DELEGATION

Author: Alene Burke RN, MSN
2 Contact Hours
Alene Burke & Associates is approved as a provider of Continuing Education by the Florida Board of Nursing, Provider # 50-2502


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DESCRIPTION:

This course will provide the learner with the knowledge, skills and abilities they need to safely and appropriately delegate aspects of patient care to others.

The scope of this course includes some guidelines for delegation and things that must be considered when delegating patient care to others. The content includes roles and aspects of care that cannot be delegated, following up on delegated roles, professional practice acts, scopes of practice, job or position descriptions, competency assessment and validation, the challenges associated with delegating to unlicensed assistive personnel and delegating during staffing shortages as well as the process of effective delegation.

OBJECTIVES:

At the conclusion of this course, the learner will be able to:
  1. Detail the legal, scope of practice, standards of care and competency aspects that must be considered and incorporated into delegation decisions.
  2. Discuss various roles that can and cannot be delegated to others, including unlicensed, assistive personnel.
  3. Relate the process of delegation, follow up, and how to delegate to unlicensed staff, especially when staff shortages are present.

INTRODUCTION

As a young child, many of us heard from our parents, teachers and others that they would make a great nurse, psychologist, pharmacist, teacher or doctor. These comments from our superiors indicated that we most likely possessed some characteristics and traits that they thought were associated with these professions. Perhaps these people thought that we would make a good nurse because we cared about others and their well-being. They may have thought that you would make a great doctor or pharmacist because they saw that you had a love for chemistry and the physiology of the human body. Some of these characteristics may have been noticeable and even obvious when you were quite young and inexperienced.

These characteristics may have led us to our current career in healthcare, however, possessing these qualities and characteristics alone were certainly not enough to make us the professional that we are today. We went to school, studied hard and then graduated. After graduation we took our state licensing exam and then began our professional career. We were clearly not born as a nurse. We had to work hard and study hard to become one. There also is no such thing as a born doctor, pharmacist, psychologist or teacher. There is also no such phenomenon as being a "born leader". We were not born as a supervisor or manager. This too takes hard work, the acquisition of knowledge and a commitment. Leadership skills must be learned in the same manner that the art and science of nursing has to learned.

Many nurses are asked to supervise others and/or become a nurse manager of a patient care unit because they have been identified by their superiors as a good candidate for supervision as based on their record of superior clinical competence, consistent dependability and their potential to perform well in this new leadership role. As with other skills, the art and the science of supervision and leadership are learned skills. They are not innate or instinctual. Although there are many aspects of leadership and supervision, this course will focus on the delegation aspects.

This course will provide you with the knowledge necessary to safely, efficiently, legally and competently delegate to others in the healthcare setting as you perform your leadership role. Take our Supervision for RNs or our Supervision for LPNs course in order to learn more about the other aspects of the leadership role in nursing.

CHARACTERISTICS OF POTENTIAL LEADERS

Some of the characteristics and traits of leaders include:

WHAT IS DELEGATION?

Simply stated, delegation is the art of giving others a part of your authority so that they can perform certain tasks. Delegation is necessary in healthcare and the corporate world so that an entire job can complement the efforts of others so that they can get a job done. Without delegation, everything would have to be done by one solitary individual and not a team or group of people.

Supervisors delegate part of their authority so that others can perform their job. These subordinates also accept the responsibility and accountability to get their part of the entire job done in the correct manner. Supervisors cannot abdicate their total responsibility; they remain ultimately responsible for the entire job and all aspects of it despite the fact that they have delegated to others. The supervisor is held accountable and responsible for delegating aspects of the job in a legal and optimal manner.

AREAS THAT MUST BE CONSIDERED WHEN DELEGATING TO OTHERS

Decisions regarding delegation are probably the most critically important decisions that supervisors make. Effective and appropriate delegation of tasks and roles to others often leads to success and a job well done. Ineffective and inappropriate delegation can lead to abysmal failure and a job not done well at all.

