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Scope
of Practice Decision Tree
Delegation
Guidelines
Find
answers to questions about the practice of nursing in Maine.
Questions Specific
to:
Position Statements
Joint Advisory
Opinions
Gastrostomy
Tubes
Role of the Registered
Professional Nurse in the Coordination and Oversight of Unlicensed
Assistive Personnel (UAP) regarding Gastrostomy Tubes (G-Tubes)
The Maine State
Board of Nursing issues this Position Statement to guide the
practice of nursing. The Board's primary concern is the health
and safety of consumers.
The purpose of
this position statement is to provide guidelines/criteria
that define the conditions under which the registered professional
nurse (RN) may coordinate and oversee the task of
G-tube care to UAP in populations with developmental disabilities.
In certain circumstances the RN may coordinate and oversee
the execution of tasks related to G-tube maintenance, feeding,
and administration of prescribed medications.
The RN must complete
a thorough assessment of the consumer's nursing care needs,
taking into consideration the consumer's overall medical condition.
Assessment of the consumer's need related to the G-tube includes
the condition of the G-tube (e.g., the maturity of the stoma
site, patency, and sustained skin integrity) and designating
the appropriate care giver. The RN is responsible for communication
and consultation regarding provision of G-tube services.
All UAP providing
G-tube care must be at a minimum Certified Residential Medication
Aides (CRMA).
The RN is responsible
to develop an instructional plan for the UAP and maintain
documentation of instructional activities. Part of the instructional
plan shall include a mechanism to evaluate competency.
Individual written
plans that address the consumer's needs must be available
for the UAP at the site at which care is rendered. Information
must be updated as needed The plan must include contingency
provisions to address unexpected G-tube occurrences.
If the stability of staffing patterns changes within a program
providing G-tube care
and consumer safety can no longer be ensured, the RN has the
authority in accordance with Chapter 6 Regulations Relating
to Coordination and Oversight of Patient Care Services by
Unlicensed Health Care Assistive Personnel to determine whether
or not the UAP may continue to provide G-tube care to the
specific consumer and report this determination to the administration
of the organization.
Approved by Board of Nursing March 1-2, 2006
Orientation
of New Graduates
Questions have
been raised regarding the hiring and utilization of new graduates
from nursing programs by health care facilities prior to the
person's licensure. Technically, these individuals are unlicensed
assistive personnel since they are not eligible to be classified
as registered professional nurse (RN) applicants or licensed
practical nurse (LPN) applicants. However, to differentiate
them from certified nursing assistants and other unlicensed
assistive personnel, it is recommended that these individuals
be referred to as new graduates. These new graduates may not
refer to themselves as RNs or LPNs and may not practice as
RNs or LPNs.
32 MRSA Section
2102 2. H. and Chapter 6 Regulations Relating to Coordination
and Oversight of Patient Care Services by Unlicensed Assistive
Personnel allow a registered professional nurse to coordinate
and oversee certain nursing tasks consistent with the standards
set forth in the regulation.
The Board has considered
the issue of the orientation of new graduates prior to licensure.
Orientation and preparation for the role of a licensed nurse
is an important aspect of a new nurse's career. It is recognized
that orientation involves both didactic and clinical components.
For purposes of orientation prior to licensure, the new graduate
must be in a structured setting with a defined educational
program for the orientation of new graduates. Conversely,
if the employer does not meet this requirement, it is not
appropriate to employ the new graduate until he or she is
licensed.
The employers
of new graduates should utilize the following criteria for
orientation of a new graduate prior to licensure.
1. The new graduate
shall have submitted an application for examination to NCLEX.
2. The new graduate
shall have submitted an application for licensure to the Board
and have been declared eligible by the Board to take the examination
prior to beginning orientation. Upon declaration of eligibility
to test by the Board, the applicant is mailed an Authorization
To Test (ATT) letter by the test service. The new graduate
should provide a copy of the ATT to the employer to show evidence
of having applied to the Board for licensure.
