Nurse delegation in LTC and assisted living

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.

• Supervision, observation and monitoring of the UAP are needed. The degree of supervision is normally within the nurse’s professional judgment, but usually spelled out in that particular state’s regulations or statutes pertaining to nurse delegation. Supervision takes two forms: direct or general. Direct supervision means the nurse is either readily available for consultation on a delegated task or is present on the premises. General supervision means the nurse is not physically present on the premises, but is generally available to the UAP. Some states, such as South Carolina, allow for an LPN or LVN supervisor.

• Evaluate the effectiveness of the delegated act. In most states, it simply is not enough to merely supervise the delegated act. The nurse is held accountable for evaluating the effectiveness not only of the delegated act, but also the performance of the UAP in performance of that act.

• Documentation of the delegation may be necessary. While documentation of the delegation is generally not required, for obvious liability and risk management reasons, documentation is recommended, both as part of the UAP’s file and the nurse’s file.

In summary, nurses can think in terms of these “five rights” of nurse delegation:

• The right task

• The right circumstances

• The right person

• The right direction/communication

• The right supervision

DOCUMENTATION: A GOOD IDEA

Nurse delegation is a two-way street. The UAP shares responsibility to understand the task being delegated, be competent performing the task, ask questions, maintain task competency through education and training, comprehend the delegation process and understand liability associated with the delegated act and its potential effect on the nurse. A written nurse delegation policy as required by some states is recommended.

Risk management for nurses delegating to UAPs begins with standards of practice for nurses. Violations of those nursing standards, including inappropriate nurse delegation, can result in a finding of unprofessional conduct or misconduct in the eyes of a state board of nursing. Several states, but not enough, provide that a nurse who delegates shall not be subject to legal liability unless the UAP acts pursuant to specific instructions from the nurse or the nurse fails to leave instructions for the UAP regarding a delegated task. Therefore, the importance of documenting the delegation becomes increasingly important.

By adhering to the common principles of delegation discussed in this article, nurses should be comfortable assigning nursing tasks to unlicensed persons.

Disclaimer: This article is not legal advice. Consultation with licensed and experienced legal counsel is advised.

Robert J. Lightfoot II, RN, is an attorney in private practice at von Briesen & Roper, s.c., a law firm in Madison, Wisc. He is also a registered nurse and represents healthcare providers on a variety of issues. Long-Term Living 2011 November;60(11):42-44

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