Delegation in the corporate world is often the defining factor when it comes to the ability of the company to be profitable and enjoy financial success or to be confronted with bankruptcy and dissolution despite the best intentions of everyone to survive. Delegation in the healthcare environment is often the defining factor when it comes to whether or not a healthcare facility will be respected and known for their ability to deliver safe and effective healthcare services or to be known for poor care and unsafe practices.

Here are some examples. When a corporate vice president in charge of manufacturing toys delegates aspects of the entire manufacturing job to others in an appropriate manner the productivity level should be high and the number of errors should be small or even nonexistent. On the other hand, productivity will be low and the number of defective toys will increase if this vice president delegates jobs to people that are not competent to do it or when those workers, who are alone able to perform one or more complex aspects of the job, are assigned to do other things so that they do not have the time to do those complex aspects of the job then failure is certain.

Similar positive and negative outcomes result from the appropriateness of delegation in the healthcare environment. For example, when a charge nurse delegates aspects of patient care outside the scope of practice of a subordinate, the patient is subjected to unnecessary physical jeopardy. The outcomes could be life threatening. Also, when a charge nurse delegates multiple aspects of care, other than admission and ongoing assessments, to the only subordinate who can legally assess patients, it is likely that the assessments will not be done and that complete care, according to established standards, will not been rendered to the group of patients that we are responsible for.

Quality patient care is contingent upon proper, appropriate delegation. Appropriate delegation requires that the supervisor have a thorough knowledge of the patients and their healthcare needs, the staff and their scopes of practice, laws, job descriptions, policies and procedures and competencies.

Some of the major areas of consideration that must enter into the equation of professional judgment which adds up to successful delegation and a job well done include: The Needs of the Healthcare Consumer

Successful delegation carefully and accurately balances the needs of the healthcare consumer with the abilities and competencies of the staff that will be fulfilling these needs, within the constraints of the law and according to established standards.

Some of our clients have healthcare needs that are simple; others are complex. Some needs are somewhat predictable; others are not. Some needs are acute and/or rarely encountered and others are chronic and more frequently encountered. Some needs require high levels of professional judgment and others are somewhat routinized. For example, the needs of a elderly person in the home with complex acute healthcare needs coupled with chronic co-morbidities require higher levels of professional judgment and skill than is needed when a person with a chronic disorder is care for in a structured long term care environment with residents having similar chronic disorders, such as diabetes and coronary heart disease.

The elderly person in the home must have the provision of quality care and services based on the complexities of: In addition to the fact that home care patients have complex needs in a complex environment, the care is also provided in an environment without the 24-hour a day administrative support that is present in a hospital or nursing home. Needless to say, the care of a home care patient with complex acute and chronic needs is something that should be delegated to a highly experienced and qualified registered nurse.

Now, lets consider some acute care hospital delegation scenarios. The maternity and newborn areas of a hospital are probably the least complex and the most predictable patient care areas in a hospital. With few exceptions pregnant women have their babies with either an uneventful, normal vaginal delivery or a Caesarian section and most babies are born without medical concerns. The goal of care for these healthy newborns is to facilitate their adaptation to extrauterine life. On the other hand, the emergency department is probably the most complex and unpredictable area in a hospital. Patients typically present in the emergency room with an unpredicted healthcare problem or concern, such as a motor vehicle accident or a ruptured aortic aneurysm. Multiple problems are common and continuous professional judgment is needed.

Some aspects of care for the pregnant woman, the newborn baby and even the emergency room admissions can be delegated to licensed practical nurses, nursing assistants and other unlicensed, assistive personnel. However, there are many needs, particularly those associated with the emergency room patients, that cannot be met by all members of the nursing team.