3. A registered
professional nurse preceptor must be designated as the responsible
individual to provide continuous, on-site supervision for
the new graduate. However, a registered professional nurse
may designate a licensed practical nurse to participate in
the orientation for the graduate of a practical nursing program.
4. The new graduate
may not engage in independent nursing responsibilities such
as: delegating nursing functions to other nursing personnel,
and independently passing medications or administering intravenous
therapy. The new graduate should not be part of the facility's
staffing pattern, i.e. does not carry a patient assignment.
5. New graduates
are required to pass the NCLEX examination within three months
of starting orientation. If the individual is not licensed
by the end of a three month orientation period or has failed
the first attempt at the NCLEX examination, the new graduate
may function only as an unlicensed assistive personnel(UAP).
Role
of RN in Dialysis Therapy
The Maine State
Board of Nursing issues this Position Statement to guide the
practice of dialysis nursing. The Board's primary concern
is the health and safety of patients.
This Position Statement
delineates nursing roles and responsibilities for the safe
delivery of specialized health care in the dialysis setting.
The Board supports the collaborative role of the registered
professional nurse (R.N.) with members of a multidisciplinary
team in the provision of care to individuals undergoing dialysis
therapy for either acute or chronic renal failure. The Board
believes that the overall accountability and responsibility
for nursing care provided to patients and the coordination
of patient care activities, including the provision of many
specific dialysis-related assessments and interventions, rests
with the registered professional nurse. Specifically, the
registered professional nurse is responsible for pre-assessment,
ongoing assessment and post assessment of the dialysis patient.
Unlicensed assistive
personnel in dialysis settings are individuals who are trained
to function in an assistive role in the provision of patient
care activities. The registered professional nurse is responsible
for continuous assessment of the patient's condition and care
needs, and for recognizing the unlicensed assistive person's
competencies and skills.
Training of the
unlicensed assistive person must be in accordance with a detailed
curriculum with outcome measures identified to evaluate the
trainee. Technological changes should be the basis for updating
competency of registered professional nurses and unlicensed
assistive personnel in providing dialysis care.
School
Nursing
The Maine State
Board of Nursing issues this Position Statement to guide the
practice of school nursing. The Board's primary concern is
the health and safety of students.
Children with special
care needs and children who are technology dependent are guaranteed
the right to a free, appropriate public education, in the
least restrictive environment, by a series of Federal laws
and State law.
The goals of school
nursing are the modification or removal of health related
barriers to learning and the promotion of an optimum level
of wellness.
This Position Statement
delineates nursing roles and responsibilities for the safe
delivery of specialized health care in the educational setting.
The registered
nurse practicing as a school nurse:
1. Develops a
nursing care plan for every student with special health
care needs
requiring nursing assessment, intervention or supervision;
2. Ensures that
the student and his/her family are involved in all decision
making
related to provision of health care in school;
3. Participates
as a member of the Individualized Education Program (IEP)
team; the nurse incorporates the care plan into the IEP;
and
4. Ensures that
the necessary and appropriate resources are available to
all
persons who are responsible for providing school health
care before a child
is placed in a classroom.
The registered
nurse practicing as a school health nurse makes decisions
about the delegation of nursing activities to unlicensed persons
in the school based on the regulations of the Board of Nursing.
Children With Special Care Needs And/Or Technology Dependent
Children
The registered
nurse practicing as a school nurse:
Determines the
level of personnel needed to care for the child in the school
setting, in consultation with the child's primary physician,
parents, the child, the nurse coordinating the child's home
care, when applicable, and a designated school representative;
1. The nurse bases
decisions about the level of personnel needed to provide nursing
care in the school on:
a. the stability
of the child's medical condition;
b. the complexity and acuteness of the observations and
judgments the caregiver
must make during the school day;
c. the nature, frequency and complexity of prescribed treatments
the child requires;
d. the number, types, routes of administration and potential
for adverse reactions of medications the child receives
in school;
e. the need to assess the child for PRN medications and
treatments;
f. the child's ability to communicate his or her needs to
the caregiver;
g. the knowledge base and proficiency of psychomotor skill
required of the direct
care provider; and
h. the level of preparation and experience of the direct
caregiver.
