It is the position of the National Association of School Nurses (NASN) that the delegation of nursing tasks in the school setting can be a valuable tool for the school nurse, when based on the nursing definition of delegation and in compliance with state nursing regulations and guidance.
Delegation in school nursing is a complex process in which the authority to perform a selected nursing task is transferred to a competent unlicensed individual (UAP) in a specific situation. The decision to delegate and the supervision of delegation of nursing tasks in the school setting rest solely with the registered nurse, who makes the determination to delegate based on nursing assessment and in compliance with applicable laws and guidance provided by professional nursing associations (American Nurses Association [ANA]/National Council of State Boards of Nursing [NCSBN], 2006; Mitts vs. Hillsboro Union High School, 1987)
The safety and welfare of the individual student and the broader school community must be the central focus of all decisions regarding the delegation of nursing tasks and functions (ANA/NCBSN, 2006). Delegation is used effectively in some areas, but unsafe and illegal delegation in school settings can occur. It is important for school districts, registered nurses, health care professionals, parents and the public to understand what activities can be delegated and when delegation is appropriate. Delegation may occur when the registered nurse determines it is appropriate to provide necessary treatment, but such delegation may not be appropriate for all students or all school nursing practices. 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.
Delegation is a valuable tool in meeting the health care needs of school children. 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 adversely impact their capacity for learning. (Gelfman, 2001) School nurses can use their expert assessment skills to appropriately delegate health-related tasks and meet the specific health care needs of students, increasing access to a free appropriate public education. (Resha, 2010)
Advances in health care and technology offer greater opportunities for children with special health care needs to attend school, bringing medically fragile students into the general school population. The incidence of chronic conditions such as asthma, diabetes, severe allergies, and seizure disorders in school-age children is increasing; and complex medical problems that were previously handled in acute care settings are now being managed in the school setting, requiring registered nurses to make care decisions that may include delegation where appropriate.
DESCRIPTION OF ISSUE
The term delegation is used in other fields, but 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 care of the client (NCBSN, 2005). Effective delegation in school nursing practice requires a registered nurse who has the requisite skill, expertise and authority to practice in the state in which the delegation occurs.
ANA defines nursing delegation as transferring the responsibility of performing a nursing activity to another person while retaining accountability for the outcome (ANA/NCSBN, 2006); National Association of State School Nurse Consultants [NASSNC], 2010). 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 that the registered nurse determines on a case-by-case basis 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, 2005) Prior to delegation, a student assessment is required to guide the school nurse in determining the level of training and supervision required for safe delegation for this specific student and assignment.
Nursing tasks commonly performed in the home setting by a parent/guardian 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). The school nurse practices in the educational setting where nurses support the primary purpose of providing education and must consider meeting federal mandates, nursing licensure standards and parental expectations when working to ensure the health and safety of all students.
Supervision of delegated nursing tasks means the delegating registered nurse must periodically monitor and assess the capabilities and competencies of the licensed practical nurse or unlicensed personnel to safely perform delegated tasks. Only the registered nurse determines how closely and often an unlicensed individual must be supervised and reassessed. If an individual who has been assigned by a school administrator is not suitable for the task, whether it is due to lack of education, attentiveness, availability or proximity, the registered nurse must work with administration to locate a better suited individual. The registered nurse adheres to the state nurse practice act and standards of nursing practice, even if it is conflicts with an administrator’s directives.
The appropriate professional to delegate nursing tasks is the registered professional nurse. Delegation is not appropriate for all students, all nursing tasks, or all school nurse practices. The American Nurses Association (2005) does not support nurses delegating steps in the nursing process, including nursing assessment or the use of nursing judgment (ANA/NCBSN, 2006). Key factors guiding determination for delegation include the following: state laws, rules, and regulations; safety issues; medical needs of students; school practice characteristics; and UAP competence.
To provide for safe care, nurses can utilize the Five Rights of Delegation (ANA/NCSBN, 2006) to guide their assessment of whether delegation is appropriate for the student and the situation.
- The Right Task
- The Right Person
- The Right Direction
- The Right Supervision
- The Right Circumstance
When a review of the Five Rights of Delegation indicates that delegation is appropriate, the school nurse must develop an individualized healthcare plan (IHP) 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.