For example, the nursing assistant can take vital signs for emergency room admissions. They can also assist the new mother to ambulate and bathe the newborn providing they are competent to do so. However, neither the nursing assistant nor the licensed practical nurse can perform ongoing assessments of the newborn or the new mother. Additionally, the licensed practical nurse can administer some medications to emergency room admissions under some circumstances, however, the licensed practical nurse cannot assume the responsibility of the total care of these new admissions because their healthcare problems, at least initially, are often unpredictable and outside of the scope of practice for the licensed practical nurse.

Legal Issues and Aspects

Healthcare professionals who delegate to others must be completely informed about the state's scope of practice and its practice acts for each of their team members. Delegated tasks must be congruent and consistent with what the individual can and cannot do according to their state's scope of practice or practice act. These legal statements exist for all professions in all states of our nation.

Read the practice act for your state. Florida State's Nurse Practice Act is included below as a sample. As you are reading, pay particular attention to the different roles, responsibilities and tasks that each of the licensed and unlicensed team members are permitted to do by law, as defined by the practice act of your state.

If you are licensed in the State of Florida, read the Nurse Practice Act below. If you are licensed outside of the State of Florida contact your state and ask for their practice act by using the link below.

http://www.allnursingschools.com/faqs/boards.php?src=goto320

FLORIDA STATUTES CHAPTER 464
NURSING
PART I
NURSE PRACTICE ACT (ss. 464.001-464.027)

The Purpose of the Nurse Practice Act

464.002 Purpose.--The sole legislative purpose in enacting this part is to ensure that every nurse practicing in this state meets minimum requirements for safe practice. It is the legislative intent that nurses who fall below minimum competency or who otherwise present a danger to the public shall be prohibited from practicing in this state.

464.003 Definitions (3)(a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to:

1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others.

2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments.

3. The supervision and teaching of other personnel in the theory and performance of any of the above acts.

"Practice of practical nursing" means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist.

The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing.
(b) Advanced or specialized nursing practice" means, in addition to the practice of professional nursing, the performance of advanced-level nursing acts approved by the board which, by virtue of post basic specialized education, training, and experience, are proper to be performed by an advanced registered nurse practitioner. Within the context of advanced or specialized nursing practice, the advanced registered nurse practitioner may perform acts of nursing diagnosis and nursing treatment of alterations of the health status. The advanced registered nurse practitioner may also perform acts of medical diagnosis and treatment, prescription, and operation which are identified and approved by a joint committee composed of three members appointed by the Board of Nursing, two of whom shall be advanced registered nurse practitioners; three members appointed by the Board of Medicine, two of whom shall have had work experience with advanced registered nurse practitioners; and the secretary of the department or the secretary's designee. Each committee member appointed by a board shall be appointed to a term of 4 years unless a shorter term is required to establish or maintain staggered terms. The Board of Nursing shall adopt rules authorizing the performance of any such acts approved by the joint committee. Unless otherwise specified by the joint committee, such acts shall be performed under the general supervision of a practitioner licensed under chapter 458, chapter 459, or chapter 466 within the framework of standing protocols which identify the medical acts to be performed and the conditions for their performance. The department may, by rule, require that a copy of the protocol be filed with the department along with the notice required by s. 458.348.
 
(d) "Nursing diagnosis" means the observation and evaluation of physical or mental conditions, behaviors, signs and symptoms of illness, and reactions to treatment and the determination as to whether such conditions, signs, symptoms, and reactions represent a deviation from normal.
 
(e) "Nursing treatment" means the establishment and implementation of a nursing regimen for the care and comfort of individuals, the prevention of illness, and the education, restoration, and maintenance of health.
 
(4) "Registered nurse" means any person licensed in this state to practice professional nursing.
 
(5) "Licensed practical nurse" means any person licensed in this state to practice practical nursing.
 
(6) "Advanced registered nurse practitioner" means any person licensed in this state to practice professional nursing and certified in advanced or specialized nursing practice. " (Florida Statutes 464.001-464.027)

The legally permissible practice roles of the registered professional nurse and the licensed practical nurse are clearly delineated in the above Florida State Nurse Practice Act.