2. Develops a nursing
care plan for every child with an identified health care need;
3. Includes provisions
in the nursing care plan to ensure that provisions are made
for the continuation
of safe care during transportation to and from school;
4. Integrates the
nursing care plan with the IEP, when one exists; and
5. Determines what
nursing tasks may be delegated, to whom, and under what conditions,
based on
the following:
a. the child's
health status, including the stability and chronicity of
health problems;
b. the nature and complexity of tasks to be performed; and
c. the extent of supervision the nurse is required to provide
to ensure the tasks are
safely carried out.
The registered
nurse ensures that there are written guidelines or protocols
addressing possible medical emergencies the child may experience
in the school setting. Guidelines should include:
1. the definition
of a medical emergency for this child;
2. individuals to be notified when an emergency occurs;
3. identification of the person who will initiate and direct
the action to be taken;
4. specific action to be taken in this emergency;
5. transport specifications (internal and external), who
will provide it, and to where; and
6. the format for documentation of actions taken in a medical
emergency.
Technology Dependent Children
The registered
nurse practicing as a school nurse is the coordinator/facilitator
of nursing care in the school, and may not necessarily be
the direct care provider, for children who are technology
dependent.
In coordinating or facilitating care, the registered nurse:
1. evaluates
the admission of a specific child to a specific school;
2. ensures placement of the child in a safe, accessible
classroom within the school;
3. assesses the school and community environment and necessary
resources to ensure a safe education setting; and
4. ensures that school personnel have the health care information
necessary to create an environment in the classroom which
is conducive to learning.
June 16, 1993
Schedule
II Drug Prescriptive Authority
Schedule II
Drug Prescriptive Authority by Nurse Practitioners and Certified
Nurse-Midwives (NP and CNM)
Purpose:
To clarify the
roles and responsibilities of physicians, nurse practitioners,
and nurse midwives regarding the prescription of Schedule
II drugs
History:
The statutes and
rules of health care regulatory agencies define the parameters
of the scope of practice of the licensed practitioner. Respective
boards provide the outside parameters of scope of practice
beyond which practice may not be exceeded by their licensees.
32 MRSA Sec. 3270-A
(BOLIM) provides the statutory framework for delegation of
medical acts by physicians, and Chapter 3 of the BOLIM rules
provides that Schedule II drug prescriptive authority may
NOT be delegated to nurse practitioners or certified nurse
midwives practicing under delegation. The rule provides for
petition by the physician for an exemption on a case by case
basis. The BOLIM, to date, has not looked at the issue of
allowing the delegation of Schedule II prescriptive authority
based solely on the basis that the nurse practitioner or nurse
midwife, if practicing under the MSBON rules' scope of practice,
could so prescribe.
32 MRSA Sec. 2102
2-A (MSBON) grants prescriptive authority to NPs and CNMs.
Chapter 8 of the MSBON rules provides that Schedule II drugs
may be prescribed by NPs and CNMs as part of their regular
scope of practice.
JOINT AGREEMENT
The Boards agree that there are three situations where the
question of Schedule II prescriptive authority arises.
Situation 1:
The NP or CNM is practicing in "independent" practice
according to the statute and rules of the MSBON. The Boards
agree that this individual may prescribe Schedule II drugs.
Situation 2:
The NP or CNM who chooses to practice under the delegation
of a physician, in accordance with 32 MRSA 2205-B(3) may NOT
prescribe Schedule II drugs because of the limitation of delegation
placed upon the physician by the BOLIM. The BOLIM's rule provides
for petition for an exception on a case by case basis.
