be accountable for the decisions and actions of the delegatee.

The NMC has established that on occasion nurses and midwives may delegate health care interventions to other registered nurses or midwives and others supporting health care interventions.  The purpose of delegation is to ensure the most appropriate use of skills within a health and social care team to achieve person-centred outcomes. In a clinical context, delegation of nursing and midwifery tasks and duties should always be focused on the needs and wishes of the person receiving care or services, and not based on professional, system or organisational drivers external to the care/service process.

Delegated healthcare activities are clinical interventions that would normally be carried out by a registered nurse/midwife,  but are formally delegated to a suitably trained and competent member of social care staff.

Examples may include:

• PEG feeding and enteral nutrition;
• Wound care;
• Tracheostomy care;
• Catheter management; and
• Stoma care.

The key word is delegated. These are not simply tasks/interventions that social care staff are trained to do. They are health care interventions delegated by a nurse/midwife who retains accountability for the outcome. This is a critical distinction.

Training Is Not Delegation

One of the most common misunderstandings, is confusing training with delegation.

For example:

A product representative from an enteral feeding company provides training on equipment. Staff complete a competency workbook. The service assumes delegation has occurred when it has not.

Nurse/Midwifery Health Care delegation requires:

• A named registered nurse/midwife professional;
• A decision that the intervention is appropriate to delegate;
• Assessment of the individual staff member’s competence;
• Clarity about accountability; and
• Ongoing review arrangements.

Supplier training, even when thorough, does not replace formal nurse delegation. This is where many services are unintentionally exposed.

Across the sector, the following patterns emerge:

• No clearly identified delegating healthcare professional;
• Supplier training assumed to equal delegation;
• Competency sign off completed once and never reviewed;
• Escalation arrangements informal or unclear;
• Delegated tasks embedded in practice but not formally documented; and
• Monthly governance audits not sampling delegation arrangements.

These are not dramatic failures. A drift often becomes visible, only during times of inspection.

For each delegated healthcare activity in your service, ask:

• Is there a named registered healthcare professional who has delegated this task?
• Is there written documentation confirming delegation?
• Is there a clear rationale explaining why delegation is appropriate?
• Have individual staff been assessed as competent by someone appropriately qualified?
• Is competence reassessed at defined intervals?
• Is there a written escalation pathway?
• Is the delegation reviewed periodically by the delegating professional?
• Are these arrangements audited as part of your monthly governance schedule?

Nurses and midwives play a vital role in ensuring that health care interventions are carried out safely, effectively and in a way that aligns with what matters most to the individual. They contribute directly to the development of a personalised care plan that:

• Reflects the person’s individual goals and health priorities;
• Clearly outlines required health care interventions and how they will be delivered;
• Sets expectations for monitoring, review and follow‑up; and
• Defines clear processes for escalation if a person’s condition changes.

The five steps outlined in the infographic figure 1, describe the principle activities in working collaboratively with other members of the care team to support health care.

By clarifying each step of the care journey and defining who is responsible for what nurses/midwives help provide transparency for both staff and the person receiving care. This structured approach enhances safety, reduces uncertainty, and ensures that everyone involved understands their role within the overall support plan.

A proactive, nurse‑led approach to coordinating health care interventions supports people to have greater choice, control, and confidence in their care. It also ensures they know which member of staff is expected to deliver each part of the intervention, strengthening continuity and trust.

Ultimately, this coordinated and person‑centred approach leads to better outcomes and improved experiences for individuals and their families.

Figure 1: Principle Activities for Coordinating Health Care Interventions (including Delegation)   ORIGINAL GRAPHIC TO GO IN

Step 1: Assess healthcare needs and goals

Step 2: Shared values and vision 

Step 3: Establish responsibility

Step 4: Implement a shared care plan

Step 5:  Monitor, follow up, and respond to change 

The Nursing and Midwifery Governance Framework for Delegation of Health Care Interventions recognises the importance of adhering to regulatory standards in a mulitprofessional and collaborative approach. Regulation covers both system‑level governance and professional regulatory standards, including the NMC Code, which guides nurses’ and midwives’ accountability, competence, delegation, communication, and conduct. Professional regulators set the standards for education, training, behaviour, and fitness to practise, ensuring practitioners work safely and within their scope. These regulatory frameworks support effective multidisciplinary collaboration by defining roles, clarifying scopes of practice, and guiding how delegation should occur across professions.

