DELEGATION TO UNLICENSED PERSONNEL

[This section is taken from TAC Title 22, Part 11, §224. Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments.]

Registered nurses must follow the rules from the Texas Administrative Code when delegating tasks to unlicensed personnel. Delegation is defined as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. It does not include situations in which an unlicensed person is directly assisting a RN by carrying out nursing tasks in the presence of a RN.

An unlicensed person is an individual not licensed as a healthcare provider:

  • Who is monetarily compensated to provide certain health-related tasks and functions in a complementary or assistive role to the RN in providing direct client care or carrying out common nursing functions (e.g., nurse aides, orderlies, assistants, etc.)
    or
  • Who is a professional nursing student, not licensed as a RN or LVN, providing care for monetary compensation and not as part of their school program

The full utilization of the services of a RN may require delegation of selected nursing tasks to unlicensed personnel. The scope of delegation and the level of supervision by the RN may vary depending on the setting, task, skills, and experience of the unlicensed person and the client’s status.

The following pertains to delegation for acute care clients or in an acute care environment. (For information regarding delegation and tasks not requiring delegation in independent living environments for clients with stable and predictable conditions, see TAC Title 22, Part 11, section 225.)

General Criteria for Delegation

The following standards must be met before the RN delegates nursing tasks to unlicensed persons. These criteria apply to all instances of RN delegation.

  • The RN must make an assessment of the client’s nursing care needs in collaboration with the client and family as appropriate prior to delegating nursing tasks.
  • The nursing task must be one that a reasonable and prudent RN would find is within the scope of sound nursing judgment to delegate. The RN should consider the five “rights” of delegation: the right task, the right person to whom the delegation is made, the right circumstances, the right direction and communication by the RN, and the right supervision as determined by the RN.
  • The nursing task must be one that, in the opinion of the delegating RN, can be properly and safely performed by the unlicensed person involved without jeopardizing the client’s welfare.
  • The nursing task must not require the unlicensed person to exercise professional nursing judgment, but may involve any action that a reasonable, prudent, nonhealthcare professional would take in an emergency situation.
  • The unlicensed person to whom the nursing task is delegated must be adequately identified. The identification may be by individual or, if appropriate, by training, education, and/or certification/permit of the unlicensed person.
  • The RN shall have either instructed the unlicensed person in the delegated task or verified the unlicensed person’s competency to perform the nursing task.
  • The RN shall adequately supervise the performance of the delegated nursing task in accordance with the requirements of nursing supervision (see below).
  • If the delegation continues over time, the RN shall periodically evaluate the delegation of tasks.

Supervision Criteria

The registered professional nurse shall provide supervision of all nursing tasks delegated to unlicensed persons in accordance with the following conditions. These supervision criteria apply to all instances of RN delegation for clients with acute conditions or in acute care environments. The degree of supervision required shall be determined by the RN after an evaluation of appropriate factors involved, including, but not limited to, the following:

  • Stability of the client’s status in relation to the task(s) to be delegated
  • Training, experience, and capability of the unlicensed person to whom the nursing task is delegated
  • Nature of the nursing task being delegated
  • Proximity and availability of the RN to the unlicensed person when the nursing task will be performed

Nursing Tasks Commonly Delegated

By way of example, and not in limitation, the following nursing tasks are ones that are most commonly the type of tasks within the scope of sound professional nursing practice to be considered for delegation, regardless of the setting, provided the delegation is in compliance with TAC Title 22, Part 11, §224.6 (relating to General Criteria for Delegation) and the level of supervision required is determined by the RN in accordance with §224.7 of the same title (relating to Supervision):

  • Noninvasive and nonsterile treatments
  • Collecting, reporting, and documentation of data, including, but not limited to:
    • Vital signs, height, weight, intake and output, capillary blood and urine test for sugar, and stool test for occult blood results
    • Environmental situations
    • Client or family comments relating to the client’s care
    • Behaviors related to the plan of care
  • Ambulation, positioning, and turning
  • Transportation of the client within a facility
  • Personal hygiene and elimination, including vaginal irrigations and cleansing enemas
  • Feeding, cutting up of food, or placing of meal trays
  • Socialization activities
  • Activities of daily living
  • Reinforcement of health teaching planned and/or provided by the registered nurse

Nursing Tasks Prohibited from Delegation

By way of example, and not in limitation, the following are nursing tasks that are not within the scope of sound professional nursing judgment to delegate:

  • Physical, psychological, and social assessment which requires professional nursing judgment, intervention, referral, or follow-up
  • Formulation of the nursing care plan and evaluation of the client’s response to the care rendered
  • Specific tasks involved in the implementation of the care plan which require professional nursing judgment or intervention
  • Responsibility and accountability for client health teaching and health counseling which promotes client education and involves the client’s significant others in accomplishing health goals
  • Administration of medications, including intravenous fluids, except by medication aides as permitted under §224.9 of this title (relating to the Medication Aide Permit Holder)
CASE

Sabrina is an RN in a busy medical-surgical department. She is in the middle of passing morning medications when her new post-op patient, Mr. Winters, reports severe pain. Sabrina performs a focused assessment of his surgical dressing and finds everything within normal limits. Sabrina consults the electronic medication administration record (eMAR) and sees that Mr. Winters has IV morphine ordered for severe pain. She also recalls the report from the PACU nurse stating that the patient’s blood pressure occasionally runs low.

Sabrina knows she needs to continue with medications for her other patients, to get a new set of vitals on Mr. Winters to be sure his blood pressure won’t drop with a new dose of IV morphine, and then to administer the pain medication to Mr. Winters. In order to accomplish her tasks in a timely manner, Sabrina determines that it is necessary to delegate a task to the appropriate assistive personnel. She remembers that Martha, a nurse aide, has also been assigned to her patients.

Sabrina contacts Martha to see if she is available to take Mr. Winters’s blood pressure, knowing that taking patients’ vitals is within Martha’s education and training. Sabrina indicates to Martha that she will continue passing medications while Martha gets the patient’s vitals, which she should carry out right away. Sabrina informs Martha that she will be with the patient in the next room by the time Martha has the vital signs. Martha agrees and begins to take Mr. Winters’s blood pressure.

Martha finds Sabrina as she is coming out of the room next door and reports that Mr. Winters’s blood pressure is 118/78, which Sabrina knows presents no contraindication to administering the IV morphine. Sabrina administers the morphine, relieving Mr. Winters’s pain. She thanks Martha for her help and then returns to her other patients.