Situation 3:
NPs and CNMs who work under delegation at a health care institution
as required by the rules governing membership or employment
at the facility whose rules or bylaws prohibit Schedule II
prescribing by other than fully licensed physicians or appropriate
delegated licensed staff, the scope of practice may be made
more restrictive, but not less. That institution may be a
clinic, hospital, nursing home or other health care provider.
When the NP or CNM accepts a contract, real or implied, to
abide by the rules of the institution, the NP or CNM may NOT
prescribe Schedule II substances.
In the instance
where a NP or CNM works in multiple settings which include
multiple categories, the NP or CNM may prescribe Schedule
II drugs only when working in "independent" practice
settings.
Signed by chairmen
of both the MSBON and BOLIM December 11, 2001
Telephone
Orders
Purpose:
1. To clarify the
roles and responsibilities of physicians and nurses regarding
telephone orders.
2. To insure public
protection and assure quality of care.
Physicians, nurses
and other health care providers rely on the professional skills
and integrity of all participants in the health care delivery
process.
Physicians are
responsible to assure that the orders communicated are appropriate
to the situation, and that orders are accurately relayed from
the physician's office.
Nurses may accept
physician orders via telephone from office personnel designated
by the physician. In receiving orders from physician offices,
nurses are responsible for recognizing the appropriateness
of the order with respect to the plan of care, and for implementing
the order or obtaining clarification.
Dated: February
1995
The
Use of Prehospital Personnel in the Hospital
Purpose:
1. To provide clarification of the role of the registered
professional nurse in the supervision and training of prehospital
personnel (EMT through paramedic).
2. To provide
clarification of the role of the prehospital provider in the
hospital.
Opinion:
The registered professional nurse may participate as an instructor
or preceptor for prehospital personnel who are in the hospital
to receive initial or refresher training.
The registered
professional nurse may not delegate nursing functions to prehospital
personnel.
The registered
professional nurse who delegates nursing functions to prehospital
personnel will be in violation of 32 MRSA Sections 2102(C)
and (D) and 2105-A (2) (D).
Prehospital personnel
are not licensed by the Board of Emergency Medical Services
to perform any skills in the hospital other than during their
training and in completing the transfer of their patient to
the hospital staff.
Prehospital personnel
will be functioning in direct conflict with 32 MRSA Section
2106(3) (Law Regulating the Practice of Nursing) if they are
employed by the hospital to perform nursing functions.
Approved by Board
of Nursing and Board of Emergency Medical Services
Dated: February
11, 1992
Delegation
Guidelines
Delegation:
Concepts and Decision-Making Process
Introduction
To meet the public's
increasing need for accessible, affordable, quality health
care, providers of health care must maximize the utilization
of every health care worker and ensure appropriate delegation
of responsibilities and tasks. Nurses, who are uniquely qualified
for promoting the health of the whole person by virtue of
their education and experience, must be actively involved
in making health care policies and decision; they must coordinate
and supervise the delivery of nursing care, including the
delegation of nursing tasks to others.
Issues related
to delegation have become more complex in today's evolving
health care environment, creating a need for practical guidelines
to direct the process for making delegatory decisions. Accordingly,
this paper expands and builds upon the National Council's
1987 and 1990 conceptual and historical papers on delegation
by presenting a dynamic decision-making process and practical
guidelines for delegation.
Purpose
The purpose of
this paper is to provide a resource for Boards of Nursing,
health policy makers, and health care providers on delegation
and the roles of licensed and unlicensed health care workers.
The paper emphasizes and clarifies the responsibility of Boards
of Nursing for the regulation of nursing, including nursing
tasks performed by unlicensed health care workers, and the
responsibility of licensed nurses to delegate nursing tasks
in accord with their legal scopes of practice. It provides
a decision-making tool which can be used in clinical and administrative
settings to guide the process of delegation. This paper also
describes the accountability of each person involved in the
delegation process and potential liability if competent, safe
care is not provided.