Key Considerations for Practice

When applying regulation within coordinated support plans or delegated care, nurses and midwives must consider:

Professional Codes of Practice, including the NMC Code and other professional Codes that apply to the Delegatee, considering how these shape accountability, communication, record‑keeping and safeguarding.

Regulations and service standards that support safe organisational decision‑making and aim to ensure health care interventions are delivered within governance frameworks. Regulatory Codes provide essential direction for safe delegation (and co-ordination of care) across professions, supporting shared decision‑making while ensuring accountability remains aligned to each practitioner’s regulatory requirements. This enables multidisciplinary teams to collaborate effectively while remaining compliant with their professional frameworks.

The Nursing and Midwifery Council (NMC)

The Nursing and Midwifery Council (2018) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates sets out expectations of people on the register when they delegate to others. These requirements apply regardless of who the activity is being delegated to. This may be another registered professional, a non-registered colleague, or a patient or carer. There is therefore the expectation that people on the NMC register are accountable for their decision to delegate interventions and duties to others, and to achieve this, they must:

• only delegate interventions and duties that are within the other person’s scope of competence, making sure that they fully understand the instruction;
• make sure that everyone they delegate interventions to are adequately supervised and supported so they can provide safe and compassionate care; and
• confirm that the outcome of any intervention delegated to someone else meets the required standard.

The NMC delegation-and-accountability-supplementary-information-to-the-nmc-code.pdf details the following definitions:-

• Delegation is defined as the transfer to a competent individual, of the authority to perform a specific task in a specified situation; and
• Accountability is the principle that individuals and organisations are responsible for their actions and may be required to explain them to others.

Delegation of tasks from one individual to another occurs commonly in all health and care settings. Delegation of an activity may be from: 

• one registered professional to another;
• a registered professional to an unregulated member of staff; or
• a registered or unregistered person to a carer or family member.

As registered professionals, nurses, midwives and nursing associates are accountable for all aspects of their practice, including accountability for what they choose to delegate, and agreement, or not, to undertake activities which are delegated to them.

What does this mean in practice?

If you’re delegating a task, it’s your responsibility to make sure that: 

• delegation does not harm the interests of people in your care;
• the task is within the other person’s scope of competence;
• the person you are delegating to understands the boundaries of their own competence;
• the person you are delegating to understands the task;
• the person you are delegating to is clear about the circumstances in which they must refer back to you;
• you take reasonable steps to identify any risks and whether any supervision might be necessary; and
• you take reasonable steps to monitor the outcome of the delegated task.

The NMC Code sets out the responsibilities of people on our register when they accept a delegated task. It states that nurses, midwives and nursing associates must, as appropriate:

• make sure that patient and public safety is not affected. You work within the limits of

your competence, exercising your professional ‘duty of candour’ and raising concerns; 

• immediately whenever you come across situations that put patients or public safety

at risk; 

• make a timely referral to another practitioner when any action, care or treatment is

required; and

• ask for help from a suitably qualified and experienced health and care professional

to carry out any action or procedure that is beyond the limits of your competence.

• complete the necessary training before carrying out a new role.

The NMC are currently reviewing the Code of Conduct and have committed to considering the issues raised by registrants regarding delegation within multidisciplinary teams. This includes the increasing number of people with complex care needs being cared for, in and out of hospital, by a wide range of health and social care practitioners.

NI Social Care Council: Regulation of Social Workers and Social Care Workers Standards and Guidance – NISCC

The Social Care Council Standards of Conduct and Practice for Social Care Workers (2015) sets out the standards required of social workers, including being accountable for the quality of work and taking responsibility for maintaining and improving knowledge and skills, this includes:

• Taking responsibility for work delegated to you, recognising and working within the limits of your knowledge, skills and experience;
• Recognising that you remain responsible for the work that you have delegated to other workers;
• Recognising and respecting the roles and expertise of workers from other disciplines and agencies and working in partnership with them; and
• Undertaking relevant training and learning to maintain and improve your knowledge and skills and meeting the Social Care Council Post Registration Training and Learning Requirements in line with your job role.

Why these matter for delegation by nurses and midwives?

The Nursing and Midwifery Governance Framework for Delegation of Health Care Interventions recognises the importance of regional and organisational policies and procedures to direct safe practice of delegation and multiprofessional collaboration in delivery of health care interventions. 

Legislation: Health care legislation in Northern Ireland provides the legal framework within which all health and social care activity must operate. Acts such as the Health and Social Care (Reform) Act (Northern Ireland) 2009 set out how services must be organised, delivered, and governed. Additional regulations apply in specialist areas including mental health, nursing agencies, and safeguarding vulnerable individuals. Employing organisations must ensure that all policies and procedures align with current legislation, including requirements linked to Self‑Directed Support (SDS) and Direct Payments (DPs).

