Delegation to Unlicensed School Personnel, What Are the Issues?

1. Delegation to Unlicensed School Personnel, What Are the Issues? Karen Erwin, RN, MSN Education School Nurse Consultant Sandi Clark, RN, KY DPH Pediatric Section Supervisor/ School Health Nurse Sharon Eli Mercer, RN, MSN, KY Board of Nursing, (Retired)

2. THE ISSUE • The numbers of children attending school with special healthcare needs & complex medical conditions continue to increase • In the U.S, 26.6% of children have special healthcare needs (Van Cleave, Gortmaker, & Perrin, 2010) • Federal laws mandate schools to provide ALLstudents equal opportunity to participate in academic, nonacademic, & extracurricular activities (including school-sponsored field trips)

3. THE ISSUE • Students who require health services may not be excluded or denied access to school or school sponsored activities • Not all school children have access to a registered professional school nurse

4. Federal Laws Three Federal Laws protect students with disabilities: • Section 504 of the Rehabilitation Act 1973 • Title II of the American Disabilities Act of 1990 (ADA) • Individuals with Disabilities Education Improvement Act (IDEIA), reauthorized in 2004

5. Delegation Defined • Transferring the responsibility of performing a nursing activity to another person, while retaining accountability for the outcome. Sources: American Nurses Association (ANA)/National Council of State Boards of Nursing (NCSBN) 2006 National Association of State School Nurse Consultants (NASSNC) 2010

6. NASNPosition on Delegation Position of NASN • Delegation of nursing tasks in school setting can be a valuable tool for school nurse • Based on the nursing definition of delegation • In compliance with state nursing regulations and guidance

7. Delegation of Nursing Care • Delegation of nursing care is a legal term • Legal parameters for nursing delegation defined by State Nurse Practice Acts, State Board of Nursing guidelines and Nursing Administrative Regulations/Rules • Delegation of Nursing Tasks not allowed in some states

8. Delegation of Nursing Care • RN determines when appropriate to delegate • Delegation may not be appropriate for all students or all school nursing practices

9. Delegation of Nursing Care • The only component of the nursing process that may be delegated is Intervention with Supervision; • Assessment, Diagnosis, Planning and Evaluation may NOT be delegated (Source: ANA (2005) and NASN(2005

10. Factors to Consider • Complexity of task • Predictability of outcomes • Availability/competency of UAP • Type and supervision required for UAP (ANA,2012

11. Components of Delegation • Based on student assessment by RN • Determined on a case by case basis • Needs and condition of the student • Stability and acuity of student’s condition • Potential for harm

12. Delegation of Nursing Activities Kentucky Board of Nursing provides guidance of nursing activities through • Nursing laws (statutes)/scope of practice (KRS 314) • Administrative Regulations • Advisory Opinion Statements

13. Delegation in School Setting School Nursing Laws • KRS 314.011 (6) Registered nursing practice - use of substantial specialized knowledge, judgment and nursing skill - May practice independently - May delegate appropriate nursing tasks to unlicensed personnel

14. Delegation in School Setting School Nursing Laws • KRS 314.011 9 (10) Licensed practical nursing practice - Must be supervised by RN, physician or dentist - May not delegate, train or supervise unlicensed school personnel

15. Delegation in School Setting • Selected nursing task transferred to a competent unlicensed individual (UAP) in a specific situation • Decision to delegate and supervise nursing task in the school setting is the sole responsibility of the registered nurse

16. Decision to Delegate Determination to delegate based on: • Nursing assessment • Compliance with applicable laws • Guidance by professional nursing associations, i.e., American Nurses Association (ANA) and National Council of State Boards of Nursing (NCSBN) • H.A.N.D.S Sample Delegation Tree (handout)

17. Delegated Nursing Task Supervision Supervising Registered Nurse must: • Periodically monitor and assess capabilities and competencies to assure delegated tasks are safely performed • RN determines how closely and how often supervision and reassessment is done

18. Delegation in Schools • Nursing tasks done in home setting becomes more complex in school setting • Parents may not understand why a seemingly higher standard is required • School nurses must meet state nursing law, federal mandates, parental expectations and other state laws related to education

