Most Western countries (Canada, USA, Great Britain and others) have introduced UAPs into their nursing teams. UAPs may appear under various names, such as unlicensed nursing personnel, patient care assistants and patient care aides. There are a variety of work settings in which this role can be found besides hospitals, and there is no uniformity in the scope of practice 1.

Despite the efforts of organizations such as the American Nursing Association (ANA) and the National Council of State Boards of Nursing (NCSBN) to regulate and define the scope of practice of UAPs, there is still ambiguity regarding the responsibilities and accountability of and within the nurse/UAP team in the provision of professional, safe and quality care 1.

The nursing literature often uses the terms "delegation" and "delegated authority" to define the professional interaction between a registered nurse and a UAP. By definition, delegation is the act of transferring the authority to perform a selected nursing task to a competent individual, while a registered nurse takes responsibility and accountability for this care 1.

Delegation is now an entry-level nursing practice skill requirement. Still, novice nurses report a lack of knowledge, skills, and attitudes for the delegation decision-making process. Learning delegation skills “on the go” is a common pattern. The literature reports that there is a gap between the expected skill levels and the actual abilities of new graduate nurses relative to delegation 34.

Delegation is a complex managerial skill that strongly affects all parties involved, i.e., the nurses, UAPs and patients 1. To provide quality and safe nursing care for their patients, nurses have to delegate the right task to the right person under the right circumstances with the right direction/communication and appropriate supervision.

The concept of delegation between nurses and UAPs, and the relationship between nurses and UAPs in clinical practice was not broadly studied since the new joint statements issued by the ANA and the NCSBN. Few studies were found in the literature regarding nursing delegation and the relationship between nurses and UAPs. Only few qualitative studies were found on this topic, of which, only one was qualitative in nature 5.

Studies have found that nurses report a lack of knowledge on how to properly delegate activities to UAPs and an insufficient knowledge regarding the UAPs training. Although still responsible for the comprehensive patient care, many nurses expressed frustration with multiple additional responsibilities unrelated to direct bedside care, even if they were assisted during the work by an UAP 6.

Despite the fact that UAPs participate in basic nurses' tasks, nurses have reported disappointment with the lack of time needed for highly professional nursing activities. However, nurses who reported to have good delegation skills were more satisfied with their work, and even reported of having more time to provide professional nursing activities 14.

Poor nursing managerial skills and poor delegation capabilities are reported to be the main cause of negative results or poor relationships between nurses and UAPs 789. Moreover, researchers 5 have found that nurses who reported of being more prepared to use delegation and supervisory skills also conveyed that positive experiences appeared more frequently. However, in the absence of regular direct supervision, more missed care events were reported.

The situation of delegation of tasks from nurses to UAPs is fairly new in Israel. Most Israeli nurses have not had any formal preparation on delegation principles either in nursing school or by specific on-the-job training programs.

Prior to the introduction of the Ministry of Health policy for nurses working with UAPs, the majority of nurses have reported favorable opinions on this issue. However, after the publication of the guidelines, nurses have reported that they expected difficulties both in guiding and in supervising the UAPs' work, as well as in their ability to execute their professional nursing duties 10 respective to other studies 5.

Based on the current international and national research, a better understanding of the collaborative relationship between nurses and UAPs, and what does this mean for nurses in clinical practice is needed. Since the knowledge on this issue is rare, the empirical qualitative approach is a better way to examine and comprehend in-depth the broad meaning of this concept from the nurses’ perspective.

The aim of this study is to describe, recognize and learn aspects regarding the working relationship between nurses and UAPs. This study seeks to explore the following research questions:

1. What are the nurses' perceptions on working with UAPs?

2. What influence UAPs have on: (A) Quality of nursing care delivered and (B)Working relationships?

3. What are the factors affecting the quality of professional interaction between nurses and UAPs?

We used the phenomenological method to describe, identify and learn aspects associated with the working environment of nurses and UAPs. Using the phenomenological methodology, the meaning and significance of the nurses’ experiences when working with UAPs were investigated in detail, since this method is designed to explore personal experience and is concerned with an individual’s personal perception. In-depth interviews with nurses were conducted in two large general hospitals in Jerusalem.

We used a wide purposive sample, representing a wide range of the nurse’s professional roles from different levels of education and responsibility. This sample was designed to provide rich, relevant and diverse data pertinent to the research questions. The study population included six nurses: four nurses at different managerial levels and two staff nurses from the internal medicine, surgical and orthopedic surgery departments. Sociodemographic characteristics are detailed in Table 1.

Inclusion criteria included nurses who were working regularly with UAPs. Data saturation was achieved based on this sample size. No new issues were raised after the last interview.

The study was approved by the Hadassah Medical Center Ethics committee. Participation in the study was voluntary. Participants were recruited through a brief phone call in which the study, its purposes and its methodology were introduced. Confidentiality was promised. There were no refusals to participate, nor any objections for recording the interviews.

All interviewees saw both positive and negative sides on working with UAPs. On the negative side, they raised concerns related to the decrease in their professional status of nursing since UAPs perform ”tasks that a nurse is supposed to do,”(P6) and the decrease of quality of nursing care provided by unskilled, non-professional staff.

On the positive side, first and foremost, all interviewees indicated a decline in the physical workload imposed on nurses. The expression "another pair of hands" was repeated in almost every interview (P3-6). Even among interviewees that expressed general discomfort with the process of working with UAPs, the overall feeling was that now, when the RN is required to do less physical work, “they are allowed more time to perform more professional tasks."(P5)

The "price" nurses need to pay for this process is to devote more time to managerial and supervisory activities. Many of the nurses felt that these activities took them away from the core of nursing – providing direct nursing care to patients--which deepened the distance between them and the patients:

Some nurses talked about the importance of supervision and monitoring of the UAPs’ work and perceived it as a managerial role: “Every nurse should be a manager ... not only the manager of patient’s treatment; she also has to manage the people she works with."(P4) However, none of the nurses felt that this role was empowering. Some nurses even saw it as a burden, not something that is really part of the process that would promote them in a professional or social aspect: "I feel like, unfortunately, a babysitter"(P5), "I feel like I constantly have to check things - was it done and was it done properly? It takes a lot of my energy."(P6)

A remarkable issue nurses noted as a result of this process is that patients received faster responses to their basic needs. Many mentioned that the response of the UAPs was not necessarily conducted on as a high professional level as it would have been had it been conducted by a nurse.

Since this study was based on the nurses’ perspective, future research is needed to examine the nurse-UAP relationship from the perspective of the UAPs.

Future research is needed to assess the nursing communication and management skills of both novice and experienced nurses.

There is a need to assess nursing outcomes as a result of the communication and the relationship level of the nurses and UAPs (such as: patient satisfaction, quality of care)

Future nursing interventions to improve relationships between nurses and UAPS is needed, accompanied with measures to evaluate the process.

There is a need to assess nursing educational programs of delegation skills on the communication of nurses and UAPs, and on the actual delegation practice in clinical settings.

The perception of the nursing role and nurses' responsibility while working with UAPs is not consistent among all nurses. In order to improve the quality of care given to patients and increase nurses' satisfaction, there is a need to: 1) strengthen the key role of the nurse in the patient care delivery pattern while working with UAPs 2) emphasize nurses' delegation skills 3) reinforce communication skills between nurses and UAPs and 4) designate specific management activities for maintaining the skills of the nurse-UAP team.