Premises
The following premises
constitute the basis for the delegation decision-making process.
1. All decisions
related to delegation of nursing tasks must be based on
the fundamental principle of protection of the health, safety
and welfare of the public.
2. Boards of Nursing are responsible for the regulation
of nursing. Provision of any care which constitutes nursing
or any activity represented as nursing is a regulatory responsibility
of Board of Nursing.
3. Boards of Nursing should articulate clear principles
for delegation, augmented by clearly defined guidelines
for delegation decision.
4. A licensed nurse must have ultimate responsibility and
accountability for the management and provision of nursing
care.
5. A licensed nurse must be actively involved in and be
accountable for all managerial decisions, policy making
and practices related to the delegation of nursing care.
6. There is a need and a place for competent, appropriately
supervised, unlicensed assistive personnel in the delivery
of affordable, quality health care. However, it must be
remembered that unlicensed assistive personnel are equipped
to assist - not replace - the nurse.
7. Nursing is a knowledge-based process discipline and cannot
be reduced solely to a list of tasks. The licensed nurse's
specialized education, professional judgment and discretion
are essential for quality nursing care.
8. While nursing tasks may be delegated, the licensed nurse's
generalist knowledge of patient care indicates that the
practice-pervasive functions of assessment, evaluation and
nursing judgment must not be delegated.
9. A task delegated to an unlicensed assistive person cannot
be redelegated by the unlicensed assistive person.
10. Consumers have a right to health care that meets legal
standards of care. Thus, when a nursing task is delegated,
the task must be performed in accord with established standards
of practice, policies and procedures.
11. The licensed nurse determines and is accountable for
the appropriateness of delegated nursing tasks. Inappropriate
delegation by the nurse and/or unauthorized personnel may
lead to legal action against the licensed nurse and/or unlicensed
personnel.
Definitions
Accountability
..... Being responsible and answerable for actions or inactions
of self or others in the context of delegation.
Delegation ........... Transferring to a competent individual
the authority to perform a selected nursing task in a selected
situation. The nurse retains accountability for the delegation.
Delegator ............ The person making the delegation.
Delegatee ............ The person receiving the delegation.
(a.k.a. Delegate)
Supervision ......... The provision of guidance or direction,
evaluation and follow-up by the licensed nurse for accomplishment
of a nursing task delegated to unlicensed assistive personnel.
Unlicensed Assistive Personnel (UAP) .. Any unlicensed personnel,
regardless of title, to whom nursing tasks are delegated.
Regulatory Perspective:
A Framework for Managerial Policies
Boards of Nursing
have the legal responsibility to regulate nursing and provide
guidance regarding delegation. Registered Nurses (RNs) may
delegate certain nursing tasks to Licensed Practical Nurses/Vocational
Nurses (LPN/VNs) and unlicensed assistive personnel (UAP).
In some jurisdictions, LPN/VNs may also delegate certain tasks
within their scope of practice to unlicensed assistive personnel.
The licensed nurse has a responsibility to assure that the
delegated task is performed in accord with established standards
of practice, policies and procedures. The nurse who delegates
retains accountability for the task delegated.
The regulatory
system serves as a framework for managerial policies related
to the employment and utilization of licensed nurses and unlicensed
assistive personnel. The nurse who assesses the patient's
needs and plans nursing care should determine the tasks to
be delegated and is accountable for that delegation. It is
inappropriate for employers or others to require nurses to
delegate when, in the nurse's professional judgment, delegation
is unsafe and not in the patient's best interest. In those
instances, the nurse should act as the patient's advocate
and take appropriate action to ensure provision of safe nursing
care. If the nurse determines that delegation may not appropriately
take place, but nevertheless delegates as directed, the nurse
may be disciplined by the Board of Nursing.
Acceptable Use
of the Authority to Delegate
The delegating
nurse is responsible for an individualized assessment of the
patient and situational circumstances, and for ascertaining
the competence of the delegatee before delegating any task.