19. Rationale in Delegation • The Registered Nurse is the appropriate professional to delegate nursing care. • In 2005, ANA clearly stated that registered nurses should not delegate steps in the nursing process including nursing assessment or the use of nursing judgment

20. Factors in Delegating • State laws, rules and regulations • Safety issues • Medical needs of students • School practice characteristics • UAP competencies

21. Five Rights of Delegation • The Right Task • The Right Person • The Right Direction • The Right Supervision • The Right Circumstance (ANA/NCSBN, 2006)

22. ANA Principles for Delegation • Nursing profession determines scope of nursing practice • Nursing profession defines and supervises the education, training and utilization for any assistant roles involved in providing direct patient care • The RN takes responsibility and accountability for the provision of nursing practice

23. ANA Principles for Delegation • RN directs care and determines the appropriate utilization of any assistant involved in providing direct patient care • RN accepts aid from nursing assistive personnel in providing direct patient care

24. NASN Position on Role of the School Nurse and UAP • Use of UAP to perform delegated nursing tasks in the school setting is appropriate only if the school nurse is in control of the decision to delegate care task and an RN conducts the training and supervision of the UAP (NASN, 2011)

25. Recommended Qualifications for UAP • Education- e.g., high school diploma or higher, first aid and CPR certification, prior health care experience, training per school district policy • Personal attributes- e.g., willing to assume responsibility for assigned tasks, works within job description, able to understand and follow direction of school nurse

26. Recommendations • Interpersonal attributes- e.g., maintains confidentiality of information, communicates clearly, enjoys working with children • Emergency effectiveness- e.g., remains calm and demonstrates good judgment when the unexpected occurs, knows how and when to call emergency medical services and or school nurse (NASN, 2005)

27. Roles and Responsibilities of UAP • Maintain competence to perform the delegated task • Ask questions if directions are not understood • Follow directions and guidelines provided • Communicate concerns promptly • Report observations and activities to the delegating school nurse • Document provision of care as directed (NASN, 2005)

28. LPN/LVN vs UAP Scope of Practice • LPN/LVN have their own license and scope of practice • RN “assigns” to the LPN/LVN • RN cannot “assign” nursing activities that are outside the scope of the LPN/LVN • The LPN/LVN scope of practice will vary from state to state

29. LPN/LVN vs UAP Scope of Practice • RN “delegates” to the Unlicensed Assistive Personnel (UAP) • UAP has no scope of practice

30. Use of unlicensed assistive personnel (UAP) to perform delegated nursing task in the school setting is appropriate only if the school nurse is in control of the decision to delegate a health care task and a registered professional nurse conducts the training and supervision of the UAP (NASN Position Statement, “Unlicensed Assistive Personnel, The Role of the Nurse”, revised 2011)

31. Additional Resources • Shannon, R. and Kubelka, S. (2013) Reducing the Risks of Delegation, Use of Procedure Skills Checklists for Unlicensed Assistive Personnel in Schools, Part 1. NASN School Nurse, 28(4), 178-181. doi:10.1177/194260X13489886 • Shannon, R. and Kubelka, S. (2013) Reducing the Risks of Delegation: Use of Procedure Skills Checklists for Unlicensed Assistive Personnel in Schools, Part 2. NASN School Nurse, 28(5), 222-226. doi: 10.1177/1942602X1340030

32. ContactInformation • Sandi Clark, RN, KY DPH, Pediatric Section Supervisor and School Health Nurse Consultant: SandiK.Clark@ky.gov • Karen Erwin, RN, MSN, KY DOE, Education School Nurse Consultant: Karen.Erwin@education.ky.gov • Sharon Eli Mercer, RN, MSN, KY Board of Nursing, Nurse Practice Consultant (retired)

33. Practice Application A middle school band is attending an in-state, 2 day competition 200 miles away. One of the students has been diagnosed this school year with diabetes and receives insulin. The student has fluctuating blood glucose levels and is not independent with their carb counting and insulin administration. One of the chaperones is a band member’s parent who is an RN, but not a school employee, and volunteers to administer the insulin. What factors should the school nurse consider in preparation for this field trip?