1 Nurse Delegation Webinar Susan C. Reinhard Senior Vice President, AARP Public Policy Institute Chief Strategist, Center to Champion Nursing in America DSW Resource Center February 17, 2010

Overview Why this issue is important Why this issue is important Policy approaches to find solutions Policy approaches to find solutions State experiences State experiences North Dakota North Dakota New Jersey New Jersey 2

Why Important to Understand? Support consumer’s desire for community living Support consumer’s desire for community living Can find legal solutions in several ways Can find legal solutions in several ways Legal barriers are not always the major barrier Legal barriers are not always the major barrier Many state nurse practice acts/ boards of nursing have enough flexibility to make it possible Many state nurse practice acts/ boards of nursing have enough flexibility to make it possible Other agencies, (public and private) are factors Other agencies, (public and private) are factors Resistance from nurses and others Resistance from nurses and others 3

Finding the regulations For nurses, state nurse practice acts (statutes) and Board of Nursing regulations. Boards of Nursing may also have policies or advisory opinions that influence nurses. For nurses, state nurse practice acts (statutes) and Board of Nursing regulations. Boards of Nursing may also have policies or advisory opinions that influence nurses. Unlicensed certified assistants (DSW) may be regulated by the board of nursing or other departments Unlicensed certified assistants (DSW) may be regulated by the board of nursing or other departments Facility or setting regulations may spell out the relationship between licensed and unlicensed personnel Facility or setting regulations may spell out the relationship between licensed and unlicensed personnel Settings that are accredited will be influenced by those requirements (JCAHO, others) Settings that are accredited will be influenced by those requirements (JCAHO, others) 4

5 What Kinds of Tasks Might DCWs Perform in Home/Community Settings? Routine health maintenance activities (with predictable outcomes). Examples of tasks could be: Routine medications, including injections (insulin) Routine medications, including injections (insulin) Blood glucose monitoring Blood glucose monitoring Bowel and bladder regimes, colostomy care Bowel and bladder regimes, colostomy care Tube feeding Tube feeding Avoid laundry lists Avoid laundry lists

Policy Models (not mutually exclusive) Exemption (Consumer Direction) Exemption (Consumer Direction) Nebraska, Arkansas, New Jersey, North Dakota Nebraska, Arkansas, New Jersey, North Dakota Delegation Delegation Oregon, New Jersey, North Dakota Oregon, New Jersey, North Dakota UAP Certification UAP Certification North Carolina North Carolina 6

Exemption Some categories of persons are exempted from practice regulations Most states have some exemptions for religious orders, family members, and sometimes domestic servants. Most states have some exemptions for religious orders, family members, and sometimes domestic servants. More recently, some states have included paid personal care aides (DCWs) in this category More recently, some states have included paid personal care aides (DCWs) in this category 7

Exemption In Practice: The consumer (or his/her non-nurse designate) instructs and directs the DCW in the tasks. The consumer (or his/her non-nurse designate) instructs and directs the DCW in the tasks. While they may enlist a nurse in teaching a task, and some programs may require initial (and periodic) nurse consultation as part of their quality monitoring, there is no routine nurse involvement with the DCW. While they may enlist a nurse in teaching a task, and some programs may require initial (and periodic) nurse consultation as part of their quality monitoring, there is no routine nurse involvement with the DCW. 8

Advantages/Disadvantages Advantage: maximizes consumer freedom Advantage: maximizes consumer freedom Disadvantages: Disadvantages: Does not serve consumers who cannot or do not want to self direct, or have no one to direct on their behalf. Does not serve consumers who cannot or do not want to self direct, or have no one to direct on their behalf. No or limited medical or nursing oversight No or limited medical or nursing oversight 9

10 Delegation Model “ One person, one task”--The nurse delegates each task to one DCW for one consumer. “ One person, one task”--The nurse delegates each task to one DCW for one consumer. Not transferable to another DCW or another consumer Not transferable to another DCW or another consumer Having been taught to perform an insulin injection for Iris Jones, the DSW cannot perform insulin injections for other clients without further delegation for the new client. Having been taught to perform an insulin injection for Iris Jones, the DSW cannot perform insulin injections for other clients without further delegation for the new client.

