RN Train-the-Trainer Course: Delegation Considerations

RN Train-the-Trainer Course

Complete all of the following modules:

Delegation Considerations

Complete the following five sections:

1. South Dakota Specific Delegation Considerations

An RN should only delegate insulin administration when a licensed nurse is not available to administer the medication.

Only an RN may delegate the task of insulin administration by the subcutaneous (SQ) route pursuant to ARSD §20:48:04.01. To delegate SQ insulin administration to an unlicensed assistive person (UAP), the RN must ensure that the UAP completes the following requirements:

Five hour SD Board of Nursing online training program for Unlicensed Diabetes Aides (UDA);
Five hour UDA clinical/lab competency assessment and validation;
Passed the SD Board of Nursing's UDA exam; and is
Registered on the SD Board of Nursing's website as a UDA.

See the SD Board of Nursing's Approved Protocol for RN Delegation of Insulin

2. Delegation Decision-Making

Nurses must often delegate various nursing care tasks to unlicensed assistive personnel (UAP) to allow the nurse to effectively manage their busy workloads. Delegating appropriately and effectively is critical for safe client outcomes.

South Dakota's delegation rules serve as a guide for nurses in making important delegation decisions. The Delegation Decision-Making Algorithm was developed and approved by the South Dakota Board of Nursing at their November 2010 meeting to serve as a reference tool for nurses. The Algorithm is attached as a reference and can also be accessed on the Board's website, http://doh.sd.gov/boards/nursing/Documents/DelegationAlgorithm.

An excellent position paper on nursing delegation was published by the National Council of State Boards of Nursing (NCSBN), Working with Others: Delegation and Other health Care Interfaces (2005) (accessed at: https://www.ncsbn.org/Working_with_Others.pdf). This module provides a basic summary of the report's recommendations specific to the laws and rules in South Dakota. The report defines delegation as an ongoing process that allows a nurse to accomplish nursing care for more clients than one nurse can provide alone.

The first recommendation of the NCSBN report prompts nurses to consider their state Nurse Practice Act laws which provide the nurse the authority to delegate. South Dakota's Administrative Rules on delegation by licensed RNs and LPNs are located in §20:48:04.01 and are included within this module for your reference. These laws can also be accessed on the web at http://legis.state.sd.us/rules/DisplayRule.aspx?Rule=20:48:04.01

Nurse Practice Act -Do's

ARSD §20:48:04.01:01 provides a list of guidelines to assist the nurse to make appropriate delegation decisions:

The nursing task is one that a reasonable and prudent licensed nurse would find within the scope of sound nursing judgment to delegate;
The nursing task is one that, in the opinion of the delegating licensed nurse, can be properly and safely performed by unlicensed assistive personnel without jeopardizing the client's welfare;
The nursing task does not require unlicensed assistive personnel to exercise nursing judgment;
The licensed nurse evaluates the client's nursing care needs before delegating the nursing task;
The licensed nurse verifies that the unlicensed person is competent to perform the nursing task; and
The licensed nurse supervises the performance of the delegated nursing task in accordance with the requirements of §20:48:04.01:02.

Nurse Practice Act -Dont's

The following list in ARSD §20:48:04.01:07 defines tasks a nurse may NOT delegate:

Assessments which require professional nursing judgment, intervention, referral, or follow-up;
Formulation of the plan of nursing care and evaluation of the patient's response to the care rendered;
Specific tasks involved in the implementation of the plan of care which require nursing judgment or intervention, such as:
- Sterile procedures involving a wound or anatomical site which could potentially become infected;
- Nasogastric tube feeding;
- Nasogastric, jejunostomy and gastrostomy tube insertion or removal;
- Tracheostomy care and suctioning, and
- Suprapubic catheter insertion and removal, with the exception of urinary Foley catheterization;
Administration of medications, except as permitted by §20:48:04.01:10 and §20:48:04.01:11;
Receiving telephone orders; and
Health counseling and health teaching.

Remember

The delegating nurse is responsible and accountable to assess a situation and make the final decision to delegate; and

The RN is responsible for the overall nursing care that a client receives under the nurse's direction (according to South Dakota's Codified Law, 36-9-3)

Keep in mind that just because a UAP previously performed a task for one specific patient does not automatically mean that the UAP can perform the task for all clients and in all situations and settings. Delegation is client and situation specific. To effectively delegate a nurse must assess the client and the situation. More complex or unpredictable care settings often require that the nurse perform the tasks themselves.

Nurse Practice Act -Supervision

Nurses are required to provide the appropriate level and type of supervision. Criteria listed in ARSD §20:48:04.01:02 offer guidelines to help you determine the appropriate level of supervision you will need to provide. Assess each of the following for each patient situation:

Stability of the client's condition
Competency of the UAP
Nature and complexity of the task delegated
Your proximity and availability to the UAP when the task is performed
Whether you or another nurse is readily available either in person or by phone

If the UAP is providing care in a client's home, make certain the time interval between supervisory visits by the licensed nurse, and whether the visit is conducted in person or via phone, is appropriate based on the above guidelines. Keep in mind that this rule in law requires the nurse to visit no less than once every 60 days to assure client safety.