When a nurse or midwife delegates a health care activity, they remain professionally accountable for the decision to delegate. Legislation, policies and procedures provide the legal and organisational safeguards that ensure delegation is:

• Lawful — preventing delegation of health care interventions that fall outside legal boundaries or the organisation’s remit;
• Safe — ensuring care is delivered by competent individuals under appropriate supervision;
• Consistent — ensuring that every delegated task follows an agreed, transparent process; and
• Defensible — protecting the nurse/midwife’s professional registration by demonstrating adherence to required standards.

These frameworks also help nurses and midwives make informed decisions about what can be delegated, to whom and under what conditions, reducing the risk of harm and supporting high‑quality care.

Policies and Procedures

Regional and organisational policies are essential in guiding nurses and midwives when they delegate healthcare interventions because they ensure safe, legal, consistent and accountable practice. Delegation is a core part of nursing and midwifery practice, but it must be done safely. Regional and organisational policies and procedures provide the framework that makes this possible. Policies and procedures are essential because they:

• Provide a standardised approach to risk enablement, safety, financial probity, quality and experience;
• Clarify expectations for safe and appropriate delegation across professions and agencies; and
• Support consistent practice and ensure all staff understand their roles and responsibilities.

What needs to be considered?

• Clear employer policies aligned to legislation, setting out lines of professional accountability to support safe multidisciplinary and multi-agency working.
• Implementation of support frameworks, training pathways and policy initiatives that guide decision‑making around delegation and working in multidisciplinary teams to ensure right care is provided by the right person with the right skills to best meet the needs of the population health.

The Nursing and Midwifery Governance Framework for Delegation of Health Care Interventions recognises the importance of transparent and open communication across people receiving care and those providing it. Organisations must establish robust communication processes to ensure delivery of safe, effective and person‑centred delegation and coordination of health care interventions across professions and agencies and with the person (people important to them) receiving the care. These processes should enable multi‑professional teams to collaborate seamlessly, agree roles and responsibilities and maintain shared accountability for care delivery. Effective communication mechanisms must also support the development of co‑produced and consented care plans, ensuring that people are fully involved in decisions about their care at all times within their care experience.

People often receive care from more than one service, organisation, hospital teams, community, or voluntary organisations. In addition, they receiving input to their health care from a range of professions e.g.  nursing, social care, mental health services, GPs etc.

Clear communication ensures:

1. Continuity and Coordination of Care:

• Everyone understands their role.
• Delegated health care interventions are carried out correctly and on time.
• No part of the health care plan is duplicated or missed.
• Avoids gaps or delays in care, especially during transitions (e.g., hospital discharge to community services).

2. Safe Practice:

• Risks are shared and understood.
• The person receiving care, condition and needs are known.
• Any changes to care needs are relayed promptly.

3. Clarification of Roles, Responsibilities and Accountability:

• Who is responsible for each part of the health care intervention.
• Who supervises health care delegated interventions.
• Who evaluates health care outcomes.

4. Supports Appropriate Health Care Delegation Decisions which considers:

• Training and competency levels of the person delivering the care.
• Capacity and workload.
• Organisational policies and scope of practice of each staff member’s role.

5. Improves the Person Receiving the Care Experience and Person‑Centred Care:

• Open and transparent across all care agencies, practitioners and the person receiving care.
• Well-organised and Seamless.
• Responsive to their needs and wishes.

6. Supports Legal, Ethical, and Professional Standards

• Consent and confidentiality are respected.
• Documentation is shared appropriately.
• Practice aligns with NMC standards and local policies.

7. Enables Fast Response to Changes or  Deterioration:

• Rapid escalation to the appropriate person with the right skills to respond.
• Adjustment of delegated health care interventions.
• Re‑assessment of risk and mitigating actions.

 What Needs to Be Considered?

• A clearly defined organisational communications plan outlining procedures for delegation and health care coordination decisions.
• Identification and use of a full range of communication mechanisms that promote effective multi‑professional/multi-agency collaboration, including electronic systems.
• Communication processes that outline safe and transparent pathways for delegation, which enables coordination of health care interventions, supporting duty of care, risk management and meaningful involvement of the person receiving care.
• An organisational culture that fosters collective leadership, supporting shared decision‑making across all levels, including the person receiving health care.
• Structures that enable cross‑sector and cross‑departmental working, ensuring continuity across health, social care, education and community settings.
• Clear and identifiable professional lines of escalation and feedback to support timely and appropriate responses to emerging concerns/changing needs.
• Robust record‑keeping and reporting mechanisms, which may include multi‑professional, multi-agency care/support plans and shared documentation systems.
• Opportunities for people who receive care, to co‑produce and contribute to records of their care, reinforcing transparency, empowerment and person‑centred practice.