The registered professional nurse, or RN, has nursing diagnosis, planning, the evaluation of care, health teaching and counseling within their exclusive domain of practice. These aspects of care are not included in the Florida State Nurse Practice Act for licensed practical nurses. Therefore, these aspects of care cannot be legally delegated to the licensed practical nurse and certainly not to unlicensed, assistive personnel. Only registered nurses can perform these roles.

The licensed practical nurse, or LPN, can, however, perform "selected acts" under the direction of a registered nurse or another licensed healthcare professional, such as a licensed physician or dentist.

The nurse practice acts of our nation's states do not include the scope of practice for unlicensed, assistive personnel, such as nursing assistants. However, all states do have other statutes, or laws, that lay out the scope of practice for these personnel.

Among the tasks that can be delegated to unlicensed assistive personnel, such as nursing assistants, patient care technicians, and personal care aides, include: The following tasks cannot be delegated to unlicensed, assistive personnel (UAP). Aspects of care that require nursing judgment cannot be delegated to unlicensed, assistive staff under any circumstances. This prohibition is expressed in the Florida State Rules of the Board of Nursing Chapter 64B9-14 and in other states of the nation.

Some examples of tasks that cannot be legally delegated to unlicensed assistive personnel include: The Phase of the Nursing Process

The nursing process consists of four phases:
  1. assessment,
     
  2. planning,
     
  3. implementation and
     
  4. evaluation.
Only registered nurses can perform a nursing assessment and arrive at a nursing diagnosis. Licensed practical nurses can collect data and contribute to the assessment, however, the assessment process and the nursing diagnosis is under the exclusive domain of practice for the registered nurse. Unlicensed, assistive personnel can assist with data collection and they can also observe the patient's condition and report their observations to the registered nurse.

Only registered nurses can plan care for the client. Again, the licensed practical nurse and unlicensed, assistive staff can contribute their input, but the planning process, including the establishment of short term and long-term goals, is within the exclusive domain of the registered nurse.

All members of the nursing care team can participate in the implementation of care, according to their scope of practice, established policies and procedures, and their level of competency. For example, nursing assistants, licensed practical nurses and registered nurses can bathe, ambulate and feed patients. Licensed practical nurses and registered nurses can provide interventions that require sterile technique and they can also administer most medications. Nursing assistants are not permitted to provide treatments that require sterile technique and they are not permitted to administer medications.

Established Policies and Procedures

Established standards of care and established policies and procedures within the healthcare facility must also be considered and incorporated into decisions regarding the delegation of aspects of care to staff.;

For example, some medications, such as IV push medications, can only given by registered nurses in specific areas of the hospital like the intensive care unit and the emergency room. These medications are sometimes also restricted to only registered nurses and only in some areas, as per the healthcare facility's established policies and procedures. Other interventions that may be restricted to only registered nurses and/or only in certain patient care areas include: Position or Job Descriptions

Obtain and thoroughly review the job or position descriptions and competency checklists for all the job titles you supervise. These should be readily available from the nursing department or your human resources department.

When you delegate and supervise others, you must know not only what is legally permissible for each job title to do, but also what your facility has formally deemed as acceptable practice for each job title and, additionally, what each person has been deemed competent to do.

The Abilities and Competencies of Staff

When delegating aspects of care, it is also essential to consider the abilities and competencies of staff. In the past it was the process of education and training that was considered a priority, not the outcomes of this education and training. For example, external bodies like the Joint Commission on the Accreditation of Healthcare Organizations used to focus on how many classes a person attended or did not attend and what the content of these courses or classes consisted of. That has changed.

Beginning in the early 1990s this external regulatory body and others began to concentrate on the outcome of education in terms of competency, rather than focusing on the process of attending a class or course.

