Unlicensed Assistive Personnel: Their Role on the School Health Service Team
It is the position of the National Association of School Nurses (NASN) that, where laws permit, unlicensed assistive personnel (UAP) can have valuable and necessary roles as assistants to school nurses. It is the professional responsibility of the registered professional school nurse (herein after referred to as school nurse) to identify UAP in the school setting and to train, evaluate for competency, monitor and supervise the selected individuals. The school nurse is accountable for ensuring continued competency of UAP beyond the initial documented training and for maintaining competency to provide health services to individual students according to individualized healthcare plans (IHPs) and/or district policies.
In school-age children, the incidence of chronic conditions such as asthma, diabetes, and life-threatening food allergies is increasing. Also on the rise is the number of complex medical conditions in school populations. All of these conditions require healthcare planning and management and may require that school nurses make care decisions including nursing delegation to UAP where appropriate (Hootman, 2013). As school nurses create IHPs for students, student safety is of paramount importance in implementation, including the decision to enlist assistance by UAP (American Nurses Association [ANA], 2012 ANA & National Council of State Boards of Nursing [NCSBN], 2006; Caldart-Olson & Thronson, 2013; Gordon & Barry, 2009). The school nurse must clearly state to school administration and UAP that ongoing supervision is a necessary component of nursing delegation.
Because a UAP works under the direction of the school nurse, the school nurse must conduct documented training, must supervise the UAP and must be in control of the decision to delegate a healthcare task (Bobo, 2014; Caldart-Olson & Thronson, 2013; Gibbons, Lehr & Selekman, 2013). The UAP must agree to function according to the written instructions of the school nurse. Informing the UAP of the laws that cover and protect them, including state and federal laws and statutes as well as district guidelines and policies, is critical to protect all parties from harm and liability (Shannon & Kubelka, 2013). The capacity of school nurses to effectively provide required supervision of multiple UAP must be considered before using UAP (Hootman, 2013).
In order to protect the UAP, the school and the health and safety of students, the school nurse must follow the scope and standards of school nursing which include carrying out the steps of nursing delegation, thereby setting the boundaries within which UAP can safely and legally function ANA (2013). To facilitate a better understanding of the school nurse role and the impact of UAP coverage, communication is needed between school nurses, school administrators, school personnel and families (Shannon & Kubelka, 2013; Bobo, 2014). It is important for administrators to understand that school nurses must address the following questions prior to delegation (ANA, 2012; Bobo, 2014; Resha, 2010; Raible, 2012; Hootman, 2013; Caldart-Olson & Thronson, 2013).
Is this the right task to be delegated?
Are the right circumstances in place to allow delegation?
Is this the right person for this task?
Is there appropriate communication and direction between the nurse and the UAP?
Is the school nurse in a position to monitor, evaluate and provide ongoing supervision of the UAP?
UAP in schools may not have health services as their primary employment role and may be called upon intermittently to assist the school nurse. UAP are school personnel who do not hold a healthcare license but are trained to provide care to students under the direction and supervision of a school nurse. Therefore, paraprofessionals, classroom assistants, administrators, teachers, bus monitors or drivers, playground attendants or office staff may perform healthcare tasks as needed and serve as UAP. In some schools, UAP may be employed specifically to work in the health office and may be identified as health clerks, nursing assistants, health aides, patient care technicians, nurses' aides, certified nursing assistants, health techs, clinic assistants or self-care aides (Bobo, 2014; Raible, 2012; Foley, 2013; Davis-Aldritt, 2013).
Whenever a UAP is responsible for the care and safety of a student, documented training by the school nurse should occur prior to delegation of the nursing task (ANA, 2012; Davis-Aldritt, 2013; Hootman, 2013). The decision to include UAP as part of a student healthcare team is made by the school nurse and guided by district policies and the students’ IHP. (Karsting, 2012). There may be times when it is inappropriate for school nurses to delegate to UAP; and standards of nursing delegation, state statutes and local policies will guide those decisions and support their rationale (Hootman, 2013). Schools must realize that, even with exemplary UAP training and supervision, adverse events can occur, (e.g., medication errors, failure to recognize early onset of health emergencies related to chronic illnesses such as asthma and diabetes) increasing the loss of school time by students (Vollinger, Bergren, & Belmonte-Mann, 2011). School nurses, therefore, make decisions regarding use of UAP based on the situation at hand, the environment, the experience and training of the UAP and the health status of the student.
UAP, although not health professionals, can play important roles within school health teams when appropriate nursing delegation is in place (Hootman, 2013). Key factors guiding delegation to UAP in addition to state statutes and rules include safety issues, medical needs of the student, and UAP competence -- including education, attentiveness, availability or proximity to the students they care for (Vollinger et al., 2011; Bobo, 2014; ANA & NCSBN, 2006; Resha, 2010; Gordon & Barry, 2009). Other key factors include the school nurse’s ability to train, monitor, supervise and evaluate the UAP (Hootman, 2013).
