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SUMMARY
It is the position of the National Association of School Nurses (NASN) that all children and adolescents deserve safe and effective management of their health care needs (Gelfman &Schwab, 2001a). Further, NASN believes delegation is a tool that school nurses may use in implementing interventions outlined in a student’s Individualized Healthcare Plan (IHP). The safety and welfare of the individual student and the broader school community, not expediency, delivery of care model, or cost, must be the central focus of all decisions regarding delegation of nursing tasks and functions (National Council of State Boards of Nursing [NCSBN], 1997). The National Association of School Nurses supports appropriate delegation of nursing services in the school setting based on the nursing definition of delegation, requirements of state nurse practice acts, state regulations, guidelines provided by professional nursing organizations and the nursing assessment of the unique needs of the individual student. In many cases, the sound decision may be to not delegate. The practice pervasive functions of assessment, planning, evaluation, and nursing judgment cannot be delegated (NCSBN, 1997, 2005).
HISTORY
Delegation is a tool that may be used by the registered professional school nurse to allow unlicensed assistive personnel (UAP) to provide standardized routine health services under the supervision of the nurse, when permitted by the state Nurse Practice Act and supported by the nurse’s clinical judgment to be appropriate. There is increased utilization of delegation as a method to meet the health care needs of children in school because of a growing population of children with significant health needs. Advances in health care and technology offer greater opportunities for children with special health care needs to attend school. The incidence of chronic conditions such as asthma, diabetes, severe allergies, and seizure disorders in school-age children is increasing. Complex medical problems that were previously managed at inpatient settings are now being managed in the school setting. In addition, federal laws set requirements for the provision of health care to children in schools. Laws such as the Individuals with Disabilities Education Act (IDEA), Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act (ADA) of 1990 ensure that children with special health care needs have the right to be educated with their peers in the least restrictive environment (Section 504 Rehabilitation Act, 1973) and to receive support and accommodations for conditions that negatively impact their capacity for learning (Gelfman, 2001).
Delegation has been used effectively in some areas, but unsafe and illegal delegation in school settings can occur. It is important for school districts and school nurses, health care professionals, parents and the public to understand what can be delegated and when delegation is appropriate. Prior to delegation, a student assessment is required. The nurse can then determine what training and supervision is required for safe delegation to occur for this specific student. The legal parameters for nursing delegation are defined by State Nurse Practice Acts, State Board of Nursing guidelines, and Nursing Administrative Rules/Regulations (NCSBN, 2005). Delegation of nursing tasks is not allowed in some states.
DESCRIPTION OF ISSUE
Although delegation is a term used in other fields, it has a unique place and meaning in the practice of nursing. Delegation of nursing care is a legal term and a complex skill requiring sophisticated clinical judgment and final accountability for patients’ care (NCBSN, 2005). Effective delegation requires experience as a practicing nurse. Nursing defines delegation as transferring the responsibility of performing a nursing activity to another person while retaining accountability for the outcome (American Nurses Association [ANA], 1994; National Association of State School Nurse Consultants [NASSNC], 2000; NCSBN, 1995). Nurses are accountable to: (1) state laws, rules, and regulations, (2) employer/agency regulations, and (3) standards of professional school nursing practice, including those pertaining to delegation. The decision to delegate is a serious responsibility and must be determined on a case-by-case basis by the registered nurse. The nurse delegates tasks based on the needs and condition of the student, stability and acuity of the student’s condition, potential for harm, complexity of the task, and predictability of the outcome (ANA, 2001).
Nursing tasks commonly performed in the home setting by a student or caregiver take on a more complex dimension in the school setting. Often parents and school administrators are confused about why what appears to be a simple task is held to a much different and higher standard at school (NASN, 2005).
Delegation becomes more complex when applied to settings that do not have organized nursing structures. The registered professional school nurse practices in an environment where health care supports but is secondary to the primary purpose of providing education. Federal mandates and parental expectations that the school is able to manage the health needs of students increase the demands for qualified personnel to ensure the health and safety of students with special health needs. School nurses may be placed in a position where it becomes necessary to decline supervision of an individual who has been designated by an administrator to perform a nursing procedure based on statutes/rules governing education (NCSBN, 2005). The school nurse may be forced to choose between following standards of nursing practice or an administrator’s directives.
RATIONALE
Only a registered nurse can delegate nursing care. Further, delegation is not appropriate for all students, all nursing tasks, or all school settings. The American Nurses Association (2005, p.3) "does not support delegation of those registered professional nursing services that require assessment and/or emergency care." Key factors guiding determination for delegation include the following: safety issues; state laws, rules, and regulations; and medical needs of students.