Attending a class does not necessarily equate to competence; attending a class may not impart knowledge. Some people attend classes and do not even devote their attention to the class. They may knit, chat with others and even sleep. Bottom sitting in class is no longer satisfactory, according to the Joint Commission on the Accreditation of Healthcare Organizations and common sense. It is the translation of this knowledge into practice that counts in terms of patient care and patient outcomes. It is competent practice that must be seriously considered when an aspect of care or service is delegated to others.

All healthcare facilities and agencies must now assess and validate competency before total care or any aspect of care is performed by an individual without the direct supervision of another, regardless of their years of experience.

Competency checklists, which document the competency of the staff, are "living documents" that must be referred to as assignments are made. They do not serve this purpose when they are locked away in the file cabinet of the nurse manager when a weekend or "off shift" supervisor has to make decisions about care. They must be accessible to those who assign care. Care can be delegated to another only when that person is deemed competent to perform the role or task and this competency is documented.

Knowing your team members and their abilities are essential to delegation. Each and every individual in the team is different and unique. Some may be expert in all aspects of the care or service that are provided by the nursing team, or other group. Other staff members may only be expert or competent in some aspects of care at the same time they are weak and not proficient in other aspects of care. Still others may be minimally competent and without the same knowledge and skills that other members of the team possess.

For example, a new graduate nurse or pharmacist cannot be expected to be proficient in all aspects of their job. A lot of teaching, coaching and guidance are needed initially. As the new graduate matures professionally and amasses more skills, and confidence, they will be able to gradually assume more complex and more numerous duties with a higher degree of precision and proficiency. Additionally, all members of the team are not equally proficient in all aspects of the total job to be done. We should be cognizant of who is the best person for the job as we continue to coach, teach and guide others to achieve the same level of proficiency.

Lastly, staff members may have personal preferences for certain aspects of their job. If at all possible these personal preferences should be accommodated for provided they are consistent with the client needs, the law, established policies, procedures, job descriptions and the competencies of the individual. For example, if a team member does not enjoy rountinized tasks like taking vital signs, but they do enjoy planning and implementing patient teaching, then attempt to accommodate these preferences as much as possible while insuring an appropriate, fair, equitable, challenging and satisfying assignment for all of the other members of your team.

Below is sample competency checklist relating to the role of the RN in terms of supervision.


Competency Checklist: RN Supervision

The registered nurse (RN) nurse has consistently, accurately and appropriately:
1. ________ delegated tasks and patient care activities to registered nurses, licensed practical or vocational nurses, nursing assistants and other unlicensed healthcare providers, as based on the patient's or resident's current condition, the healthcare provider's scope of practice, the facility's policies and procedures and the documented competency of the healthcare provider
2. ________ developed assignments that are fair, equitable and sound
3. ________ directed, led, supervised and managed the members of the patient care team
4. ________ empowered the members of the patient care team
5. ________ employed effective motivational and negotiation skills
6. ________ utilized communication, team building, problem solving and conflict resolution techniques
7. ________ served as a change agent
8. ________ measured and accepted responsibility for the optimal performance of the group
9. ________ evaluated the performance of those supervised
10. ________ employed time management skills

DELEGATING CARE TO NONLICENSED, ASSISTIVE STAFF

The implications of supervision and delegation are loaded with challenges and legal concerns, particularly with the emergence of new unlicensed assistive personnel with widely varying roles from healthcare facility to healthcare facility. Some unlicensed personnel are certified and regulated by the state but others are simply credentialed within a particular health care facility, and not licensed or certified by the state. These unlicensed, uncertified assistive personnel, therefore, are not regulated by the state, but only by the facility that is training and employing them.

Nurses, pharmacists, physical therapists, occupational therapists and other professionals work with and supervise unlicensed, assistive staff, including but not limited to nursing assistants, personal care assistants, telemetry aides, physical or occupational therapy assistants, pharmacy technicians, restorative aides, etc.

Some of these job titles include nontraditional functions that have historically been assigned to others. For example, a patient care assistant may perform venipuncture, something typically done by a laboratory technician, EKGs, a skill usually performed by an EKG technician, patient transportation, rehabilitation or restorative care and/or telemetry monitoring.