UAP may assist school nurses thereby allowing school nurses time to fully implement professional school nursing roles including care coordination for students, and development of IHPs, Emergency Care Plans (ECP), 504 plans and Individualized Educational Plans (IEPs). UAP assistance also allows school nursing time to contribute to the education of students with special healthcare needs through assessment, planning, providing proper nursing care, and evaluating outcomes. School nurse professional practice requires critical thinking and judgment integral to the nursing process, as well as health promotion, disease prevention and addressing special health issues (Hootman, 2013; Foley, 2013; Davis-Aldritt, 2013; Resha, 2010; Quelly, 2014).
When the school nurse determines the appropriateness of using a UAP and conducts the proper documented training and supervision, the UAP can contribute to the healthcare needs of students in schools (Shannon & Kubelka, 2013; Resha, 2010). Tasks that may be performed by and delegated to UAP are dependent on state nurse practice laws. If allowed by law, tasks UAP can perform with proper training and oversight by the school nurse include first aid, screenings, maintaining student health records, non-complex daily procedures and other health office tasks. In addition to following verbal and written directions, UAP may also be trained to do selected emergency procedures, perform selected student-specific nursing tasks and administer medications allowable in their states (Raible, 2012; Hootman, 2013; Foley, 2013; Davis-Aldritt, 2013; Bobo, 2014).
Where laws permit, the use of unlicensed assistive personnel who are trained, monitored, supervised and assessed by the school nurse can be a positive asset to the healthcare team. UAP perform valuable supportive roles in meeting healthcare needs of students and in assuring that available resources are managed both safely and effectively. The use of UAP in schools for specific tasks is a decision the school nurse makes on a case-by-case basis and is determined through a nursing decision-making process that includes the five components of nursing delegation (ANA, 2012;ANA/NCSBN, 2006; Bobo, 2014).
American Nurses Association. (2012). ANA’s principles for delegation by registered nurses to unlicensed assistive personnel (UAP). Silver Spring, MD: Nursesbooks.org.
American Nurses Association. (2013). School nursing: scope and standards of practice, second edition. Silver Spring, MD: Nursesbooks.org.
American Nurses Association & National Council of State Boards of Nursing. (2006). Joint statement on delegation. Retrieved from https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf
Bobo, N. (2014). Nursing delegation to unlicensed assistive personnel in the school setting: Principles of Practice. Silver Spring, MD: National Association of School Nurses.
Caldart-Olson, L. & Thronson, G. (2013). Legislation affecting school nurses. In J. Selekman (Ed.), School nursing: A comprehensive text (2nd ed.) (pp.225-256). Philadelphia, PA: F.A. Davis Company.
Davis-Aldritt, L. (2013). Budgeting and accessing funding. In J. Selekman (Ed.), School nursing: A comprehensive text (2nd ed.) (pp.1245-1265). Philadelphia, PA: F.A. Davis Company.
Foley, M. (2013). Health services management. In J. Selekman (Ed.), School nursing: A comprehensive text (2nd ed.) (pp.1190-1244). Philadelphia, PA: F.A. Davis Company.
Gibbons, L., Lehr, K., & Selekman, J. (2013). Federal laws protecting children and youth with disabilities in the schools. In J. Selekman (Ed.), School nursing: A comprehensive text (2nd ed.) (pp. 257-283). Philadelphia, PA: F.A. Davis Company.
Gordon, S. & Barry, C. (2009). Delegation guided by school nursing values: Comprehensive knowledge, trust, and empowerment. The Journal of School Nursing, 25, 352-360. doi: 10.1177/1059840509337724
Hootman, J. (2013). Staff management. In J. Selekman (Ed.), School nursing: A comprehensive text (2nd ed.) (pp.1290-1321). Philadelphia, PA: F.A. Davis Company.
Karsting, K. (2012). How can individualized healthcare plans be used most effectively? NASN School Nurse, 27(4), 189-191. doi: 10.1177/1942602X12446660
Quelly, S.B. (2014). Influence of perceptions on school nurse practices to prevent childhood obesity. The Journal of School Nursing, 30(4), 292-302. doi: 10.1177/1059840513508434
Raible, C. (2012). Training UAP to care for special needs students in the classroom. NASN School Nurse, 23(4), 187-188. doi: 10.1177/1942602X12444452
Resha, C., (2010). Delegation in the school setting: Is it a safe practice? Online Journal of Issues in Nursing, 15(2). doi: 10.3912/OJIN.Vol15No02Man05
Shannon, R., & 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: 10.1177/1942602X13489886
Vollinger, L., Bergren, M. & Belmonte-Mann, F. (2011). Substitutes for school nurses in Illinois. The Journal of School Nursing, 27(2), 111-119. doi:10.1177/1059840510388517
Acknowledgement of Authors:
Kathleen C. Rose, MHA-N, BS, RN
Jody Disney, PhD, RN, NCSN
Kathleen Andresen, DNP, RN
Christine Tuck, MS, BSN, RN, NCSN
Jessica Porter, BSN, RN, NCSN
Nicole Bobo, MSN, RN
Adopted: January 2015
This document replaces the position statement Unlicensed Assistive Personnel: The Role on the School Nurse(Adopted 2002, revised January 2011).
Suggested citation: National Association of School Nurses. (2015). Unlicensed assistive personnel: Their role on the school health services team (Position Statement). Silver Spring, MD: Author.
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.