Most often delegation is a shared responsibility among nurses. Nurses must:

Be competent to perform the tasks/activities themselves;
Have access to pertinent client and staff information, relevant agency policies, procedures and guidelines;
Understand the role and scope of functions of UAPs in their settings;
Be able to rely on nursing management to validate the credentials and qualifications of UAPs;
Have the authority to enforce delegation and be available to communicate, observe and supervise the UAP and to provide consultation and direction as necessary;
Share in the responsibility of assuring that UAPs have training, knowledge, skills and abilities to perform delegated tasks/activities according to agency policy;
Communicate clearly and provide complete directions to the UAP on delegated tasks,and be aware of their knowledge level and capability to perform the task, including when to report to the nurse;

Delegating effectively can be an excellent way to complement the services of a licensed nurse while recognizing that unlicensed aides do not replace, or substitute for the nurse.

Acknowledge that the UAP has accepted responsibility to accomplish the task delegated or understands the need to inform the nurse if they cannot accept the delegation because it is beyond their level of knowledge or skills, or if they cannot complete the task;
Understand and inform the UAP that once a task has been delegated to him/her they cannot re-delegate the task to another person. The nurse may delegate the task to another person;
Allow the UAP to ask questions, clarify expectations and to seek additional education, training, or supervision; and
Follow-up on problems or concerns and intervene in a timely manner.
Examples of when to intervene:when tasks are not completed in a timely manner or not according to expectations, and when the client's condition changes unexpectedly.

Through effective delegation nurses are able to safely expand the cares and services they provide. Appropriate delegation may allow nurses to spend more time handling more complex situations and to keep healthcare costs down.

Diabetes Delegation Considerations

Diabetes practice and technology change rapidly. Nurses that provide care to individuals diagnosed with diabetes, and who facilitate the diabetes management training for unlicensed persons, have a professional responsibility to acquire and maintain current knowledge and competency related to diabetes management on a regular and ongoing basis.

The following list provides additional guidance on how you as an RN can appropriately plan and delegate diabetes care. The list was adapted from Helping the Student with Diabetes Succeed, 2012.

Understand your role in ensuring compliance with Federal and State lawsthat may apply to persons with diabetes, including Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act, see Individuals with Disabilities Education Act http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=97&redirect=true#section4 for more information. Review laws regarding delegation of nursing tasks in Module 3.
Use medical orders, Diabetes Medical Management Plan (DMMP) (http://ndep.nih.gov/media/sample-diabetes-medical-management-plan-508.pdf), or other information obtained from a thorough nursing assessment to develop an individualized health care plan (link to: http://ndep.nih.gov/media/sample-template-individualized-health-care-plan-508.pdf) which promotes a supportive environment for the implementation of diabetes care in your practice setting. The plan should ensure a person's confidentiality and privacy rights and promote and encourage independence and self-care consistent with the person's ability, skill, maturity, and development.
Review the care plan with the person with diabetes and family members and update as needed.
Facilitate team meetings to discuss implementing the plan of care and schedule follow-up meetings to discuss concerns, receive updates, and evaluate the need for changes to the care plan.
Supervise compliance of delegated tasks and maintain accurate documentation of all diabetes care provided.
Collaborate with coworkers and outside agencies to obtain current and relevant diabetes and nutrition information.
Make certain assistive personnel know when and where to get help, where emergency supplies are kept, and procedures for handling an emergency. Prepare an Emergency Care Plan for hypoglycemia and hyperglycemia based on medical orders and provide copies of the emergency plans to all personnel who have responsibility for the person with diabetes. (See sample plans at http://ndep.nih.gov/media/sample-emergency-care-plans-for-hypoglycemia-and-hyperglycemia-508.pdf).
Plan and implement diabetes assistant training for the unlicensed assistive personnel who have responsibility for the person with diabetes.
Assess the competence of all personnel providing diabetes care tasks using the SD Board of Nursing approved competency checklist. Make certain to maintain documentation of the training and supervision of trained unlicensed diabetes assistants.
Provide ongoing education and training for staff and new staff, as needed, and when the care plan changes. (See also the National Diabetes Education Program: http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=97#section5 for resources on training programs and materials.)

Optional Learning Module Available

National Council of State Boards of Nursing's Learning Extension Module: Delegating Effectively

You may choose to complete additional training in the area of delegation. A course offered by the National Council of State Boards of Nursing (NCSBN) can be made available to you. This course provides 4.2 contact hours of continuing education following completion. Contact the South Dakota Board of Nursing for an access code to take the course or for more information.
This course was developed by NCSBN to provide learners with information to build confidence in using delegation and to help nursing assistive personnel provide safe, competent nursing care. The course consists of an introduction, 3 course sections, a glossary, a reference list, Links to Knowledge, and a posttest. Also, within the course are several reflective and interactive exercises where learners can assess their understanding of the material.