Which Client's Care May A Registered Nurse (Rn) Safely Delegate To The Nursing Assistant?

Board Dominion 224 - Overview of Delegation

Delegation is an essential nursing skill that RNs use to maximize the nursing care that clients receive.

Delegation is based upon:

The needs of the patient and the stability of the patient's status;
The RN assessment of the potential for patient harm;
The complexity of the chore;
The predictability of the outcomes;
The abilities of the unlicensed assistive personnel (UAP) staff to whom the job is delegated;
The context of other patient needs to achieve the most benefit from nursing care since the RN is responsible and accountable for safe and appropriate delegation (§224.5, RN Accountability for Delegated Tasks), delegation is utilized at the RN's discretion.

The delegation process is multifaceted. It begins with decisions fabricated at the authoritative level of the organization and extends to the staff responsible for delegating, overseeing the process, and performing the responsibilities (NCSBN, 2016). Employers have a responsibility to ensure that practices specified in task descriptions comply with applicative state and federal laws, regulations and credentialing requirements (e.k., Texas Department of State Health Services; Centers for Medicare & Medicaid Services). Toggle Expand/Collapse Text

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Delegation/Assignment

Delegation & Consignment Defined

The utilise of terms delegate and assign can be confusing and lead to questions regarding the licensure responsibilities associated with the terms. Delegation is defined equally "authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. It does not include situations in which an unlicensed person is direct assisting a RN by conveying out nursing tasks in the presence of a RN." [§224.iv(3)]... Toggle Expand/Collapse Text

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Advanced Practice Registered Nurses

May an Advanced Practise Registered Nurse (APRN) delegate tasks to other nurses or unlicensed assistive personnel?

Nether the RN licensure and office, APRNs may but delegate tasks to unlicensed staff or assistive personnel utilizing the applicable RN Delegation Rules 224 or 225 equally appropriate and in compliance with Dominion 217.eleven(3)(B). APRNs are not authorized to exceed the delegation criteria in Rules 224 and 225. While APRNs take collaborative working agreements with physicians, APRNs do non have the same delegatory authorization as physicians and therefore are limited to delegation of nursing tasks within the RN licensure and role. The BON's delegation rules (§224 & §225) utilize to both RNs and APRNs... Toggle Expand/Collapse Text

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Licensed Vocational Nurses

What is the LVN'south scope of practice and role in delegation?

The LVN scope of practice is both directed and supervised [NPA §301.002(ii); NPA §301.353; §217.11(two)]. The LVN performs a focused assessment [§217.11(ii)]. The delegation decision is based on the comprehensive assessment that is performed by the RN [§217.xi(3)]. Since the LVN practice is not autonomous, and the LVN is not educated or licensed to perform a comprehensive assessment, it is beyond the LVN scope of practice to delegate tasks. Even so, the LVN may assign tasks not requiring delegation and provide supervision to the UAP for assigned tasks... Toggle Expand/Collapse Text

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Unlicensed Assistive Personnel

RNs may be asked to delegate tasks to UAPs with minimal skill levels or skill sets. Organizations may have policies regarding delegation and delegation duties may be included in RN job descriptions. If an RN refuses to delegate based on the cess, can the RN be required to delegate?

Delegation is widely viewed as an essential nursing skill the RN uses at their discretion based upon the RN assessment. Since the RN is accountable for the delegation procedure, the determination to delegate belongs to the RN (Rules §224.five & §225.v concerning accountability). Notwithstanding, others (e.thou., the client, client's family/meaning others, the RN's supervisor, the UAP) may have input that the RN needs to consider in the conclusion making procedure. The decision to consul is based on a thorough working noesis of BON Rules (§224, §225, and §217 .11) and other relevant regulations. When delegating a chore, RNs have a duty to maintain patient safety [Rule 217.eleven(i)(B)] which supersedes other mandates such as facility policy or physician orders (Position Statement 15.14, Duty of A Nurse in whatsoever Practise Setting)... Toggle Expand/Collapse Text

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Emergency Medical Technicians/Paramedics

Can an RN delegate nursing tasks to an emergency medical technician (EMT) or paramedic?

The BON's rules in Chapter 224 draw the requirements for RN delegation to unlicensed personnel in an astute intendance environment such as the emergency department. The BON does non regulate practice settings or facility policies, nor does the Board regulate emergency medical technicians or paramedics. Whether certified or licensed, the BON views the EMT or paramedic role within the acute care, inpatient setting or emergency department setting to be equivalent with the UAP for the purposes of RN delegation. While EMTs and paramedics exercise accept out-of-hospital training and licensure/certification applicative to the out-of-hospital setting, within the acute intendance surroundings the scope of practice of the EMT or paramedic is limited to the role of the UAP... Toggle Expand/Collapse Text

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Family unit Members

Patients' families may assist in patient intendance. When instructing family members in providing intendance, is this considered delegation?

