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Delegation and Supervision
Guidelines for Registered Nurses
Working With Unlicensed Assistive Personnel
Table of Contents
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Introduction
The Professional Nurse and UAP
Who are UAP?
What are the areas of concern when working with UAP?
What does ANA say about working with UAP?
What does the law say about working with UAP?
What is the difference in supervision, delegation and assignment
What parts of patient care may RNs delegate to UAP?
What guidelines may assist employer decision making?
What does the Tennessee Nurse Practice Act say about discipline?
Background
Summary
Selected References
Committee on Nursing Practice
Introduction
Historically, nursing aides were hired to assist Registered Nurses (RNs). They had clearly defined parameters for training, job content, responsibilities and role limitations. Many RNs were comfortable in the delegation of tasks to this health care team member.
Changes in the health care landscape have produced unlicensed health care workers with a variety of titles, training, roles and expectations in all patient care settings. The settings in which they function and the kinds of tasks they are being asked to perform have grown in complexity. These changes have caused confusion among RNs about the appropriate utilization of unlicensed health care personnel as well as concern about their own liability in determining tasks to be delegated to the unlicensed person.
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The Professional Nurse and UAP
Who are UAP?
Unlicensed Assistive Personnel (UAP) are individuals employed to function in an assistive role to the Registered Nurse (RN) and the Licensed Practical Nurse (LPN) in the provision of patient care. These patient care activities are most often delegated by and performed under the supervision of the RN. UAP are often permanently working as aides to RNs, assigned to and accountable to the RNs.
The roles of UAP are delineated by the employing organization’s policies, and they may be trained by the employer as certified nursing assistants (CNA’s), dialysis technicians, medical technicians, etc.
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What are the areas of concern when working with UAP?
UAP are trained to perform a task, to make basic observations, and to report. They are not trained in critical thinking, which would require them to interpret cues (Boucher, 1998). When UAP are required to care for patients who are acutely ill or are asked to perform increasingly complex tasks without adequate professional nursing supervision, the risk of negative patient outcomes is likely to increase.
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What does the American Nurses Association (ANA) say about working with UAP?
There is no substitute for professional nursing judgement and any decisions regarding delegation must be based on the welfare of the patient, no matter whether the patient is an individual, a family, or a community.
The ANA Code of Ethics for Nurses offers this principle related to delegation:
“The nurse acts to safeguard the client and the public when health care and safety are affected by the incompetent, unethical, or illegal practice of any person.”
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What does the law that regulates nursing practice in the state of Tennessee say about working with UAP?
The Nurse Practice Act in Tennessee, TCA § 63-7, defines the practice of professional nursing in Section 63-7-103 as follows:
(a) (1) “Practice of professional nursing” means the performance for compensation of any act requiring substantial specialized judgment and skill based on knowledge of the natural, behavioral and nursing sciences, and the humanities, as the basis for application of the nursing process in wellness and illness care”
(2) “Professional nursing” includes:
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A. Responsible supervision of a patient requiring skill and observation of symptoms and reactions and accurate recording of the facts;
B. Promotion, restoration and maintenance of health or prevention of illness of others;
C. Counseling, managing, supervising and teaching of others;
D. Administration of medications and treatments as prescribed by a licensed physician, dentist, podiatrist or nurse authorized to prescribe pursuant to 63-7- 123.
E. Application of such nursing procedures as involve understanding of cause and effect;
F. Nursing management of illness, injury or infirmity including identification of patient problems.
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What is the difference in supervision, delegation and assignment?
Supervision, in its broadest sense, is the active process of directing, guiding and influencing the outcome of an individual’s performance on a task or activity. Supervision thus includes aspects of both delegation and assignment.
Delegation means passing along the responsibility for an activity or performance of a task, but not the accountability for the process or the outcome of the task. Tasks therefore may be delegated to the UAP, but accountability remains with the registered nurse and the employing agency.
Assignment of an activity or task from one person to another includes the shift of responsibility and accountability for the performance of the activity or task. This may include other licensed personnel who are given assignments appropriate to their license and current experience and skills. UAP are not assigned responsibility or accountability. Therefore, overall supervisory responsibility remains with the person making the assignment, e.g., the RN, representatives of employing agencies, or the agency itself.
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What parts of patient care may the RN safely and legally delegate to UAP?
Administrative Rule 1000-1-.04(2)(c) of the Tennessee Board of Nursing defines “assisting” and “adequate supervision” and describes the tasks usually delegated to assistive personnel.
“…Assisting is defined to mean helping, aiding or cooperating. Adequate supervision is defined to mean overseeing or inspecting with authority. The basic responsibility of the individual nurse who is required to supervise others is to determine which of the nursing needs can be delegated safely to others, and whether the individual to whom the duties are entrusted must be supervised personally. The following are tasks commonly performed by such persons:
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1. Answers patients’ signals, provides necessary assistance in conformance with delegated tasks, and notifies the appropriate nurse when the situation so indicates.
