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Nurse delegation in LTC and assisted living

November 8, 2011
by Robert J. Lightfoot II, RN
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Before assigning duties to unlicensed staff, consider these principles

Nurses in today's LTC and assisted living settings act in a variety of roles, both clinical and nonclinical. Nurses assist with or administer medications, perform assessments and documentation, write care plans or service plans, check blood sugar levels, draw blood, change dressings and, in general, serve as the facility or company-wide “clinical expert.”

On the nonclinical side, nurses often act as the facility manager or administrator. They train and educate staff, serve as mentors or risk managers or deal with difficult family members and state inspectors. They prepare budgets; manage staffing, admissions, discharges and preadmission assessments; and can even serve as the facility marketer.

The only realistic way of accomplishing efficient, cost-conscious quality care in these settings is for the nurse to delegate certain nursing tasks to unlicensed staff. This process is commonly referred to as “nursing delegation.”

THE TERMINOLOGY

Professional nursing, by most accepted definitions, is the performance for compensation of any act in the observation of care of the ill, injured or infirmed; or for the maintenance of health or prevention of illness of others that requires substantial nursing skill, knowledge or training or the application of nursing principles based on biological, physical and social sciences. When surveying the definition of professional nursing in the 50 states, several key concepts, among others, arise:

  • the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering and advocacy;

  • observing and recording symptoms and reactions;

  • performing procedures and techniques in the treatment of the sick, under the general or special supervision or direction of a physician;

  • the supervision of a patient and the supervision and direction of an LPN and less skilled assistants;

  • evaluating responses to interventions;

  • teaching nursing knowledge/skills; and

  • consulting and coordinating with other healthcare professionals.

Many state statutes related to nursing delegation use the term “unlicensed assistive personnel,” or “UAP.” UAP are persons who may have training that documents their knowledge and competency but do not have a professional scope of practice or perform authorized nursing tasks. UAPs are certified nursing assistants, personal care workers and other unlicensed care workers.

To delegate means to entrust another, to appoint as one's representative or to assign responsibility or authority. Nurse delegation varies slightly from state to state as demonstrated by the following examples of nurse delegation:

  • The nurse transfers the performance of selected nursing tasks to competent UAPs in selected situations, retaining the responsibility and accountability for the nursing care. (Arizona)

  • Delegation is per occurrence and limited to patients that are stable and where the outcome of the delegated task is predictable. It is the responsibility of the delegator to verify adequate skills of the delegatee. (North Carolina)

  • Delegation means that a nurse authorizes an unlicensed person to perform a task of nursing care in selected situations and indicates that authorization in writing. The delegation process includes nursing assessment of a client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, ensuring supervision of the unlicensed person and re-evaluating the task at regular intervals. (Oregon)

COMMON PRINCIPLES OF NURSING DELEGATION

Several key principles of nurse delegation appear to be consistent in most states and are as follows:

  • Delegate tasks that are within the nurse's scope of practice, expertise, knowledge and abilities. For example, a nurse competent in blood glucose monitoring may determine that delegation to the UAP is appropriate. Conversely, a nurse who has never managed a feeding tube may not delegate that task to the UAP.

  • Assess the patient to determine his or her condition and stability. Delegation is not appropriate for unstable residents or residents with complex medical and nursing needs. A resident's condition is stable if it is unchanging, predictable and does not require complex medical intervention.

  • Only delegate those tasks that are commensurate with the educational preparation and demonstrated abilities of the UAP. It is the nurse's duty to determine whether the UAP has the capacity to learn and the ability to competently perform a delegated task safely. Nursing judgment comes into play and the nurse may decide that the UAP, even with minimal education and experience, may competently perform a nursing task with the appropriate guidance, training, monitoring and supervision.

  • Direction and assistance are to be employed. The nurse must be available for questions raised by the UAP regarding the delegated task. By providing direction, teaching, assistance, support and praise, the nurse can “professionalize the nonprofessional.”

  • The delegated task must not require complex nursing skill and judgment. For example, any nursing task requiring complex medication dosage calculations or assessment of a resident in distress are obviously not tasks that may be delegated. Those tasks are mastered only through a nurse's training and experience. In general, the nursing process may not be delegated to unlicensed persons.

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