NURSE EDUCATION WEBINAR SERIES Susan Hoffmann MSN RN
NURSE EDUCATION WEBINAR SERIES Susan Hoffmann MSN, RN, NCSN May 1, 2019
CARE COORDINATION DELEGATION AND DOCUMENTATION
OBJECTIVE • Participants will be able to explain the key criteria of when, where, to whom and how nursing delegation can be implemented. • Participants will describe essential elements of documentation of nursing delegation.
• Principles of Delegation CONTENTS • Deciding What Nursing Tasks to Delegate and To Whom • Documenting Delegation
Delegating in nursing, including tasks and responsibilities POLLING QUESTION #1 continues to be legal minefield? Agree or Disagree?
WHAT IS DELEGATION? Ø“Transfer of responsibility for the performance of an activity to another, with the former retaining accountability for the outcome” (ANA, 2012, pg. 5) ØAllowing a delagatee to perform a specific nursing activity, skill, or procedure that is beyond the delagatee’s traditional role and not routinely performed (NCSBN, 2016, pg. 6)
NCBSN (2016) Delegation Model National Council of State Boards of Nursing
DELEGATION VS. ASSIGNMENT • Assignment is the transfer of responsibility and accountability of the activity from the licensed nurse (APRN or RN) to another licensed nurse (LPN, LVN) or unlicensed assistive personnel • Activity is part of their traditional role • Key difference if the activity is within their scope of practice or routine responsibility Examples: Health aid taking temperatures LPN performing routine gastrostomy tube feeding (after assessment by RN and IHP developed)
WHY DELEGATION? Ø 2006 NCSBN and ANA Joint statement on delegation https: //www. ncsbn. org/Delegation_joint_statement_NCSB N‐ANA. pdf ØIncreased patient acuity ØTechnological advances ØStaffing shortages ØCost effective
POLICY CONSIDERATIONS • Defined by state nurse practice act • Need and place for competent, appropriately supervised nursing assistive personnel in the delivery of affordable, quality health care • The RN delegates tasks using professional judgement • All decision related to delegation are based on the fundamental principles of protection of the health, safety and welfare of the public
PRINCIPLES OF DELEGATION
PRINCIPLES OF DELEGATIO N The RN takes responsibility and accountability for the provision of nursing practice
PRINCIPLES OF DELEGATIO N The RN directs care and determines the appropriate utilization of any assistant involved in providing direct patient care
PRINCIPLES OF DELEGATIO N The RN may delegate components of care but does not delegate the nursing process itself. The practice pervasive functions of assessment, planning, evaluation, and nursing judgment cannot be delegated.
PRINCIPLES OF DELEGATIO N Decision of whether or not to delegate or assign is based upon the RN’s judgment concerning the condition of the patient, the competence of all members of the nursing team, and the degree of supervision that will be required of the RN if a task is delegated.
DELEGATION PROCESS: KEY QUESTIONS Does the activity require nursing judgement? Is there potential for harm? What is the complexity of care? What is the predictability of the outcome?
5 RIGHTS OF DELEGATION 1. The right task 2. Under the right circumstances 3. To the right person 4. With the right directions and communication 5. Under the right supervision and evaluation
DECISION TREE: NURSING DELEGATION IN THE SCHOOL SETTING ü Does the state’s Nurse Practice Act also delegation? NO – Cannot delegate YES- Can delegate ü Does school policy support raining and supervision of the UAP by the school nurse? NO – Cannot delegate YES- Can delegate ü Has a healthcare provider ordered the health care task? NO – Cannot delegate YES- Can delegate ü Does the school nurse have the competence to train the UAP on the nursing task? NO – Cannot delegate YES- Can delegate ü Does the student’s IHP – based on the nursing assessment, in combination with the HCP’s orders- outline the nursing task required to help meet the students health goals? NO – Cannot delegate YES- Can delegate
DECISION TREE: NURSING DELEGATION IN THE SCHOOL SETTING Does the nursing care task meet the criteria of delegation? (Right Task) ü Not complex NO – Cannot delegate YES- Can delegate ü Part of the student’s routine plan of care, whether at school or at home NO – Cannot delegate YES- Can delegate ü Follows an established sequence of steps NO – Cannot delegate YES- Can delegate ü Does not require modification NO – Cannot delegate YES- Can delegate ü Has a predictable outcome NO – Cannot delegate YES- Can delegate ü Does not involve assessment, judgment, interpretation of results or decision making By the UAP NO – Cannot delegate YES- Can delegate
DECISION TREE: NURSING DELEGATION IN THE SCHOOL SETTING ü Did the nursing assessment of the student’s health status and health goals identify any unique needs that my deem delegation inappropriate? (Right circumstance) NO – Cannot delegate YES- Can delegate ü Is an appropriate, competent, and willing UAP available? (Right person) NO – Cannot delegate YES- Can delegate ü Is the school nurse able to develop the UAP training, implement the training, provide a written sequence of steps for the nursing task evaluate competence? (Right direction and communication) NO – Cannot delegate YES- Can delegate ü Can the school nurse provide ongoing supervision of the UAP and evaluation of the student’s health outcomes? (Right supervision and evaluation) NO – Cannot delegate YES- Can delegate
DECISION TREE: NURSING DELEGATION IN THE SCHOOL SETTING For out-of-state school-sponsored events: ü Are both the home and visiting states members of the Nurse Licensure Compact? NO – Cannot delegate YES- Can delegate ü Does the visiting state allow delegation to the UAP? NO – Cannot delegate YES- Can delegate
NASN RESOURCES: NURSING DELEGATION IN THE SCHOOL SETTING: • Recommended Qualifications for the Unlicensed Assistive Personnel • Sample Skills Checklist for Unlicensed Assistive Personnel Training https: //www. nasn. org/nasn-resources/professional-topics/delegation
MISSOURI DELEGATION REGULATIONS • Administration of medication is a nursing activity that must be performed by a registered professional nurse or a licensed practical nurse. • A registered professional nurse may delegate the administration of medications to unlicensed personnel provided they are trained and supervised by the delegating nurse.