The practice-pervasive functions of assessment, evaluation
and nursing judgment must not be delegated. Supervision, monitoring,
evaluation and follow-up by the nurse are crucial components
of delegation. The delegatee is accountable for accepting
the delegation and for his/her own actions in carrying out
the task.
The decision to
delegate should be consistent with the nursing process (appropriate
assessment, planning, implementation and evaluation). This
necessarily precludes a list of nursing tasks that can be
routinely and uniformly delegated for all patients in all
situations. Rather, the nursing process and decision to delegate
must be based on careful analysis of the patient's needs and
circumstances. Also critical to delegation decisions are the
qualifications of the proposed delegatee, the nature of the
nurse's delegation authority set forth in the law of the jurisdiction,
and the nurse' personal competence in the area of nursing
relevant to the task to be delegated.
Delegation Decision-Making
Process
In delegating,
the nurse must ensure appropriate assessment, planning, implementation
and evaluation. The delegation decision-making process, which
is continuous, is described by the following model:
I. Delegation criteria
A. Nursing Practice Act
1. Permits delegation
2. Authorizes task(s) to be delegated or authorizes the nurse
to decide delegation
B. Delegator qualifications
1. Within scope of authority to delegate
2. Appropriate education, skills and experience
3. Documented/demonstrated evidence of current competency
C. Delegatee qualifications
1. Appropriate education, training, skills and experience
2. Documented/demonstrated evidence of current competency
Provided that this
foundation is in place, the licensed nurse may enter the continuous
process of delegation decision-making.
II. Assess
the situation
A. Identify the needs of the patient, consulting the plan
of care
B. Consider the circumstances/setting
C. Assure the availability of adequate resources, including
supervision
If patient needs,
circumstances, and available resources (including supervisor
and delegatee) indicate patient safety will be maintained
with delegated care, proceed to III.
III. Plan for
the specific task(s) to be delegated
A. Specify the nature of each task and the knowledge and skills
required to perform it
B. Require documentation or demonstration of current competence
by the delegatee for each task
C. Determine the implications for the patient, other patients,
and significant others
If the nature of
the task, competence of the delegatee, and patient implications
indicate patient safety will be maintained with delegated
care, proceed to IV.
IV. Assure
appropriate accountability
A. As delegator, accept accountability for performance of
the task(s)
B. Verify that delegatee accepts the delegation and the accountability
for carrying out the task correctly
If delegator and
delegatee accept the accountability for their respective roles
in the delegated patient care, proceed to V.
V. Supervise
performance of the task
A. Provide directions and clear expectations of how the task(s)
is to be performed
B. Monitor performance of the task(s) to assure compliance
to established standards of practice, policies and procedures
C. Intervene if necessary
D. Ensure appropriate documentation of the task(s)
VI. Evaluate
the entire delegation process
A. Evaluate the patient
B. Evaluate the performance of the task(s)
C. Obtain and provide feedback
VII. Reassess
and adjust the overall plan of care as needed
The Five Rights of Delegation provided an additional resource
to facilitate decisions about delegation.
______________________________________________________________________________
- The Five
Rights of Delegation
One that is delegable for a specific patient.
- Right Circumstances
Appropriate patient setting, available resources, and other
relevant factors considered.
- Right Person
Right person is delegating the right task to the right person
to be performed on the right person.
- Right Direction/Communication
Clear, concise description of the task, including its objective,
limits and expectations.
- Right Supervision
Appropriate monitoring, evaluation, intervention, as needed,
and feedback.
______________________________________________________________________________
Conclusion
The guidelines
presented in this paper provide a decision-making process
that facilitates the provision of quality care by appropriate
persons in all health care settings. The National Council
of State Boards of Nursing believes that this paper will assist
all health care providers and health care facilities in discharging
their shared responsibility to provide optimum health care
that protects the public's health, safety and welfare.
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