The Nursing and Midwifery Governance Framework for Delegation of Health Care Interventions recognises the importance of joint workforce planning in delivery of safe and effective, person centred care to meet the needs of the population.  Understanding what the multiprofessional workforce requirements are, both now and in the future, is essential to meeting the increasingly complex health and social care needs of people living at home and across community settings. This includes ensuring an appropriate skill‑mix and that all staff contributing to health care interventions are trained, competent and well supported.

As population needs evolve and workforce shortages emerge, nurses and midwives play a central role in shaping skill‑mix and designing systems that maintain safe health care delivery. This requires robust mechanisms to assure the competence of the wider team in the delivery of delegated interventions. Policy makers and employers must set clear practice standards and ensure that knowledge, skills and behavioural competencies are embedded across training, supervision, appraisal and ongoing professional development.

Nursing and midwifery staff must also be fully engaged and supported to develop the skills required for:

• Delegation;
• Allocation to care providers or services;
• Referrals to relevant professionals or services; and
• Advising on appropriate health care interventions.

What needs to be considered?

• Workforce Roles, Scope and Clarity:
  • Clear job descriptions outlining roles, responsibilities that reflect commonly health care delegation responsibilities.
  • Adherence to minimum standards, scope of practice and organisational policies governing collaborative health care delivery.
  • Interprofessional awareness training to ensure all staff understand each other’s roles, capabilities and contributions.
• Competence, Skills and Training:
  • Competence development across all staffing groups to promote confidence in skill‑mix and safe health care delegation.
  • Delegation training embedded in nursing and midwifery pre‑ and post‑registration programmes, induction and ongoing professional development.
  • Joint training opportunities for NMC‑registered and unregistered staff on safe delegation and competency assessment.
• Supervision, Support and Professional Development:
  • Appropriate supervision and appraisal processes for all staff involved in collaborative working to maintain safe practice standards.
  • Consistent monitoring and review arrangements to ensure ongoing competence in those allocating, delegating, supervising and delivering delegated interventions.
• Governance, Assurance and Regulation:
  • Monitoring compliance with regulatory requirements (e.g., RQIA) and with contractual obligations when working with independent or third‑sector providers.
  • Robust mechanisms to assure competence, ensuring safe delivery of delegated health care interventions across multiprofessional teams.
  • Commitment to organisational oversight, with policies that support safe, accountable delegation practices.
• Person‑Centred and Shared Decision‑Making:
  • A commitment to shared decision‑making, ensuring people receiving care are empowered and supported in their choice and control.

Care planning informed by collaborative practice, ensuring interventions are appropriate, safe and aligned with individual needs and preferences.

The Nursing and Midwifery Governance Framework for Delegation of Health Care Interventions recognises that nurses and midwives play a central role in evaluating, monitoring and continually improving health care delegation through collaborative working as part of the multidisciplinary team.

Effective evaluation aims to ensure that decisions about the coordination and delegation of health care interventions remain safe, effective and person‑centred. Nursing and midwifery leadership is critical in identifying whether care arrangements are delivering the intended outcomes, maintaining standards and ensuring that learning is embedded across teams and services.

What Needs to Be Considered?

• Stakeholder Feedback: Nurses and midwives should actively gather and use feedback from people receiving care, families and colleagues to understand the safety, quality and effectiveness of delegated health care decisions.
• Outcome Measures: Short‑term and long‑term indicators should be in place to track experience, quality and safety outcomes, ensuring any gaps in delegation of health care are identified early.
• Record‑keeping Systems: Evaluation must align with professional and organisational documentation standards so that decision‑making processes for delegation, are transparent, traceable and auditable.
• Peer Review Opportunities: Multidisciplinary peer review across Health and Social Care (HSC) Trusts can strengthen shared learning and highlight improvements in practice.
• A Shared Evaluative Framework: Teams should use an agreed framework that supports consistent evaluation of delegated health care decisions across organisations in Northern Ireland.
• Training for Evaluation: Nurses, midwives and wider team members require training in evaluation methods to support effective implementation and interpretation of findings.
• Standardised Recording Frameworks: Consistent systems for documenting care across statutory, independent, voluntary and education providers support continuity, quality assurance of safe delegation.
• Quality Improvement Methods: Small‑scale quality improvement activities should be encouraged to support continuous learning about how delegation and coordination functions across professions/agencies.
• Inclusion in Existing Evaluation Programmes: Evaluative work on delegation of health care, such as service-user experience studies, should be integrated into wider organisational processes (e.g., initiatives like 10,000 Voices).
• Support for Raising Concerns: Mechanisms such as the Patient and Client Council should be available to ensure individuals can easily raise concerns about delegated health care, supporting a culture of openness and safety.

