HEAD 2 TOE

DELEGATION OF NURSING TASKS IN

THE SCHOOL SETTING

MAY 9, 2013

J A N I E L E E H A L L B S N R N

N W R E G I O N S C H O O L H E A L T H A D V O C A T E

N M D O H - P U B L I C H E A L T H D I V I S I O N

K A Y E W H I T N E Y M S N R N

A S S O C I A T E D I R E C T O R O F E D U C A T I O N / U A P

N E W M E X I C O B O A R D O F N U R S I N G

AMERICAN NURSES ASSOCIATION (ANA) AND

NATIONAL COUNCIL OF STATE BOARDS OF NURSING (NCSBN)

JOINT STATEMENT (2006)

The abilities to delegate, assign, and supervise are critical

competencies for the 21st century nurse.

Delegation is a process that, used appropriately, can result in

safe and effective nursing care.

Delegation can free the nurse for more complex

patient care needs, develop the skills of nursing

assistive personnel, and promote cost-

containment for the healthcare organization.

Why do you think

delegation is important

in the school setting?

NATIONAL ASSOCIATION OF SCHOOL NURSES

(NASN) POSITION STATEMENT (2010)

It is the position of NASN that the delegation of

nursing tasks in the school setting can be a

valuable tool, when based on the nursing

definition of delegation and in compliance with

state nursing regulations and guidance.

NASN (CONT…)

The decision to delegate and the supervision of the delegation of nursing tasks in the school setting rest solely with the registered nurse, who makes the determination to delegate based on nursing assessment and in compliance with applicable laws and guidance provided by professional nursing organizations.

NASN (CONT…)

Delegation in school nursing is a complex process

in the which the authority to perform a selected

nursing task is transferred to a competent

individual in a specific situation.

Sometimes referred as unlicensed assistive personnel (UAP)

NASN (CONT…)

The safety and welfare of the individual student and

the broader school community must be the central

focus of all decisions regarding the delegation of

nursing tasks & functions.

Would you share some of your most challenging

stories concerning delegation?

Would you share some of your most rewarding

stories concerning delegation?

NM BOARD OF NURSING RULES- STANDARDS

OF NURSING PRACTICE (16.12.2.12 NMAC)

B. The nurse shall assign/delegate to licensed and unlicensed

persons only those nursing actions which that person is

prepared, qualified or licensed or certified to perform.

1) The nurse is accountable for assessing the situation and

is responsible for the decision to delegate or make the

assignment.

NM BON STANDARDS OF NURSING PRACTICE (CONT…)

2) The delegating nurse is accountable for each activity

delegated, for supervising the delegated function or

activity, and for assessing the outcome of the delegated

function or activity;

3) The nurse may not delegate the specific functions of

nursing assessment, evaluation and nursing judgment to

non-licensed persons.

NMBON DEFINITIONS (16.12.2.7)

Assessment

The review and interpretation of a licensed individual of specific data

necessary to determine the patient’s/client’s care and treatment

needs (see also data collection)

Data Collection

The process of obtaining information, material, fact or clinical

observations which will be used in the assessment process; data

collection is not limited to licensed individuals

NMBON DEFINITIONS (CONT…)

Delegation

The transferring to a competent individual the authority to perform a

selected nursing task in a selected situation. The nurse retains

accountability of the delegation.

Supervision/Direction

Initial verification of a person’s knowledge and skills in the performance of

a specific function or activity, followed by periodic observation, direction

and evaluation of that person’s knowledge and skills as related to the

specific functions or activity.

DELEGATION DECISION TREE (NCSBN, 2005)

Step 1: Assessment & Planning

Step 2: Communication

Step 3: Surveillance & Supervision

Step 4: Evaluation & Feedback

STEP 1: ASSESSMENT & PLANNING

Are there laws/rules that support the delegation?

Is the task in the scope of the delegating nurse?

Has there been an assessment of the client needs?

Is the delegating nurse competent to make delegation decisions?

Is the task consistent with recommended criteria for delegation to UAP?

RECOMMENDED CRITERIA FOR DELEGATION TO UAP

Within UAP range of functions

Frequently recurs in daily care of the client or group of clients

Performed according to established sequence of steps

Involves little no modification from one situation to another

May be performed with a predictable outcome

Does not inherently involve ongoing assessment, interpretation, or decision-making, which cannot be logically separated from the procedure itself

Does not endanger a client’s life or well-being.

ASSESSMENT & PLANNING (CONT…)

Does the UAP have the appropriate knowledge, skills, and abilities

to accept the delegation?

Does the ability of the UAP match the care needs of the client?

Are there agency policies, procedures, and/or protocols in place for

this activity?

Is appropriate supervision available?