2. Assists with the admission, transfer and discharge of patients.
3. Assists with the dressing and undressing of patients.
4. Assists with the patients’ baths.
5. Assists with the measuring of fluid intake and output of patients and the records on appropriate forms.
6. Assists with the collection of urine, stool, and sputum specimens.
7. Assists with the feeding of patients
8. Assists with the weighing of patients.
9. Assists with the making of patients’ beds.
10. Assists with the application and removal of such protective devices as side rails, footboards, bed cradles….”
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What guidelines may assist decision-making if the employer has added skills to the UAP job description other than those specified in the Rules of the Board of Nursing?
The responsibility remains with the RN to maintain a “nursing presence” with the patient, to value what she or he knows, and to delegate effectively (Boucher, 1998).
The Registered Nurse may delegate to UAP when there is:
Low potential for harm – The greater the risk for harm, the less likely it is that the task is one that is appropriate for delegation. Harrell (1995) defines harm as “increased risk for infection, hemorrhage, hypoxemia, nerve damage, or psychological distress.” Black’s Law Dictionary defines harm as “…the existence of loss or detriment in fact of any kind to a person resulting from any cause.” The professional nurse must determine not only the nature of the task but the status of the patient for whom the task is being performed in deciding potential for harm.
Minimal complexity of nursing activities –When critical thinking and interpretation of complex cues are required, delegation to UAP is not appropriate. Nursing judgment is not a skill possessed by UAP. (Harrell, 1995)
Minimal required problem solving and innovation – When independent problem solving and flexible interventions are required, these are not activities that should be delegated. Routine, controllable tasks are appropriate for delegation. (Harrell, 1995)
High predictability of outcome – When the outcome of the patient care activity is reasonably predictable, it is appropriate to delegate. For example, a first post-operative ambulation should usually require the presence of a licensed person, while subsequent ones may be delegated. Even a more complex activity may be delegated to well-trained, competent UAP when a patient’s typical response to the activity has been established, and a safe routine planned for that activity, e.g., ambulation of a patient who always experiences a degree of vertigo when standing. (Harrell, 1995)
Ample opportunity for patient interaction with the RN – The patient should always know who her/his registered nurse caregiver is for that shift, and should know to whom the UAP are answerable. In some cases, the RN may choose to provide care that could have been delegated in order to spend more time with the patient for the purpose of assessment. This choice must be made carefully with consideration for the impact on performance of professional activities related to other patients. (Harrell, 1995)
Adequate RN ability to supervise the delegated activity and its outcome – There are always barriers to delegation activities:
(1) Agency policies and procedures may be outdated (i.e., “we can’t do it; it is against policy.”) Examination and revision of some policies and procedures may free the professional nurse to create a safe, effective environment for appropriate delegation.
(2) Inadequate training of UAP as well as inadequate orientation to the specific nursing unit and types of patients are often obstacles in planning delegation. A competency based UAP training program, which the licensed nursing staff has helped develop and is familiar with, provides a standard on which to base delegatory decisions.
(3) Lack of skill in supervising, teaching and mentoring a less-skilled person. Often licensed staff (who may have “grown up” with a form of primary care delivery) do not know how to appropriately accomplish work through others and would benefit from additional education.
(4) Lack of confidence and trust between licensed professionals and UAP. This may occur when either is a relatively new employee, when either perceives the other as minimally prepared or incompetent, when UAP fear having the majority of the workload “dumped” on them, when experienced UAP do not feel trusted, or when UAP are asked to perform tasks which they do not feel prepared to perform, and are afraid of alienating the RN by making this known.
(5) Concerns about legal accountability. Delegation must be consistent with the practice act of the state, the rules of the Board of Nursing, and the specific facility or agency policies and procedures. (Harrell, 1995)
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In relation to delegating activities to UAP, what does the Tennessee Nurse Practice Act say about disciplining the RN?
In TCA §§63-7-115(a)(1), the law states: “The board has the power to deny, revoke or suspend any certificate or license to practice nursing or to otherwise discipline a licensee upon proof that the person:
(F) Is guilty of unprofessional conduct;…”
The Administrative Rules of the Tennessee Board of Nursing define unprofessional conduct of the RN and include the following actions related to delegation or assignment that are subject to disciplinary procedures.
Rule 1000-1-.13(1) Unprofessional conduct, unfitness, or incompetency by reasons of negligence, habits or other causes, as those terms are used in the statute, is defined as, but not limited to, the following [includes items (a) through (u)]:
(l) Assigning unqualified persons to perform functions of licensed persons or delegating nursing care functions and tasks and/or responsibilities to others contrary to the Nurse Practice Act or rules and regulations to the detriment of patient safety;
(m) Failing to supervise persons to whom nursing functions are delegated or assigned;
(r) Failing to take appropriate action in safeguarding the patient from incompetent health care practices;
(s) Failing to report, through proper channels, facts known to the individual regarding incompetent, unethical or illegal practice of any health care provider.