All of these numerous job titles and roles require supervision and delegation by the healthcare professional, typically a nurse, pharmacist, physical or occupational therapist. As a result, it is the licensed healthcare professional (nurse, pharmacist, physical or occupational therapist) the independent practitioner, who is held ultimately accountable for all aspects of care delegated to other members of the health care team, including unlicensed assistive personnel. This responsibility can lead to significantly disastrous results if supervision and delegation is not done according to provisions of the law.

Unlicensed personnel have appeared on the scene because the cost of health care has skyrocketed to such a degree that is no longer cost-effective to employ an all licensed staff. Additional driving forces for these unlicensed positions are associated with the shortages of healthcare workers nationwide. In order to deliver care to the public, healthcare organizations and corporations have created new categories of unlicensed workers to insure the provision of healthcare in an economically feasible manner. These unlicensed, assistive staff cannot work independently - these positions were created to assist, NOT replace the nurse, pharmacist, physical or occupational therapist. Unlicensed personnel do not perform professional functions, that is, those functions that require professional judgment; they perform routine, highly structured, assistive functions, as delegated, under the direct supervision of the licensed professional.

In 1992 and 1997, the American Nurses Association published two position papers to address the delegation issues associated with unlicensed, assistive personnel. These position statements can also provide guidance to other disciplines whose national organizations have not formally addressed this concern. The two American Nurses Association (ANA) position papers are:
  1. Registered Nurse Utilization of Unlicensed Assistive Personnel (1997) and
     
  2. Registered Nurse Education Relating To The Utilization of Unlicensed Assistive Personnel (1992).
The following terms are clearly defined in both documents, as follows:
  1. "UNLICENSED ASSISTIVE PERSONNEL: An unlicensed individual who is trained to function in an assistive role to the licensed registered nurse in the provision of patient/client care activities as delegated by the nurse. The term includes, but is not limited to nurses aides, orderlies, assistants, attendants, or technicians.
     
  2. TECHNICIAN: A technician is a skilled worker who has specialized training or education in a specific area, preferably with a technological interface. If the role provides direct care of supports the provision of direct care (Monitor tech, ER tech, GI tech) it should be under the supervision of a Registered Nurse.
     
  3. DIRECT PATIENT CARE ACTIVITIES: Direct patient care activities assist the patient/client in meeting basic human needs within the institution, at home or other health care settings. This includes activities such as assisting such as assisting the patient with feeding, drinking, ambulating, grooming, toileting, dressing, and socializing. It may involve the collecting, reporting, and documentation of data related to the above activities. This data is reported to the RN who uses the information to make a clinical judgment about patient care. Delegated activities to the UAP do not include health counseling, teaching or require independent, specialized nursing knowledge, skill or judgment.* (*Judgment as it relates to the above definitions is defined as the intellectual process that a nurse exercises in forming an opinion and reaching a clinical decision based upon an analysis of the evidence or data.)
     
  4. INDIRECT PATIENT CARE ACTIVITIES: Indirect patient care activities are necessary to support the patient and their environment, and only incidentally involve direct patient contact. These activities assist in providing a clean, efficient, and safe patient care milieu and typically encompass chore services, companion care, housekeeping, transporting, clerical, stocking, and maintenance tasks.
     
  5. DELEGATION: The transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome. Example: the nurse, in delegating an activity to an unlicensed individual, transfers the responsibility for the performance of the activity but retains professional accountability for the overall care.
     
  6. ASSIGNMENT: The downward or lateral transfer of both the responsibility and accountability of an activity from one individual to another. The lateral or downward transfer must be made to an individual of skill, knowledge and judgment. The activity must be within the individuals scope of practice.
     
