Delegation: The Professional School Nurses Role Julie Lindley, RN, BSN Director of Health Services and PE Grapevine-Colleyville ISD

Delegation Let’s Begin with the End in Mind!  Patient Safety  School Nurse Protection

Delegation Know the:  Nurse Practice Act (NPA)  BON Rules and Regulations

Delegation What is Delegation? As defined by the ANA (2007) it is the ability of the nurse to transfer the responsibility of a nursing task to an unlicensed person while the nurse continues to be accountable for the outcomes.

Delegation Accountable…  State Laws, Rules & Regulations  Employer Rules  Standards of Professional Nursing Practice

Delegation What do the Rules require?  Collaboration  Accountability  Assessment  Supervision

Delegation Collaboration As defined by the BON is the process of working with the student and/or student’s parent to ensure that the highest possible degree of independence for the student is achieved in the school setting.

Delegation Accountability The RN is accountable for proper performance of the assessment and decisions made based on the assessment including the performance of a particular ADL or HMA for a student qualifies as not requiring delegation.

Delegation Assessment – Delegation Must make an assessment to determine if the care:  Qualifies as an ADL or HMA not requiring delegation  Can be delegated  Should not be delegated

Delegation Assessment – Student Must make an assessment to determine if the:  Adequacy and reliability of the support system  Degree of stability and predictability of the student’s health status  Frequency of reassessments

Delegation Assessment – UAP Must make an assessment to determine if the:  Knowledge level of the UAP  Skill set of the UAP  Willingness of the UAP

Delegation Supervision Must periodically monitor and assess the capabilities and competencies of the UAP to safely perform delegated tasks.  The RN determines the frequency of reassessment & amount of supervision required.  Assignment by principal – RN still has a role!

Delegation Supervision – Definition Is the process of directing, guiding and influencing the outcomes of individuals performance of delegated tasks. Supervision may be:  In person  Telephonic  Skype The supervisor must be readably available in case of an emergency

Delegation 5 Rights of Delegation 1.Right Task 2.Right Person 3.Right Direction 4.Right Supervision 5.Right Circumstances

Delegation Rule 225 Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments (ILE) for Clients with Stable and Predictable Conditions

Delegation Definitions: ADL’s not requiring delegation ADL’s that don’t fall within the practice of professional nursing may be performed by UAP in accordance to § 225 without being delegated. The following must be met:  Performed for a person with a functional disability & the client would perform the task if not for the disability  RN determines based on assessment that the task is such that it could be performed by any UAP without RN supervision If these can’t be met, then the task may be delegated if they meet delegation requirements.

Delegation Definitions: ADL’s – Limited to the following activities:  Grooming  Feeding  Toileting  Transfer/ambulation.

Delegation Definitions: HMA’s not requiring delegation HMA’s that don’t fall within the practice of professional nursing may be performed by UAP in accordance to § 225 without being delegated. The following must be met:  Performed for a person with a functional disability & the client would perform the task if not for the disability  The task can be directed by the client or client’s responsible adult to be performed by any UAP without RN supervision.

Delegation Definitions: HMA’s not requiring delegation cont.  Client’s responsible adult is able, and has agreed in writing, to participate in directing the UAP’s actions writing, to participate in directing the UAP’s actions in carrying out the HMA; and the client’s in carrying out the HMA; and the client’s responsible adult is capable of: responsible adult is capable of: Training the UAP in the proper performance of the task Training the UAP in the proper performance of the task Will be present when task is performed Will be present when task is performed If not present, will observe the UAP performing the task at least once and be immediately available If not present, will observe the UAP performing the task at least once and be immediately available If these can’t be met, then the task may be delegated if they meet delegation requirements.

Delegation Definitions: HMA’s – Limited to tasks that enable the client to remain in an ILE & that go beyond ADL’s:  G-tubes – medication administration & feedings through permanently placed tubes  Elimination – stoma care, pouch changes & intermittent catheterizations

Delegation RN Accountability  Proper performance of the assessment and decision made as a result of the assessment including the determination that performance of a particular ADL or HMA for a specific client qualifies as not requiring delegation  The RN is NOT accountable for an unlicensed person’s actual performance of ADL/HMA’s not requiring delegation

Delegation Delegation Criteria  Assess the client  Task does not require professional nursing judgment  Verify the experience & competency of the UAP to perform the task including the ability to recognize and inform the RN of changes related to the task through: Instructed in performance of task Instructed in performance of task Verified competency Verified competency

Delegation Delegation Criteria cont.  Determined the level of supervision required taking into account: The stability of the client The stability of the client Training & experience of the UAP Training & experience of the UAP Nature of the delegated task Nature of the delegated task Proximity of the RN to the UAP Proximity of the RN to the UAP  Can the 5 Rights of Delegation be met?

Delegation Tasks that may be Delegated  ADL/HMA’s that require delegation  Non-invasive or non-sterile treatments  Vital Signs, I & O  Reinforcement of teaching provided by the RN the RN  Intermittent Catheterizations  Administration of Insulin

Delegation Delegation of Insulin  RN must be available on call  Provide training on all aspects of insulin administration  Provide written instructions including physician orders for the performance of the insulin administration to be used as a reference  Limits the number of UAP’s who will administer insulin

Delegation Delegation of Insulin cont.  Supervisory visits at least 3 times in first 60 days (1 within first 2 weeks)  Make supervisory visits if there are changes in the client’s status  Provide written instructions including physician orders for the performance of the insulin administration to be used as a reference  Written permission for delegation

Delegation Tasks PROHIBITED from Delegation  Assessment  Formulation of care plans  Health teaching/counseling  Calculation of medications  Administration of initial dose of a medication

Delegation Case Studies

Delegation Questions

Delegation References: American Nurses Association & National Councils of Boards of Nursing (2007). Joint Statement on Delegation. Retrieved from: Board of Nursing Practice Act (2009). Texas Board of Nursing for the State of Texas Resha, C. (2010). Delegation in the school setting: Is it a safe practice? The Online Journal of Issues in Nursing, 15(2), Manuscript 5. Retrieved from: MainMenu Categories/ANAMarketplace/ANAPeriodicals/ OJIN/TableofContents /Vol152010/No2May2010/Delegation-in-School-Setting.aspx National Association of School Nurses (2010). Delegation Position Statement. Retrieved from: Advocacy/ PositionPapersandReports/NASNPositionStatements FullView/ tabid/462/smid/824/ArticleID/21/ Default.aspx