11 General Process for Nurse Delegation State’s Board of Nursing guidelines generally direct nurse to State’s Board of Nursing guidelines generally direct nurse to Make sure task is within nurse’s scope of practice and can be done with little risk to consumer and without need for nursing judgment Make sure task is within nurse’s scope of practice and can be done with little risk to consumer and without need for nursing judgment Assess consumer for stability and DSW for competence Assess consumer for stability and DSW for competence

12 General Process for Nurse Delegation Standard practice: The nurse instructs the DSW in how to perform the task and demonstrates task performance, then the DSW demonstrate the task to document competency. Standard practice: The nurse instructs the DSW in how to perform the task and demonstrates task performance, then the DSW demonstrate the task to document competency. The nurse provides written instructions for the DSW and continues to monitor the consumer. The nurse provides written instructions for the DSW and continues to monitor the consumer.

13 Regulatory Specificity Kinds of things states specify Kinds of things states specify Factors to consider when delegating (client condition, type of task, aide experience) Factors to consider when delegating (client condition, type of task, aide experience) What to verify when delegating (training, task observation) What to verify when delegating (training, task observation) Instruction to provide (demonstration, written--what to include) Instruction to provide (demonstration, written--what to include) Monitoring (frequency, in person or phone) Monitoring (frequency, in person or phone) Tasks that can or cannot be delegated Tasks that can or cannot be delegated

14 Barriers to Delegation Though delegation is allowed in most states, in many cases it does not happen. Why? Nurse uncertainty about what constitutes appropriate delegation and fear of losing her/his license for inappropriate delegation  easier to just perform the task herself/himself. Nurse uncertainty about what constitutes appropriate delegation and fear of losing her/his license for inappropriate delegation  easier to just perform the task herself/himself. Nurse fears of being forced to delegate when he/she feels it is inappropriate to do so. Nurse fears of being forced to delegate when he/she feels it is inappropriate to do so. Payer rules may require a nurse to perform a task for reimbursement. Payer rules may require a nurse to perform a task for reimbursement.

15 Strategies to Address Uncertainty Clarifying the delegation process—boards of nursing or nurse employers may address questions like: What does the nurse need to verify? What does the nurse need to verify? How does the nurse document instructions? How does the nurse document instructions? How often should the nurse monitor? How often should the nurse monitor?

16 Orientation or Training Both Oregon and Washington provide training for contract nurses Both Oregon and Washington provide training for contract nurses Washington also provides training for DSW Washington also provides training for DSW New Jersey creating orientation process through Pilot (Bill Ditto will address) New Jersey creating orientation process through Pilot (Bill Ditto will address)

17 Liability Washington “Nurses acting within the protocols of their delegation authority are immune from liability for any action performed in the course of their delegation duties.” “Nursing assistants following written delegation instructions from registered nurses performed in the course of their accurately written, delegated duties shall be immune from liability.”

18 Liability Oregon goes beyond the question of professional liability to address civil liability: Nurses who delegate nursing care to an unlicensed person “shall not be subject to an action for civil damages for the performance of a person to whom nursing care is delegated unless the person is acting pursuant to specific instructions from the nurse or the nurse fails to leave instructions when the nurse should have done so.”

19 UAP Certification Model DSW receives a general training and has own “scope of practice,” outlined in laws/regs, but is generally supervised by a nurse.

20 UAP Certification Examples North Dakota’s Medication Assistant Certification Program North Dakota’s Medication Assistant Certification Program North Carolina’s Nurse Aide I and II and Medication Aide Programs North Carolina’s Nurse Aide I and II and Medication Aide Programs

21 UAP Certification Advantages Advantages May put less of a teaching burden on the nurse by ensuring some common background May put less of a teaching burden on the nurse by ensuring some common background Formal recognition of UAP skills may be beneficial for UAP’s career Formal recognition of UAP skills may be beneficial for UAP’s career Disadvantages Disadvantages Costly and time consuming—less flexibility for consumers Costly and time consuming—less flexibility for consumers May involve training UAP about things he/she will never encounter May involve training UAP about things he/she will never encounter May put nurse too much at ease regarding UAP competence May put nurse too much at ease regarding UAP competence

22 Message to Nurses As states move toward serving more people in community settings, they may need to restructure the way nursing care is delivered and utilize nurses more in their teaching and consulting roles.

23 Susan C. Reinhard