Safety issues unique to providing health services in a school setting, versus in a health care setting or home. (e.g., safety of a fragile student in a large group of other students; safety of other students and school staff; the stimuli of the school environment distracting attention from safe execution of health tasks by a student; use of unlicensed assistive personnel (UAP) versus assistive personnel with standardized credentials typically used in health care settings).
State laws, rules and regulations that govern nursing practice, including delegation of care.
Medical needs of the student, including complexity, stability and acuity of his/her health care status.
To provide for safe care, nurses use the Five Rights of Delegation (ANA, 1997; NCSBN, 2005) to guide their assessment of whether delegation is appropriate for the student and the situation.
- The Right Task
• Is the task within the nurse’s scope of practice?
• Is the task reasonably routine with a predictable outcome?
• Is it based on written medical orders?
• Is it one that is repeated frequently?
• Is it performed according to an established sequence of steps, without modification?
• Is the task one that does not involve assessment, interpretation, or decision-making?
- The Right Person
• Who is immediately available to the student, willing, and competent to do the task at the required time?
- The Right Direction
• How much training will be required by the UAP to perform the task in a safe and appropriate way?
• How many tasks will the UAP need to learn?
• What other duties does she/he have?
- The Right Supervision
• How much initial training will the nurse need to provide to the delegatee for the performance of this task?
• What type of ongoing supervision will be needed (on site, periodic, episodic)?
- The Right Circumstance
• Is the child particularly vulnerable due to age, developmental level, cognitive abilities, gender, or specific health issues?
• Is the environment safe for UAP to perform the delegated task as planned?
When review of the Five Rights of Delegation indicates that delegation is appropriate, the registered professional school nurse must develop an Individualized Healthcare Plan outlining the level of care and health care interventions needed by the student and indicating which tasks can and cannot be delegated. Further, the continuous process of evaluation should be based on outcomes of care, ensuring that the delegated task is completed properly and produces the desired outcome.
Thus, delegation is a complex process that requires thorough attention to safety parameters, student health status, and legal standards. The appropriateness of delegation can only be determined by the registered professional school nurse and is determined through a nursing decision-making process.
References/Resources
American Nurses Association (ANA). (1994). Registered professional nurses and unlicensed assistive personnel. Washington, DC: Author.
American Nurses Association. (1997). Unlicensed assistive personnel legislation. Washington, DC: Author.
American Nurses Association. (2001). The code of ethics. Washington, DC: Author.
American Nurses Association. (2005). Consent action report to the board of directors on delivery of care in schools for children with diabetes. Washington, DC: Author.
Gelfman, M. (2001). Special Education Law. In N. Schwab and M. Gelfman (Eds). Legal issues in school health services: A resource for school administrators, school attorneys, and school nurses. North Branch, MN: Sunrise River Press.
Gelfman, M., & Schwab, N. (2001). Discrimination in school: 504, ADA, and Title IX. In N. Schwab and M. Gelfman (Eds.). Legal issues in school health services: A resource for school administrators, school attorneys, and school nurses (pp. 335-371). North Branch, MN: Sunrise River Press.
National Association of School Nurses (NASN). (2004). Issue brief: School health nursing services role in health care: Delegation of care in the school setting. Castle Rock, CO and Scarborough, ME: Author.
National Association of School Nurses (NASN). (2005). Delegation of care: Overview for the registered nurse practicing in the school setting. Castle Rock, CO and Scarborough, ME: Author.
National Association of State School Nurse Consultants (NASSNC). (1996). Delegation of school health services to unlicensed assistive personnel: A position paper of the National Association of State School Nurse Consultants. Journal of School Health, 66(2), 72-74.
National Association of State School Nurse Consultants. (2000). Position statement: Delegation of school health services. Kent, OH: Author.
National Council of State Boards of Nursing (NCSBN). (2005). Working with others: A position paper. Retrieved February 4, 2005, from http://www.ncsbn.org/pdfs/Working_with_Others.pdf.
Schwab, N., & Gelfman, M. (Eds.) (2001). Legal issues in school health services: A resource for school administrators, school attorneys, and school nurses. North Branch, MN: Sunrise River Press.
U.S. Department of Health and Human Services (DHHS). Section 504 Rehabilitation Act 1973. Retrieved from http://www.hhs.gov/ocr/504.html
Adopted: June 2006 |