DELEGATION DOCUMENTATION • Include delegation of nursing tasks in IHP • Documentation competency – utilize a skills checklist • Periodic review (not just a one and done) • Include two way communication plan for routine questions and emergency situations
CASE SCENARIOS
CASE SCENARIO JOHNNY Johnny is an 8 -year-old student with asthma, which is well managed on inhaled corticosteroids. Johnny has a prescription order to take 2 puffs of a bronchodilator via a metered-dose inhaler (MDI) prior to physical education. ØCan the task be delegated?
CASE SCENARIO JOHNNY Johnny’s condition is stable and predictable as evidenced by a nursing assessment ü The task is not prohibited from being delegated ü A reasonable, prudent nurse would delegate administration of the 2 puffs from the MDI ü Administration of 2 puffs from the MDI prior to physical education does not require the exercise of professional nursing judgment; ü The unlicensed person possesses the experience and competency to safely perform the task; ü The RN is available to the unlicensed person either in person or by telecommunications when the unlicensed person is performing the task; ü Verification of the unlicensed person’s competency to perform the task is documented; ü An emergency plan is in place in the event the student’s condition becomes acute, unstable or unpredictable. ØThe task may be delegated.
CASE SCENARIO DEVON Devon is an 8 -year-old student with an allergy to bee sting. Today, Devon is going on a fieldtrip. Prior to the fieldtrip, the unlicensed person and the RN review Devon’s emergency care plan, discuss emergency interventions in the event of a bee sting, and administration of an Epi Pen. üCan the task be delegated?
CASE SCENARIO DEVON The RN determines that: ü In the event of a bee sting, Devon may develop an unstable and unpredictable condition; ü Devon’s anaphylactic reaction to a bee sting would be an emergency situation; ü In the state of Missouri, administration of medications is a nursing task within the scope of sound professional nursing judgment to delegate and, the unlicensed person may take any action that a reasonable, prudent non-healthcare professional would take in an emergency situation ü An Epi Pen is a common intervention provided by lay persons in an anaphylactic emergency; ü The RN has appropriately instructed the unlicensed person in the use of the Epi Pen or verified competency ü The RN is available to the unlicensed person either in person or by telecommunications Ø The task may be delegated.
CASE SCENARIO MARIA Maria is a 6 -year-old student with spina bifida. She attends school with an unlicensed aide that is on contract with the school district via an agency, the school RN has delegated the task of in-and-out catheterizations to the unlicensed aide. A substitute RN is assigned to the school during the school RN’s absence. The substitute RN conducts a nursing assessment. ØCan the task be delegated?
CASE SCENARIO MARIA The substitute RN determines that: ü The school RN has delegated in-and-out catheterizations to the unlicensed person; ü The unlicensed person has the appropriate training to perform the task; ü The unlicensed person is able to properly and adequately perform the task without jeopardizing Maria’s welfare; ü S/he is able to adequately supervise performance of the task either in person or by telecommunications. ØThe task may be completed by the unlicensed person.
REDUCING THE RISKS • Don’t underestimate the complexity of a student’s health care needs • Don’t go it alone. • Check out your school policies • Educate school administrators who do not understand nursing delegation
QUESTIONS? SUEHOFFM@GMAIL. COM
WORKS CITED American Nurses Association. (2012). Principles for delegation by registered nurse s to unlicensed assistive personnel (UAP). Silver Spring, MD: Nursesbooks. org. American Nurses Association & National Council of State Boards of Nursing. (200 6). Joint statement on delegation. Retrieved from https: //www. ncsbn. org/Delegation_joint_statement_NCSBN‐ANA. pdf Missouri Manual for School Health Programs https: //health. mo. gov/living/families/schoolhealth/pdf/Manual. For. School. Healt h. pdf
WORKS CITED National Association of School Nurses. (2014). Nursing delegation to unlicensed assistive personnel in the school setting (Position Statement). Silver Spring, MD: Author. National Association of School Nurses. (2016). Role of the 21 st century school nurse (Position Statement). Silver Spring, MD: Author. National Association of School Nurses (2013). School-sponsored trips - Role of the school nurse (Position Statement). Silver Spring, MD: Author. National Association of School Nurses. (2015). Unlicensed assistive personnel: Their role on the school health services team (Position Statement). Silver Spring, MD: Author. National Council of State Boards of Nursing. (2016). Delegation. https: //www. ncbsn. org/1625. htm Resha, C. (2017) Process for Delgation in the School Setting, in Legal Resource for School Health Services, School Nurse. com, Nashville, TN.
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