Nursing Delegation& Practice Boundaries

Will your license be stretched by delegation? Know your boundaries!

Decisions related to delegation of nursing tasks are based on the principle of protection of the health, safety and welfare of the public. Boards of Nursing are responsible for the regulation of nursingA licensed nurse has the ultimate responsibility and accountability for the management and provision and delegation of nursing care.

The Basis for Decision Making Process

Decision Making Process cont.Unlicensed assistive personnel (UAPs) are equipped to assist--not replace--the nurseThe licensed nurse's specialized education, professional judgment and discretion are essential for quality nursing care. A task delegated to an (UAP) cannot be re-delegated by the unlicensed assistive person.

There is a greater need for increased delegation of skills because of:increased use of UAPs,increased need for RNs/ decreased numbers of RNs available,increased acuity of care,increased number of elderly,increased number of very sick, young & old

(continued)increased technology, number & type of technologists,corporate downsizing to decrease cost,client-to-home faster to decrease costs, increased availability of information on www,accelerated pace of changing health care technology, &increased # of physician specialists.

Nurse Practice Acts for the RN usually include the :Assessment process,Diagnosis of nursing or collaborative problems,Creating a plan of care,Defining outcomes,Selection of nursing interventions,Choosing who will complete nursing interventions (delegation), &Evaluating the plan of care. Retains responsibility/ accountability for plan of care & its delivery.

The Delegation Process

Accountability: Being responsible and answerable for actions or inactions of self or others in the context of delegation.Delegation: Transferring to a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains accountability for the delegation.Delegator: The person making the delegation.Delegatee: The person receiving the delegation. (a.k.a. Delegate)Supervision: The provision of guidance or direction, evaluation and follow-up by the licensed nurse for accomplishment of a nursing task delegated to unlicensed assistive personnel.Unlicensed Assistive Personnel (UAP): Any unlicensed personnel, regardless of title, to whom nursing tasks are delegated.

Definitions

When any nurse delegates they are:accountable to the patient,accountable to the State Board of Nursing,accountable to their peers;accountable to the employer;required by law to practice within the State Nurse Practice Act,required to practice within their job description,ethically and possibly legally required to report unsafe delegatory issues.

The licensed nurse determines and is accountable for the appropriateness of delegated nursing tasks. Inappropriate delegation by the nurse and/or unauthorized performance of nursing tasks by UAPs may lead to legal action against the licensed nurse and/or UAP.

Acceptable Use of the Authority to Delegate The delegating nurse is responsible for an individualized assessment of the patient/situational circumstances, & for knowing the competence of the delegatee before delegating any task. The decision to delegate must be based on careful analysis of the patient's needs and circumstances. Supervision, monitoring, evaluation and follow-up by the nurse are crucial components of delegation. The delegatee is accountable for accepting the delegation and for his/her own actions in carrying out the task.The following must not be delegatedAssessmentEvaluation Nursing judgment ( any task that doesnt have a certain or stable outcome)

The Five Rights of Delegation

Right Task One that is delegable for a specific patient. Right Circumstances Appropriate patient setting, available resources, and other relevant factors considered. Right Person Right person is delegating the right task to the right person to be performed on the right person. Right Direction/Communication Clear, concise description of the task, including its objective, limits and expectations. Right Supervision Appropriate monitoring, evaluation, intervention, as needed, and feedback.

Considerations for DelegationDelegation criteria Nursing Practice Act Permits delegation Authorizes task(s) to be delegated or authorizes the nurse to decide delegationDelegator qualifications within scope of authority to delegate Appropriate education, skills and experience Documented/demonstrated evidence of current competencyDelegatee qualifications Appropriate education, training, skills and experience Documented/demonstrated evidence of current competency

The Steps to the Delegation Process

Assess the situation Identify the needs of the patient, consulting the plan of care Consider the circumstances/setting Assure the availability of adequate resources, including supervision

The process cont.

Plan for the specific task(s) to be delegated Specify the nature of each task and the knowledge and skills required to perform it Require documentation or demonstration of current competence by the delegatee for each task Determine the implications for the patient, other patients, and significant others

The process cont.

Assure appropriate accountability As delegator, accept accountability for performance of the task(s) Verify that delegatee accepts the delegation and the accountability for carrying out the task correctly

The process cont.