RNs may be involved in patient/family education and this is non delegation. The RN is responsible for providing consummate and accurate instructions and oversight, in add-on to client assessment (§ 224.6(i) and 225.v(a)). However, the requirements of the rules in Capacity 224 & 225 typically practice not apply in this context. Farther, the BON defines UAPs as individuals who are "monetarily compensated" to provide health care services. Since families and pregnant others are not usually compensated for providing care to their loved one, this is non a delegation situation.

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Nursing Students

Many organizations employ nursing students (i.e., individuals who are employed in the organization and are currently students in an accredited school of nursing).

Is it an adequate practice for nursing students who provide documented didactic education and demonstration of competence from their nursing program, to perform such duties as urinary catheter placement, sterile dressing changes, and venipuncture in acute intendance settings?
May they perform patient assessments and independently certificate these assessments in astute care settings?

Employers may hire nursing students to work equally UAPs in positions such every bit aides or nursing assistants. This is a different situation than nursing students who are completing their clinical course work requirements in a facility and are monitored by nursing school kinesthesia. In that scenario, students are authorized to perform nursing tasks every bit a part of their academic program; therefore, RN delegation is not required. Even so, nursing students who are employed by a facility equally UAPs must function under the delegated authority of a RN to perform nursing tasks [see Dominion 224.iv(iv)(C)... Toggle Expand/Collapse Text

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Documentation

When a RN delegates a task to a UAP, is that UAP responsible for documenting the care provided or is the RN responsible? Does the RN have to co-sign this documentation?

Responsibilities regarding documentation and co-signature are not specified in the delegation rule but may be addressed in facility policies and procedures. The RN's responsibility for complete and authentic documentation is delineated in the Standards of Nursing Practise [BON Rule §217.11 (1)(D)]. As determined by the employing agency/facility with nursing collaboration, UAPs might play a role in the documentation of care they provide. Co-signature indicates that the RN was nowadays or observed all the activities that the UAP is reporting in the record. Without this presence or ascertainment, the BON does not recommend that a RN co-sign others' documentation.

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Supervision

What is the RN's/APRN's responsibility when s/he supervises an unlicensed assistive person who has been delegated tasks by a doctor or other non-RN practitioners?

Board rules §224.ten and §225.fourteen accost situations where the RN is supervising a UAP, yet that RN is not the delegating practitioner because some other licensed practitioner is delegating to this UAP. The Documentation Supervision delegation rules allow this practice since delegation, as addressed by BON rule, is not restricted by employment relationships. That is, it is permissible past BON rule for a treating physician or a RN from i employing agency (due east.thousand., a dwelling house wellness agency) to consul to a UAP from a different agency (eastward.thousand., an assisted living facility)... Toggle Expand/Collapse Text

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Doctor Orders

In what circumstances is a physician order required for nursing delegation?

Since RN delegation is defined as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task, the BON does not require RNs to obtain dr. orders for RN delegation nor can a dr. force an RN to consul. The RN is accountable for the delegation process, therefore the conclusion to consul belongs to the RN (Rules §224.5 & §225.5 pertaining to accountability). However, others (i.e., the physician, the client, client'southward family/significant others, the RN's supervisor, the UAP) may have input into the decision making process. The decision to delegate is based on a thorough working knowledge of BON Rules (§224, §225, and §217.xi) and other relevant regulations.

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Procedures/Treatments

Tin a RN delegate finger sticks to collect capillary blood for blood glucose testing?

Yes, a RN may delegate finger sticks for blood glucose monitoring [§224.8(a)(two)(A) and §225.10(four)(A)]. In Board Rule §225.12, Delegation of Insulin or Other Injectable Medications Prescribed in the Treatment of Diabetes Mellitus, blood glucose monitoring [§225.12(2)] is an important component of this delegated chore... Toggle Expand/Collapse Text

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Medication Administration

Can UAPs administer immunizations?

The laws regarding immunizations are not within the BON's authorization. With regard to vaccines of any kind, an Attorney General opinion in 1981 (MW-318) adamant immunizations are preventative, thus no medical diagnosis is required or fabricated when a person receives an immunization.

However, RN/APRNs may not delegate the assistants of immunizations nether the delegation rules. Where allowed by state constabulary, advisable not-physician personnel may provide vaccinations under a physician-approved continuing order without the demand for physician exam and a client-specific club. An additional document that may provide guidance is the FAQ: Seasonal Influenza, and Vaccinations available on the Board'due south website as well as the Board's Position Statement fifteen.5 Nurses with Responsibility for Initiating Standing Orders.