The Nursing and Midwifery Governance Framework for Delegation of Health Care Interventions is based on shared operational principles, person-centred values and leadership behaviours designed to facilitate choice, control and flexibility.

Effective and sustainable collective leadership offers us a real opportunity for creating a culture of high quality, continually improving, compassionate care and support.

Underpinning such collective leadership are the core values and associated behaviours adopted by Health and Social Care (HSC) in Northern Ireland. These values provide clarity for all health and social care staff, on the behaviours expected, ultimately reassuring people who use our services about the care and support that they can expect, and how this should be delivered.  Useful resources for collective leadership can be found:

https://www.health-ni.gov.uk/publications/hsc-collective-leadership-strategy

Leadership: A Collective Leadership Framework for Nursing and Midwifery | NIPEC

• Working Together 

Working together ensures collaborative working across the HSC, with organisations, agencies, and education providers, people and carers recognising that leadership is the responsibility of all. Meaningful recognition of the contribution that others can make requires taking time to listen to different viewpoints, to achieve equal partnership. Strong relationships support working across traditional boundaries. Within the context of multi-professional health care coordination this means ensuring a common goal and vision for how health and social care is delivered to each individual. Strategies for working together include having mechanisms in place for staff and people engagement in the decisions and outcomes of interventions, developing clear processes to enable feedback, having effective communication channels and learning together.

• Compassion 

Compassion is demonstrated through a sensitive, caring and respectful approach towards people and colleagues. Demonstrating kindness in interactions enhances every contact with people, ensuring they feel valued and listened to, even in situations where they may not agree or like what is being said. Key components include listening to understand, care for others, inclusivity, accessibility of information and language, and self-care. A compassionate approach identifies where there are concerns about how health care  is being managed and seeks to improve practice. A learning organisation that promotes supervision supports a compassionate approach to coordination of care.

• Excellence

Excellence commits to best practice in coordination of care, striving towards continuous improvement through shared learning and evidence informed practice to achieve positive change. In the context of multi-professional collaboration, it should demonstrate how stakeholders intend to deliver safe, high quality, compassionate care and support.

People receiving health and social care should be at the centre of discussions and decisions about their health care. Responsibility for decision making is shared across professions and with the people involved. Excellence means that monitoring and review of outcomes demonstrates impact and informs improvement.

• Openness and Honesty

Openness and honesty requires staff and people to have conversations based on mutual respect. Being open means sharing professional views, experience and expertise, particularly to improve the care being delivered. Collaboration across boundaries in an open and honest way requires everyone to challenge unacceptable behaviour and practice. It also requires an honest appraisal of the skills and competence of the health care professional and the social care practitioner.  Working with transparency supports understanding and respect for everyone’s contribution enhancing people’s experience of the service being delivered.

We will maximise people’s health and wellbeing by:

• Ensuring people are supported to stay well
• Supporting people to make their own choices
• Engaging people in positive health behavioural change

We will deliver SAFE, evidence-based quality of care by:

• Improving the experience of care through development of excellence in person-centred practice
• Ensuring safety by preventing avoidable harm (physical and psychological)
• Developing healthful workplace cultures

We will value our people and ensure safe and effective staffing by:

• Ensuring practitioners are provided with the support and supervision to undertake their roles safely and effectively
• Providing staff with support and time for continuous professional development
• Embedding mechanisms to provide safe, adequate levels of staffing ensuring the well-being of our staff

We will provide everyone with the opportunity to reach their full potential by:

• Identifying and reducing health inequalities
• Providing equal access to training and career development across professions (including undergraduate students)
• Collaborating with communities and services to meet the needs of individuals

We will deliver value and ensure effective stewardship of all resources by:

• Exploring innovative solutions to improve timely access to services
• Making the best use of our resources
• Embedding sustainability in all activities and partnerships to provide co-ordinated care across boundaries