Supervise performance of the task Provide directions and clear expectations of how the task(s) is to be performed Monitor performance of the task(s) to assure compliance to established standards of practice, policies and procedures Intervene if necessary Ensure appropriate documentation of the task(s)

The process cont.

Evaluate the entire delegation process Evaluate the patient Evaluate the performance of the task(s) Obtain and provide feedback Reassess and adjust the overall plan of care as needed

Potential for harm? great or smallComplexity of task? simple or difficultProblem solving needed? minimal or maximumUnpredictability of outcome? stable or unstableLevel of interaction required with client? simple or complex (Refer to the NCSBN Delegation Decision Tree) AACN Key Factors to Consider before Delegating?

American Nurses Association says RNs cant delegate:Initial nursing assessment & subsequent assessment if nursing judgement is needed;Decisions/judgements about the nursing diagnoses;Decisions/judgements about outcomes;Determining & approving of plan of care; Interventions that require professional nursing knowledge, decisions, or skill; &Decisions/judgements of the evaluation of care.

Activities That May Be Outside the Scope of Practice for the LPNAdministering infusions of blood/blood products;Administering infusions of total parenteral nutrition;Administering infusions of chemotherapeutic or antineoplastic agents;Administration of IV therapy to neonates.Administration of IV push medications.Mixing IV medications.Initiation of TPN in peripheral or arterial lines.Ongoing administration of TPN in central lines.

(continued)Programming or setting certain types infusion pumps, i.e. PCA Pumps, Epidural PumpsDiscontinuing central or arterial lines. Arterial puncture and management of arterial lines.Advanced Cardiac Life Support (ACLS).Expanded roles that are performed outside of facilities;Leading group therapy.

RNLPNUAPAssessmentTeaching from standard care planActivities of daily livingNursing diagnosisVital signsHygienePlanning & implementingPass medications except those specifiedSpecimen collection, I&O, vital signsIV lines, blood and TPN admin.Maintain IV lines, start IVs with trainingDocumentation of I&O, V/S

Barriers to Successful DelegationUnderdelegationOverdelegationChoosing a person who lack skills, education or ability to perform taskDelegation by defaultPoor timingPoor communication'" I can do this myself attitude

Acts or Condition(s) That Would Be Evidence of Inappropriate DelegationInadequate direct assessment of needs or circumstances,Incomplete estimation of competence of delegatee,Foreseeable harm- the possibility that tasks assigned would not be performed safely under the circumstances. (www.ncsbn.org/files/delegati.html)

When the State Board of Nursingmay hold the nurse accountable ?

Foreseeable harm was present.Patient may or may not suffer physical or psychological harm.A standard of care is breeched.Actions do not follow those of a reasonable nurse.Practice does not follow the states Nurse Practice Act.Advisory Opinions or guidelines from the state BON are not followed. (Are not law, but are a guideline directly from them).

All decisions related to delegation of nursing tasks must be based on the fundamental principle of protection of the health, safety and welfare of the public. Boards of Nursing are responsible for the regulation of nursing. Provision of any care which constitutes nursing or any activity represented as nursing is a regulatory responsibility of Boards of Nursing. Boards of Nursing should articulate clear principles for delegation, augmented by clearly defined guidelines for delegation decisions. A licensed nurse must have ultimate responsibility and accountability for the management and provision of nursing care. A licensed nurse must be actively involved in and be accountable for all managerial decisions, policy making and practices related to the delegation of nursing care. There is a need and a place for competent, appropriately supervised, unlicensed assistive personnel in the delivery of affordable, quality health care. However, it must be remembered that unlicensed assistive personnel are equipped to assist--not replace--the nurse. Nursing is a knowledge-based process discipline and cannot be reduced solely to a list of tasks. The licensed nurse's specialized education, professional judgment and discretion are essential for quality nursing care. While nursing tasks may be delegated, the licensed nurse's generalist knowledge of patient care indicates that the practice-pervasive functions of assessment, evaluation and nursing judgment must not be delegated. A task delegated to an unlicensed assistive person cannot be redelegated by the unlicensed assistive person. Consumers have a right to health care that meets legal standards of care. Thus, when a nursing task is delegated, the task must be performed in accord with established standards of practice, policies and procedures. The licensed nurse determines and is accountable for the appropriateness of delegated nursing tasks. Inappropriate delegation by the nurse and/or unauthorized performance of nursing tasks by unlicensed assistive personnel may lead to legal action against the licensed nurse and/or unlicensed assistive personnel

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