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Practice Questions

Scope of Practice Decision Tree

Delegation Guidelines

 

Find answers to questions about the practice of nursing in Maine.

Questions Specific to:

Position Statements

Joint Advisory Opinions

Gastrostomy Tubes

Role of the Registered Professional Nurse in the Coordination and Oversight of Unlicensed Assistive Personnel (UAP) regarding Gastrostomy Tubes (G-Tubes)

The Maine State Board of Nursing issues this Position Statement to guide the practice of nursing. The Board's primary concern is the health and safety of consumers.

The purpose of this position statement is to provide guidelines/criteria that define the conditions under which the registered professional nurse (RN) may coordinate and oversee the task of
G-tube care to UAP in populations with developmental disabilities. In certain circumstances the RN may coordinate and oversee the execution of tasks related to G-tube maintenance, feeding, and administration of prescribed medications.

The RN must complete a thorough assessment of the consumer's nursing care needs, taking into consideration the consumer's overall medical condition. Assessment of the consumer's need related to the G-tube includes the condition of the G-tube (e.g., the maturity of the stoma site, patency, and sustained skin integrity) and designating the appropriate care giver. The RN is responsible for communication and consultation regarding provision of G-tube services.

All UAP providing G-tube care must be at a minimum Certified Residential Medication Aides (CRMA).

The RN is responsible to develop an instructional plan for the UAP and maintain documentation of instructional activities. Part of the instructional plan shall include a mechanism to evaluate competency.

Individual written plans that address the consumer's needs must be available for the UAP at the site at which care is rendered. Information must be updated as needed The plan must include contingency provisions to address unexpected G-tube occurrences.

If the stability of staffing patterns changes within a program providing G-tube care
and consumer safety can no longer be ensured, the RN has the authority in accordance with Chapter 6 Regulations Relating to Coordination and Oversight of Patient Care Services by Unlicensed Health Care Assistive Personnel to determine whether or not the UAP may continue to provide G-tube care to the specific consumer and report this determination to the administration of the organization.


Approved by Board of Nursing March 1-2, 2006

Orientation of New Graduates

Questions have been raised regarding the hiring and utilization of new graduates from nursing programs by health care facilities prior to the person's licensure. Technically, these individuals are unlicensed assistive personnel since they are not eligible to be classified as registered professional nurse (RN) applicants or licensed practical nurse (LPN) applicants. However, to differentiate them from certified nursing assistants and other unlicensed assistive personnel, it is recommended that these individuals be referred to as new graduates. These new graduates may not refer to themselves as RNs or LPNs and may not practice as RNs or LPNs.

32 MRSA Section 2102 2. H. and Chapter 6 Regulations Relating to Coordination and Oversight of Patient Care Services by Unlicensed Assistive Personnel allow a registered professional nurse to coordinate and oversee certain nursing tasks consistent with the standards set forth in the regulation.

The Board has considered the issue of the orientation of new graduates prior to licensure. Orientation and preparation for the role of a licensed nurse is an important aspect of a new nurse's career. It is recognized that orientation involves both didactic and clinical components. For purposes of orientation prior to licensure, the new graduate must be in a structured setting with a defined educational program for the orientation of new graduates. Conversely, if the employer does not meet this requirement, it is not appropriate to employ the new graduate until he or she is licensed.

The employers of new graduates should utilize the following criteria for orientation of a new graduate prior to licensure.

1. The new graduate shall have submitted an application for examination to NCLEX®.

2. The new graduate shall have submitted an application for licensure to the Board and have been declared eligible by the Board to take the examination prior to beginning orientation. Upon declaration of eligibility to test by the Board, the applicant is mailed an Authorization To Test (ATT) letter by the test service. The new graduate should provide a copy of the ATT to the employer to show evidence of having applied to the Board for licensure.

3. A registered professional nurse preceptor must be designated as the responsible individual to provide continuous, on-site supervision for the new graduate. However, a registered professional nurse may designate a licensed practical nurse to participate in the orientation for the graduate of a practical nursing program.

4. The new graduate may not engage in independent nursing responsibilities such as: delegating nursing functions to other nursing personnel, and independently passing medications or administering intravenous therapy. The new graduate should not be part of the facility's staffing pattern, i.e. does not carry a patient assignment.

5. New graduates are required to pass the NCLEX® examination within three months of starting orientation. If the individual is not licensed by the end of a three month orientation period or has failed the first attempt at the NCLEX® examination, the new graduate may function only as an unlicensed assistive personnel(UAP).

Role of RN in Dialysis Therapy

The Maine State Board of Nursing issues this Position Statement to guide the practice of dialysis nursing. The Board's primary concern is the health and safety of patients.

This Position Statement delineates nursing roles and responsibilities for the safe delivery of specialized health care in the dialysis setting. The Board supports the collaborative role of the registered professional nurse (R.N.) with members of a multidisciplinary team in the provision of care to individuals undergoing dialysis therapy for either acute or chronic renal failure. The Board believes that the overall accountability and responsibility for nursing care provided to patients and the coordination of patient care activities, including the provision of many specific dialysis-related assessments and interventions, rests with the registered professional nurse. Specifically, the registered professional nurse is responsible for pre-assessment, ongoing assessment and post assessment of the dialysis patient.