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Board Rule 225 - Applicability

In relation to delegation, what types of clients and settings should a RN refer to Chapter 225? In relation to delegation, what types of clients and settings should a RN refer to Chapter 225?

In that location are iii criteria that must be met in gild for a Registered Nurse to apply the delegation rules from Chapter 225. The criteria is one) the client is in an independent living environment such as a home a group domicile, foster home, assisted living facility or school; (two) the client, if 16 or older, or customer's responsible developed is willing and able to participate in decisions most the overall management of the client's health care; and (iii) the chore is for a stable, predictable condition equally defined by §225.4. [Board Rule 225.ane(a)] Toggle Expand/Collapse Text

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Customer's Responsible Adult

Who is eligible to serve as the "client's responsible adult" (CRA)? Is it possible for the CRA and the unlicensed assistive person (UAP) to be the same person? Tin can the CRA be an employee of the facility/agency providing the services?

BON Rule 225.4(5) defines CRA as "an individual, 18 or older, usually chosen past the client, who is willing and able to participate in decisions about the overall management of the client'due south wellness care and to fulfill any other responsibilities required under this affiliate for care of the client. The term includes only is not express to parent, foster parent, family member, significant other, or legal guardian."... Toggle Expand/Collapse Text

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Health Maintenance Activities

RNs in contained living environments such equally, home and community-based settings or school health while caring for clients with stable and anticipated weather must utilize the rules in Affiliate 225, RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions when making decisions that pertain to delegation... Toggle Expand/Collapse Text

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Medication Administration

Is cartoon upwards a required dose of insulin a delegated chore?

According to Dominion §225.12, the RN may delegate administration of insulin or other injectable medications prescribed in the handling of diabetes mellitus subcutaneously, nasally or via an insulin pump. As function of the medication administration process, the UAP may be required to draw up the insulin or other injectable medications utilizing a sliding calibration to determine the required dose of insulin or medication. These are generally permissible tasks and should be specified in the RN'due south instructions and physician's order. The RN may not delegate these activities if due south/he will have to brand decisions that require professional person nursing or medical judgment. The calculation of insulin doses may non exist delegated. The BON does not consider the application of a sliding scale to exist of the same complexity of calculating a dose based on saccharide-to-insulin ratios. Toggle Expand/Collapse Text

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Medication or Procedures in an Emergency State of affairs

Are there whatever medications or procedures that may be delegated in an emergency situation in independent living environments such as in home wellness or school health?

Planning for emergencies in contained living environments requires the RN to apply both Chapter 224 , Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Astute Conditions or in Acute Care Environments and Chapter 225, RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions... Toggle Expand/Collapse Text

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Hospice

Is a customer receiving hospice care considered stable & predictable?

Yes, co-ordinate to Rule §225.4(11). Stable and predictable is defined as "a situation where the client's clinical and behavioral status is adamant to be non-fluctuating and consistent. A stable/predictable condition involves long term health care needs which are not recuperative in nature and do not require the regularly scheduled presence of a registered nurse or licensed vocational nurse. Excluded by this definition are situations where the client'due south clinical and behavioral status is expected to change rapidly or in need of the continuous/continual assessment and evaluation of a registered nurse or licensed vocational nurse. The status of clients receiving hospice intendance in an independent living environment where deterioration is anticipated shall exist deemed to be stable and predictable."

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Delegation for the School Nurse

Can RNs delegate medication administration via envelopes or sealed plastic numberless and requite it to the instructor or some other UAP when s/he accompanies students on field trips?

According to Board Dominion 225.11(1), a RN may consul the administration of medications from a daily reminder pill container. This dominion department likewise applies to RNs who delegate medication administration to UAPs in the school setting when at that place is from a properly labeled unit dosage container filled past a registered nurse or some other qualified commune employee... Toggle Expand/Collapse Text

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References

Nursing Practice Act (http://world wide web.bon.texas.gov/laws_and_rules_nursing_practice_act.asp)
Board Rules & Regulations(http://world wide web.bon.texas.gov/laws_and_rules_rules_and_regulations.asp)
Position Statements (http://world wide web.bon.texas.gov/practice_bon_position_statements.asp)
Delegation Resources Bundle (http://world wide web.bon.texas.gov/practice_delegation_resource_packet.asp)
National Quango of Country Lath of Nursing (NCSBN) and the American Nurses Association (ANA) (2006). Joint argument on delegation. Retrieved from: https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf
National Council of State boards of Nursing (NCSBN) National Guidelines for Delegation 2016. Retrieved from: https://www.ncsbn.org/NCSBN_Delegation_Guidelines.pdf

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