Unlicensed assistive personnel (UAP) are providing care in a growing number of health care facilities as the need for accessible, affordable, quality health care increases. Nurses are qualified to promote health for their patients because of their nursing education and experience. Nurses need to be involved in making health care policies and decisions about the delivery of nursing care. Therefore nurses must take responsibility of delegation of nursing tasks to others. The National Council of State Boards of Nursing (NCSBN) has written a position paper that clarifies the position and responsibility of Boards of Nursing specifically as related to the issue of delegation by nurses of nursing tasks to unlicensed persons. This course will explore the concept delegation and clarify the responsibilities of the licensed nurse regarding delegation of nursing care of patients to the UAP. (NCSBN, 1995). The course will also present information about delegation related to Ohio Nursing Law and Rules in Chapter 4723-13 of the Ohio Administrative Code (OAC). This course meets the Ohio Board of Nursing (OBN) criteria for one contact hour of continuing nursing education on Ohio Nursing Law and Rules. Since there may be differences in other states those licensed nurses should investigate the Nursing Practice Act of the state in which they practice.
Jane is a new RN practicing in an extended care skilled nursing facility, Heavenly Health Care Nursing Home (HHCNH). Jane is one of four registered nurses who are responsible for the care of 50 residents who have varying health care needs. The facility also employs six licensed practical nurses (LPN) and a number of unlicensed assistive personnel (UAP) all of whom provide care for the 50 residents 24 hours a day and seven days a week.
The director of nursing, Margaret M., has indicated that when Jane RN is in charge she has been clocking in too much overtime on her time card. Margaret states that Jane must delegate more nursing tasks to the UAPs so that Jane can complete her duties in a timely manner. Jane discusses the issue with the other RN on duty and asks what else can the UAP do besides empty bedpans and give residents their morning shower. What is meant by delegation?
While this scenario may seem simplistic, the concerns related to delegation of responsibilities for patient care are numerous and complex. First of all one must understand the definitions of the terms being used.
Delegation is a means of getting a task done. Parents delegate responsibilities to their children like cleaning their room, or raking the lawn. In the work setting delegation is a management tool that allows workloads to be distributed and, furthermore, delegation is a legal concept used to "empower one to act for another" (Momentum, 1998). According to the Ohio Administrative Code (OAC), "Delegation means the transfer of responsibility for the performance of a selected nursing task from a licensed nurse authorized to perform the task to an individual who does not have the authority to perform the activity or task." (OAC 4723-13-01 C, based on rules in effect 5/2008)
The licensed nurse who is delegating the task must first of all be certain that the task is within the nurse?s scope of practice. The nurse cannot delegate that the UAP discontinue IV morphine since the physician has not ordered the IV to be discontinued and the UAP does not have the professional nursing knowledge to carry out this task. In this case neither the nurse nor the UAP have the authority to discontinue the IV morphine. Another example would be the nurse cannot ask the nursing assistant to perform a physical assessment on a patient as the UAP does not have the skill or professional nursing knowledge to carry out this task.
The term "licensed nurse" as used throughout this course means a registered nurse or a licensed practical nurse as both can delegate nursing tasks to unlicensed persons. However the RN has the authority to direct the LPN to delegate a nursing task or activity.
The term "direction" is used when referring to communication about plan of care by the registered nurse to the licensed practical nurse. It does not mean that the RN is supervising the LPN in an employment context. (OAC 4723-13-01 F, based on rules in effect 5/2008).
In addition a licensed practical nurse can delegate to a trained unlicensed person only at the direction of another licensed person such as the physician, or dentist, or registered nurse, etc. The nursing task being delegated must be within the knowledge, skill, and ability of the nurse (or other licensed person) and the nursing task must be within the training, ability, and skill of the trained unlicensed person who will perform the task. There must be in place support and resources for the management of the task and the licensed nurse must be available to provide adequate supervision for the performance of the task. Supervision of performance by a trained unlicensed person is discussed in more depth later in this course.
In the above scenario why would the new nurse, Jane, be reluctant to delegate more responsibilities to the UAP? Most frequently, the answer is the nurse fears loss of control. These fears are related to a misunderstanding about the nurse?s duty regarding delegation and confusing delegation with accountability and liability. Nurses may believe that their nursing license is in jeopardy if the UAP improperly performs the task. This is not the case as no one can "practice on another person?s license."
Accountability: Licensed nurse is accountable to perform an activity or task according to the acceptable and prevailing standards of safe nursing care.
Legality: The activity or task is within the scope of practice of the licensed nurse and not precluded by any other law or rule.
Liability: A risk to legal responsibility.
The nurse is accountable for the decision to delegate as well as whether there was adequate supervision and evaluation provided to the unlicensed person. Being held accountable does not mean that the nurse is necessarily "liable" in a legal sense. However, liability is always a risk if the nurse does not follow the established standards of care including principles of delegation.
Scope of Practice
To further understand the roles of the registered nurse (RN) and the licensed practical nurse (LPN) with respect to the delegation of nursing tasks, it is essential to clearly identify the scope of practice of each licensed nurse. The RN is licensed to perform independent functions in providing nursing care including:
- Assessing health status for the purpose of providing nursing care;