STEP 2: COMMUNICATION

Effective communication is built on mutual trust/respect, and must

be a two-way process.

The nurse provides clear written & verbal instructions, assesses UAP

understanding of how the task is to be accomplished & what info

is to be reported, and verifies individual competency & the

acceptance of the delegation.

COMMUNICATION

The UAP affirms understanding of the expectations,

asks questions, seeks clarification, requests

additional training & supervision as needed, and

determines communication/documentation

methods & the plan of action in emergency

situations with the nurse.

What can you do to build positive

relationships that promote effective

communication?

STEP 3: SURVEILLANCE & SUPERVISION

The nurse supervises the delegation by monitoring the performance of

the task or function, and assures compliance with standards of

practices, policies or procedures.

The nurse determines the frequency of onsite supervision and

assessment based on the needs of the client, the complexity of the

task, and the proximity of the nurse’s location.

The nurse is responsible for timely intervention & follow up of any

problems or concerns.

STEP 4: EVALUATION AND FEEDBACK

In considering the effectiveness of the delegation:

Was the delegation successful? Was the task performed correctly? Were the desired outcomes achieved?

Was communication timely & effective? Were there problems or concerns? How were they addressed?

Is there a better way to meet the client’s needs? Is there a need to adjust the plan of care? Were there any “learning moments” for the NAP/UAP or the nurse?

Was appropriate feedback provided to the NAP/UAP? Was the NAP/UAP acknowledged for accomplishing the task/activity?

5 RIGHTS OF DELEGATION (NSCBN, 1997)

Right Task

Right Circumstances

Right Person

Right Directions & Communication

Right Supervision & Evaluation

DELEGATION IN THE SCHOOL SETTING: IS IT A SAFE PRACTICE?

(RESHA, 2010)

School nurses can use their expert

assessment skills to appropriately

delegate health-related tasks and meet

the specific health care needs of

students, increasing access to a free &

appropriate education in the least

restrictive environment.

DELEGATION IN THE SCHOOL SETTING: IS IT A SAFE PRACTICE? (RESHA, 2010)

Delegation can be a valuable tool in meeting the growing

health needs of students, as long as the nurse and

the UAP (unlicensed assistive personnel) adhere to

established legal parameters, sound delegation

policies are in place, the “five rights” of delegation are

considered, education for both the nurse and UAP is

provided, and trust exists among all members of the

health care team.

A Few Legal Cases…

MITTS, CAROL V. HILLSBORO UNION HIGH (1987)

Case brought by health assistant who was assigned by principal (at the parent’s request) to perform clean intermittent catheterization on a student with spina bifida.

Court asked Oregon State Board of Nursing for a declaratory ruling.

Principal was found to be practicing nursing without a license, not so much because he assigned the task of CIC, but because he assumed responsibility for student health assessment, diagnosis & planning.

Health assistant found to be practicing nursing without a license because she accepted the principal’s directive.

School nurse disciplined for failing to make her own assessment & failing to comply with applicable delegation regulations.

MACOMB FEDERATION OF TEACHERS V. MACOMB INTERMEDIATE SCHOOL (1991)

Case brought by union in response to proposed “routine” delegation of

certain procedures (CIC, suctioning, etc) to teachers & paraprofessionals.

Court issued a permanent injunction against the school district’s plan—

reinforcing that the decision to delegate must be made by a professional

nurse, and that the delegator must meet the supervisory standard

(available for direct communication).

NANCE V. MATTHEWS (1993)

Case in which a special education aide failed to carry out urinary

catheterization (as delegated by the school nurse) on a student with spina

bifida--resulting in physical injuries and mental trauma.

Parents sued special education aide, school nurse, principal, and special

education director.

Suits were dismissed against all but the educational aide, because “the

delegation was within the scope of the supervisory nurse’s responsibility”,

and “no one could have predicted that the aide would neglect to carry out

the catheterization on that day”.

RESOURCES & TOOLS

Legal Issues in School Health Services (Nadine Schwab and Mary Gelfman, Sunrise River Press,

2001)

National Association of School Nurses www.nasn.org

NASN Position Paper on Delegation

ANA/NCSBN Joint Statement on Delegation

NCSBN: Working with Others A Position Paper

Delegation in the School Setting: Is it a Safe Practice? (OJIN, Cheryl Resha, 2010)

NM Board of Nursing Standards of Nursing Practice (16NMAC 12.2.12(B))

http://www.bon.state.nm.us/rules.php

NM School Health Manual, Section XVIII: Delegation of Health Services

www.nmschoolhealthmanual.org

Systems to Support Safe Delegation in New Mexico Schools (News and Views, Summer 2013,

Volume 7 (Number 3), Janie Lee Hall)