Nurse Education Webinar Series Susan Hoffmann MSN, RN, NCSN May 1, 2019

Care Coordination Delegation and Documentation

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. Objective

Contents Principles of Delegation Deciding What Nursing Tasks to Delegate and To Whom Documenting Delegation

Delegating in nursing, including tasks and responsibilities continues to be legal minefield? Agree or Disagree? Polling Question #1 This statement by Nancy J. Brent MS, JD, RN

What is Delegation? “Transfer of responsibility for the performance of an activity to another, with the former retaining accountability for the outcome” (ANA, 2012, pg. 5) Allowing 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) Legal term – different than a teacher delegating a task to a paraprofessional in the classroom. School administrators may be unaware.

This delegation model outlines the employer/nurse leader’s responsibilities along with those for the delegating nurse and the delagatee. Because school nurses often work autonomously, the employer/nurse leader may be a school nurse administrator, or lead nurse. 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? 2006 NCSBN and ANA Joint statement on delegation https://www.ncsbn.org/Delegation_joint_statement_NCSBN‐A NA.pdf  Increased patient acuity Technological advances Staffing shortages Cost effective September 13, 2006 -- The National Council of State Boards of Nursing (NCSBN) and the American Nurses Association (ANA) have issued a joint statement on delegation designed to reinforce that delegation is an essential nursing skill and to support the practicing nurse in using delegation safely and effectively. The escalating shortage of nurses, greater acuity of patient illnesses, technological advances and increased complexity of therapies contribute to today's current chaotic and multifaceted health care environment. The recognition that registered nurses (RNs) need to work effectively with assistive personnel and the abilities to delegate, assign, and supervise are critical competencies for the 21st century nurse led both NCSBN and the ANA to separately adopt papers on delegation in 2005. These delegation papers were conceptually similar thus providing the impetus for NCSBN and ANA to approach this important topic from both regulatory and professional practice positions and work toward a joint statement that distills the best work of both organizations and advances the common ground between the two. "ANA Principles of Delegation" and NCSBN's "Decision Tree on Delegation" that reflects the four phases of the delegation process.

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 NCSBN and the ANA recognize the following policy considerations: -- State nurse practice acts define the legal parameters for nursing practice. Most states authorize RNs to delegate. – There is a need and a place for competent, appropriately supervised nursing assistive personnel in the delivery of affordable, quality health care. -- The RN assigns or delegates tasks based on the needs and condition of the patient, potential for harm, stability of the patient's condition, complexity of the task, predictability of the outcomes, abilities of the staff to whom the task is delegated, and the context of other patient needs. -- All decisions related to delegation and assignments are based on the fundamental principles of protection of the health, safety and welfare of the public.

Principles of Delegation • The RN takes responsibility and accountability for the provision of nursing practice. • The RN directs care and determines the appropriate utilization of any assistant involved in providing direct patient care. • 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. • The 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.

Principles of Delegation The RN takes responsibility and accountability for the provision of nursing practice The RN takes responsibility and accountability for the provision of nursing practice

Principles of Delegation The RN directs care and determines the appropriate utilization of any assistant involved in providing direct patient care The RN directs care and determines the appropriate utilization of any assistant involved in providing direct patient care

Principles of Delegation 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 Delegation 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 Delegation 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. Principles of Delegation The 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 Does the state’s Nurse Practice Act also delegation? NO – Cannot delegate YES- Can delegate Does school policy support raining and supervision of the UAP by the school nurse? Has a healthcare provider ordered the health care task? Does the school nurse have the competence to train the UAP on the nursing task? 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?

Decision Tree: Nursing Delegation in the School Setting Does the nursing care task meet the criteria of delegation? (Right Task) Not complex NO – Cannot delegate YES- Can delegate Part of the student’s routine plan of care, whether at school or at home Follows an established sequence of steps Does not require modification Has a predictable outcome Does not involve assessment, judgment, interpretation of results or decision making By the UAP

Decision Tree: Nursing Delegation in the School Setting 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 Is an appropriate, competent, and willing UAP available? (Right person) 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) Can the school nurse provide ongoing supervision of the UAP and evaluation of the student’s health outcomes? (Right supervision and evaluation)

Decision Tree: Nursing Delegation in the School Setting For out-of-state school-sponsored events: Are both the home and visiting states members of the Nurse Licensure Compact? NO – Cannot delegate YES- Can delegate 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. https://health.mo.gov/living/families/schoolhealth/pdf/ManualForSchoolHealth.pdf#page=48 Role of the School Nurse in Medication Administration The administration of medications in schools, including over-the-counter (OTC) medications, is a nursing activity that must be under the control of a registered professional nurse and/or licensed practical nurse. A registered nurse may delegate, train, and supervise the administration of medication by unlicensed personnel who are qualified by education, knowledge, and skill to administer medication. (See Medication Administration in Missouri Schools, Guidelines for Training School Personnel, DHSS, 2004). It is the responsibility of the registered professional nurse to: 1. Document the training, education, competency verification, and supervision of unlicensed personnel who are delegated medication administration. A registered nurse may delegate the training of unlicensed personnel to licensed practical nurses who have demonstrated the competency to provide such training. The nurse must periodically monitor medication administration procedures of those trained by the nurse and licensed practical 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 SHARE SAMPLE DELEGATION FORM

Case Scenarios

Case Scenario Johnny Can the task be delegated? 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. Can the task be delegated?

The task may be delegated. Case Scenario Johnny Johnny’s condition is stable and predictable as evidenced by a nursing assessment The task is not prohibited from being delegated A reasonable, prudent nurse would delegate administration of the 2 puffs from the MDI Administration of 2 puffs from the MDI prior to physical education does not require the exercise of professional nursing judgment; The unlicensed person possesses the experience and competency to safely perform the task; The RN is available to the unlicensed person either in person or by telecommunications when the unlicensed person is performing the task; Verification of the unlicensed person’s competency to perform the task is documented; An emergency plan is in place in the event the student’s condition becomes acute, unstable or unpredictable. The task may be delegated.

Case Scenario Devon Can the task be delegated? 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. Can the task be delegated?

Case Scenario Devon The RN determines that: In the event of a bee sting, Devon may develop an unstable and unpredictable condition; Devon’s anaphylactic reaction to a bee sting would be an emergency situation; 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 An Epi Pen is a common intervention provided by lay persons in an anaphylactic emergency; The RN has appropriately instructed the unlicensed person in the use of the Epi Pen or verified competency The RN is available to the unlicensed person either in person or by telecommunications The task may be delegated.

Can the task 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. Can the task be delegated?

Case Scenario Maria The substitute RN determines that: The school RN has delegated in-and-out catheterizations to the unlicensed person; The unlicensed person has the appropriate training to perform the task; The unlicensed person is able to properly and adequately perform the task without jeopardizing Maria’s welfare; S/he is able to adequately supervise performance of the task either in person or by telecommunications. The 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 nurses to  unlicensed assistive  personnel (UAP).  Silver Spring, MD: Nursesbooks.org.    American Nurses Association & National Council of State Boards of Nursing. (2006).  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/ManualForSchoolHealth.pdf National Association of School Nurses (2014) Principles for Practice: Nursing Delegation to Unlicensed Assistive Personnel in the School Setting. Silver Spring, MD: Author.

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 21st 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.