  7. SUPERVISION: The active process of directing, guiding and influencing the outcome of an individual's performance of an activity. Supervision is generally categorized as on-site (the nurse being physically present or immediately available while the activity is being performed) or off-site (the nurse has the ability to provide direction through various means of written and verbal communication." (American Nurses Association, 1992, 1997)
The American Nurses Association (ANA) recognizes the need for unlicensed, assistive personnel, however, this group is also aware of the fact that some of these personnel are performing outside of their scope of practice and, therefore, violating the states' nurse practice acts as well as jeopardizing the safety of the healthcare consumer.

They advocate for clear and appropriate roles and job descriptions for unlicensed assistive personnel (UAPs) including the functions they can perform in direct patient care, including their appropriate utilization for toileting, grooming, feeding, ambulation, drinking, positioning, toileting, socialization, dressing, collecting, reporting and documentation of data related to these activities and the functions they can appropriately perform in indirect patient care, including environmental roles that facilitate an efficient, clean, and safe patient care with housekeeping, stocking, clerical and transporting. Nurses can delegate responsibility for a function to an unlicensed assistive staff member but they still retain full accountability for the outcome. Specialized professional judgment and skills cannot be delegated to such staff (American Nurses Association, 1997).

The American Nurses Association has also addressed the need for the educational preparation of professional nurses who delegate to others, including unlicensed assistive personnel. This educational preparation must address the legal aspects of delegation including a thorough education about what nursing is and what constitutes the practice of nursing and: Many states, including New York, have addressed the issue of unlicensed staff in official position papers. According to the nursing practice act in New York State, a nurse is guilty of unprofessional conduct if the nurse delegates inappropriate responsibilities to another person "when the licensee delegating such responsibilities knows or has reason to know that such person is not qualified, by training, by experience or by licensure, to perform them." (New York State Nurses Association,1986) The licensed nurse must use judicious decision making when delegating tasks to others. The nurse is ultimately responsible for all delegated tasks and functions. (New York State Nurses Association, 1986)

In a Position Paper written by the New York State Nurses Association, the nurse "bears responsibility for nursing practice based on specialized knowledge, judgment and skill derived from principles of basic and applied sciences; remains accountable when delegating nursing activities and uses nursing judgment to decide what task can be delegated and to whom it is delegated; is accountable for the unlicensed person's performance of nursing related activities and the consequences of the delegated action; has the responsibility to verify the preparation and ability of unlicensed personnel; distinguishes between the nurse's responsibilities and those of unlicensed personnel; and is responsible for developing, implementing and evaluating the plan of nursing care." (New York State Nurses Association, 1986).

These statements are highly similar to, if not identical to, those position statements of the American Nurses Association and other states in reference to unlicensed personnel.

Professionals and nonlicensed personnel cannot and should not perform the same tasks and roles. It is the responsibility of the professional to assess the total group, for example, the total nursing care needs of the group being cared for, and to identify those tasks which can be appropriately delegated to nursing aides, nursing assistants and other unlicensed personnel.

DELEGATING CARE WITH STAFFING SHORTAGES

During 1992, the American Nurses Association in collaboration with the National Federation of Licensed Practical Nursing, Inc. and the National Council of State Boards of Nursing published a position paper entitled "Maintaining Professional and Legal Standards During a Shortage of Nursing Personnel", in response to the nursing shortage. The goal of this collaborative statement was to insure continued access to safe nursing care and to address the increasing demand for nurses during the crisis of a shortage. Again, the same principles and guidance can be applied to other healthcare professions in addition to nursing.