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Background
The impact of increased use of UAP on patient care and outcomes is difficult to define and measure because multiple perspectives must be considered: patients, families, professional nurses, licensed practical nurses, physicians, facilities or agencies, and society. Efforts to measure this impact should include morbidity and mortality, a variety of quality of care outcomes, and satisfaction of patients, families, nurses, physicians, UAP and employing agencies. Although patients and families may not be aware of professional standards of care, satisfaction measures of outcomes from them are of some value. Of greater value in considering the impact of UAP are three recent publications, two from the University of Iowa and another from New York University, showing that inpatient care units with higher proportions of care delivered by registered nurses have lower rates of adverse patient outcomes. (Blegen & Vaughn, 1998; Blegen, Goode & Reed, 1998; Kovner & Gergen, 1998)
A significant concern among health care providers is the valuing of cost containment over quality outcomes. The UAP can be trained to perform a variety of patient care tasks. As cross-trained personnel, they may move freely between or among nursing units, and appear to be a less expensive use of human resources for the employing agency. Amid the rising profits and prolific physical plant expansions of institutions (Kusserow, 1992), the benefit of employing UAP is measured in accounting terms (Flood & Diers, 1988). However, accounting is the least effective tool for measuring patient outcomes. Until existing research that measures the patient outcome in terms of safety and quality of care is utilized by institutions, the increase in mortality and morbidity will continue (Modern Healthcare, 1993).
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Summary
The RN retains the accountability for actions of the unlicensed persons (UAP) under her/his supervision. Therefore, it is incumbent upon the professional nurse to:
> know the policies and procedures of the institution regarding use of UAP
> know the Tennessee Nurse Practice Act and the Administrative Rules of the Board of Nursing regarding delegation
> ensure that the employing agency is aware of the law and the rules in relation to use of UAP
> participate in development of standardization of UAP training programs within the employing institution
> know the background and skill level of all UAP and request a history of training or demonstration of tasks from the new and unknown UAP
> improve delegatory and supervisory skills that include trust building with UAP, making patients aware of the RN role as well as the role of UAP
> participate in any studies of the utilization of UAP at the employing institution
It is beyond the scope of this document to address RN supervision of other licensed health care professionals. Resources such as position papers that address this supervisory role can be obtained by contacting specialty nursing associations. The Emergency Nurses Association has a position paper entitled “The Use of Non-Registered Nurse Caregivers in Emergency Care” that can be found, along with others, on their website at www.ena.org. Rules that govern the licensure requirements of health care facilities (Chapter 1200-8) may be obtained from the Department of Health, Bureau of Manpower and Facilities Administration by calling 615/741-8402.
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Selected References
American Nurses Association. (1996). Registered professional nurses & unlicensed assistive personnel. Washington DC: American Nurses Publishing.
Blegen, M.A. & Vaughn, T. (1998). A multisite study of nurse staffing and patient occurrences. Nursing Economics, 16 (4), 196-203.
Blegen, M.A., Goode, C.J., & Reed, L. (1998). Nurse staffing and patient outcomes Nursing Research, 47 (1), 43-49.
Boucher, M.A. (1998). Delegation alert! American Journal of Nursing, 98 (2), 26-32.
Harrell, M.S. (1995). Practical strategies for delegation and team building in a redesigned environment. Seminars for Nurse Managers, 3, 180-184.
National Council of State Boards of Nursing, Inc. (1995) Delegation: concepts and decision-making process. Chicago, IL: National Council Publishing.
Parkman, C. (1996). Delegation: Are you doing it right? American Journal of Nursing, 96, (9), 43-47.
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Tennessee Nurses Association
Committee on Nursing Practice
1996-1998
Dava Shoffner, Chairperson
Susan Adams, At-Large Member
Karen Bell, Staff Nurse Council
Jean Blackburn, Psychiatric-Mental Health Nursing Council
Mary Donovan, At-Large Member
Jeanne Drost, Staff Nurse Council
Karen Emison, Advanced Practice Council
Delores Fox, Gerontological Council
Christa Hedstrom, Nursing Administration Council
Edna Mason, Staff Nurse Council
Brenda Mills, Representative, ANA Institute on Practice
Elaine McIntosh, Advanced Practice Council
Delores Philpot, Nursing Education Council
Leslie Reed, Maternal-Child Nursing Council
Julie Rosof, Forensic Nursing Council
Rosalie Seymour, Nursing Education Council
Pat Speck, Forensic Nursing Council
Ben Stafford, At-Large Member
Judy Thompson, At-Large Member
Sharon Adkins, Past President, Tennessee Nurses Association
Peggy Strong, President Tennessee Nurses Association – ex-officio
The Nurse Practice Act and The Board of Nursing Administrative Rules may be obtained at no charge from:
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