Additional tools available to the school nurse when determining if delegation is appropriate include the American Nurses Association’s Principles of Delegation and the National Council of State Boards of Nursing Decision Tree - Delegation to Nursing Assistive Personnel (ANA/NCSBN, 2006).
American Nurses Association • Principles for Delegation
- The nursing profession determines the scope of nursing practice.
- The 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.
- The RN directs care and determines the appropriate utilization of any assistant involved in providing direct patient care.
- The RN accepts aid from nursing assistive personnel in providing direct patient care.
- The RN may delegate elements of care but does not delegate the nursing process itself.
- The RN has the duty to answer for personal actions relating to the nursing process.
- The RN takes into account the knowledge and skills of any individual to whom the RN may delegate elements of care.
- The decision of whether or not to delegate or assign is based upon the RN’s judgment concerning the condition of the patient, the competence of all members of the nursing team and the degree of supervision that will be required of the RN if a task is delegated.
- The RN delegates only those tasks for which she or he believes the other health care worker has the knowledge and skill to perform, taking into consideration training, cultural competence experience and facility/agency policies and procedures.
- The RN acknowledges that there is a relational aspect to delegation and that communication is culturally appropriate and the person receiving the communication is treated respectfully.
- Chief nursing officers are accountable for establishing systems to assess, monitor, verify and communicate ongoing competence requirements in areas related to delegation, both for RNs and delegates.
- RNs monitor organizational policies, procedures and position descriptions to ensure there is no violation of the Nurse Practice Act, working with the state board of nursing if necessary.
American Nurses Association (ANA). (2005). Principles of delegation. Silver Spring, MD: Author.
American Nurses Association / National Council of State Boards of Nursing (ANA/NCSBN). (2006). Joint statement on delegation. Retrieved from https://www.ncsbn.org/Joint_statement.pdf
Davis-Alldritt, L. (2009). If I delegate, am I at risk? NASN School Nurse, 24, 180 – 183. Retrieved from http://nas.sagepub.com/content/24/5/180.full.pdf+html
Gelfman, M. H. (2005). Special education law. In N. C. Schwab and M. H. Gelfman (Eds). Legal issues in school health services: A resource for school administrators, school attorneys, and school nurses (pp. 373-394). Lincoln, NE: Authors Choice Press.
Gelfman, M. H. & Schwab, N. C. (2005). Discrimination in school: 504, ADA, and Title IX. In N. C. Schwab and M. H. Gelfman (Eds.). Legal issues in school health services: A resource for school administrators, school attorneys, and school nurses (pp. 335-371). Lincoln, NE: Authors Choice Press.
National Association of School Nurses (NASN). (2005). Delegation of care: Overview for the registered nurse practicing in the school setting. Silver Spring, MD: Author.
National Association of State School Nurse Consultants (NASSNC) (2010). Position statement: Delegation of school health services. Retrieved from: http://www.nassnc.org/files/pdf/NASSNCDelegationPostAug2010.pdf
National Council of State Boards of Nursing (NCSBN) (2005). Working with others: A position paper. Retrieved from http://www.ncsbn.org/pdfs/Working_with_Others.pdf
Mitts, Carol v. Hillsboro Union High School district 3-8 Jt et al., Washington County Circuit Court Case 87-1142C (1990).
Resha, C. (2010). Delegation in the school setting: Is it a safe practice? OJIN: The Online Journal of Issues in Nursing, 15(2). doi: 10.3912/OJIN.Vol15No02Man05. Retrieved from: http://www.medscape.com/viewarticle/730445
U.S. Department of Health and Human Services (DHHS). (2006). Section 504 Rehabilitation Act 1973. Retrieved from http://www.hhs.gov/ocr/504.html
Acknowledgement of Authors:
Connie Board, BSN, RN, NCSN
Margo Bushmiaer, MNSc, RN, NCSN
Linda Davis-Alldritt, MA, PHN, RN, FNASN
Nina Fekaris, BSN, MS, RN, NCSN
Judith Morgitan, M.Ed, BSN, RN
M. Kathleen Murphy, DNP, FNP-BC, RN
Barbara Yow, BSN, RN, CSN