According to the American Nurses Association (1992), nursing shortages are a direct response to the laws of supply and demand. Generally speaking the response to shortages include: Although these initiatives are often successful, they sometimes need additional supports, such as governmental or professional regulation, in order for them to achieve the optimal outcome of safe, quality healthcare. For example, a less prepared and skilled nurse or physical therapist will be injected into the healthcare workforce when entry level preparation requirements are lowered beyond the extent that they insure patient safety. Additional problems and concerns, such as described above, can arise when unlicensed, assistive personnel move into the scope of practice for the professional. (American Nurses Association, 1992)

With their concern about the safety of the consuming public, the American Nurses Association, the National Federation of Licensed Practical Nursing, Inc. and the National Council of State Boards of Nursing raise the possibility of jeopardy if we permitted: Shortages in healthcare are serious and complex. Decreasing standards jeopardize care and decreasing number of staff to provide care also jeopardizes care. There is no easy and simple solution, especially when the safety of the public is at stake and the gravity of unintended consequences can jeopardize life itself. (American Nurses Association, 1992)

This position paper opposes " the delivery of nursing care by non-nursing personnel who are not under the supervision of a licensed nurse; the substitution of licensed nurses with unlicensed personnel; the unnecessary creation of a new categories of health care personnel as well as other efforts that serve to fragment care; the lowering of established legal standards designed to prohibit the licensure of persons who have not demonstrated competence to practice nursing; and the lowering of professional nursing standards that exist to ensure accountability of nurses for safe and effective nursing practice." (American Nurses Association, 1992)

The American Nurses Association, the National Federation of Licensed Practical Nurses, Inc., and the National Council of State Boards of Nursing "strongly support solutions to the nursing shortage that maintain and expand the efficient utilization and employment of existing licensed nurses. These organizations support registered and practical/vocational nursing education and registered and practical/vocational nursing licensure. Coordinated efforts to promote nursing and to ensure an adequate supply of nurses in the future will serve both the public and nursing's best interests." (American Nurses Association, 1992)

"For these reasons, professional nursing will continue to: (1) closely monitor and address quality of care concerns through organizational and educational channels, and (2) promptly report violations of nurse practice acts to the state boards of nursing. State boards of nursing will continue to: (1) promulgate and enforce rules and regulations that protect the public from unsafe and ineffective nursing practice and (2) take corrective action against those individuals whose activities violate the respective state nurses practice acts. The American Nurses Association, the National Federation of Licensed Practical Nurse, Inc., and the National Council of State Boards of Nursing believe that such activities, which require a cooperative spirit between those who practice nursing and those who regulate it, are needed to maintain the public's trust, health, safety, and welfare during the current nursing shortage. "(American Nurses Association, 1992)

SUMMARY

Florida State Rules of the Board of Nursing 64B9-14.002 states that "total nursing care responsibility remains with the qualified nurse delegating the task or assignment for supervision."

Here are some basic rules to follow in reference to the assignment of care and the delegation of patient care responsibilities:
  1. Assign and delegate only those tasks that are permissible according to state law, federal regulations and your facility's policies and procedures.
     
  2. Because the person delegating is still ultimately responsible and accountable, closely supervise and follow up on delegated tasks. If something is done incorrectly or a patient is harmed, it is the person who has delegated that is ultimately responsible.
     
  3. Assign the right person to the right job. Assess patients to insure that you are delegating the appropriate tasks based on the patient's condition and the abilities of the staff. Base assignments on the patient's current condition and the competency or skills of the staff members.
     
  4. Monitor the patient for responses to the care provided by others and document those responses in a complete and timely manner.
     
  5. Regularly follow up and monitor the performance of all those you supervise. Corrective action must be immediately taken if someone is not performing according to established standards.

REFERENCES

American Nurses Association (1992). Registered Nurse Education Relating To The Utilization of Unlicensed Assistive Personnel. [cited 2000 May 6], Available from: URL:
http://nursingworld.org/readroom/position/uap/uaprned.htm

American Nurses Association (1997). Registered Nurse Utilization of Unlicensed Assistive Personnel. [cited 2000 May 6], Available from: URL:
http://www.nursingworld.org/readroom/position/uap/uapuse.htm

New York State Nurses Association Board of Directors (1986). Position Paper. [cited 2000 May 6], Available from: URL:
http://www.nysna.org/pga/nps/position/position26.htm

Contact Hours: 2
Price: $15.00
Course Title: DELEGATION
Course Number: 20-59367

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