Unlicensed assistive personnel in dialysis settings are individuals who are trained to function in an assistive role in the provision of patient care activities. The registered professional nurse is responsible for continuous assessment of the patient's condition and care needs, and for recognizing the unlicensed assistive person's competencies and skills.

Training of the unlicensed assistive person must be in accordance with a detailed curriculum with outcome measures identified to evaluate the trainee. Technological changes should be the basis for updating competency of registered professional nurses and unlicensed assistive personnel in providing dialysis care.

School Nursing

The Maine State Board of Nursing issues this Position Statement to guide the practice of school nursing. The Board's primary concern is the health and safety of students.

Children with special care needs and children who are technology dependent are guaranteed the right to a free, appropriate public education, in the least restrictive environment, by a series of Federal laws and State law.

The goals of school nursing are the modification or removal of health related barriers to learning and the promotion of an optimum level of wellness.

This Position Statement delineates nursing roles and responsibilities for the safe delivery of specialized health care in the educational setting.

The registered nurse practicing as a school nurse:

1. Develops a nursing care plan for every student with special health care needs
requiring nursing assessment, intervention or supervision;

2. Ensures that the student and his/her family are involved in all decision making
related to provision of health care in school;

3. Participates as a member of the Individualized Education Program (IEP)
team; the nurse incorporates the care plan into the IEP; and

4. Ensures that the necessary and appropriate resources are available to all
persons who are responsible for providing school health care before a child
is placed in a classroom.

The registered nurse practicing as a school health nurse makes decisions about the delegation of nursing activities to unlicensed persons in the school based on the regulations of the Board of Nursing.


Children With Special Care Needs And/Or Technology Dependent Children

The registered nurse practicing as a school nurse:

Determines the level of personnel needed to care for the child in the school setting, in consultation with the child's primary physician, parents, the child, the nurse coordinating the child's home care, when applicable, and a designated school representative;

1. The nurse bases decisions about the level of personnel needed to provide nursing care in the school on:

a. the stability of the child's medical condition;
b. the complexity and acuteness of the observations and judgments the caregiver
must make during the school day;
c. the nature, frequency and complexity of prescribed treatments the child requires;
d. the number, types, routes of administration and potential for adverse reactions of medications the child receives in school;
e. the need to assess the child for PRN medications and treatments;
f. the child's ability to communicate his or her needs to the caregiver;
g. the knowledge base and proficiency of psychomotor skill required of the direct
care provider; and
h. the level of preparation and experience of the direct caregiver.

2. Develops a nursing care plan for every child with an identified health care need;

3. Includes provisions in the nursing care plan to ensure that provisions are made for the continuation
of safe care during transportation to and from school;

4. Integrates the nursing care plan with the IEP, when one exists; and

5. Determines what nursing tasks may be delegated, to whom, and under what conditions, based on
the following:

a. the child's health status, including the stability and chronicity of health problems;
b. the nature and complexity of tasks to be performed; and
c. the extent of supervision the nurse is required to provide to ensure the tasks are
safely carried out.

The registered nurse ensures that there are written guidelines or protocols addressing possible medical emergencies the child may experience in the school setting. Guidelines should include:

1. the definition of a medical emergency for this child;
2. individuals to be notified when an emergency occurs;
3. identification of the person who will initiate and direct the action to be taken;
4. specific action to be taken in this emergency;
5. transport specifications (internal and external), who will provide it, and to where; and
6. the format for documentation of actions taken in a medical emergency.

Technology Dependent Children

The registered nurse practicing as a school nurse is the coordinator/facilitator of nursing care in the school, and may not necessarily be the direct care provider, for children who are technology dependent.
In coordinating or facilitating care, the registered nurse:

1. evaluates the admission of a specific child to a specific school;
2. ensures placement of the child in a safe, accessible classroom within the school;
3. assesses the school and community environment and necessary resources to ensure a safe education setting; and
4. ensures that school personnel have the health care information necessary to create an environment in the classroom which is conducive to learning.

June 16, 1993

Schedule II Drug Prescriptive Authority

Schedule II Drug Prescriptive Authority by Nurse Practitioners and Certified Nurse-Midwives (NP and CNM)

Purpose:

To clarify the roles and responsibilities of physicians, nurse practitioners, and nurse midwives regarding the prescription of Schedule II drugs

History:

The statutes and rules of health care regulatory agencies define the parameters of the scope of practice of the licensed practitioner. Respective boards provide the outside parameters of scope of practice beyond which practice may not be exceeded by their licensees.

32 MRSA Sec. 3270-A (BOLIM) provides the statutory framework for delegation of medical acts by physicians, and Chapter 3 of the BOLIM rules provides that Schedule II drug prescriptive authority may NOT be delegated to nurse practitioners or certified nurse midwives practicing under delegation. The rule provides for petition by the physician for an exemption on a case by case basis. The BOLIM, to date, has not looked at the issue of allowing the delegation of Schedule II prescriptive authority based solely on the basis that the nurse practitioner or nurse midwife, if practicing under the MSBON rules' scope of practice, could so prescribe.

32 MRSA Sec. 2102 2-A (MSBON) grants prescriptive authority to NPs and CNMs. Chapter 8 of the MSBON rules provides that Schedule II drugs may be prescribed by NPs and CNMs as part of their regular scope of practice.

JOINT AGREEMENT
The Boards agree that there are three situations where the question of Schedule II prescriptive authority arises.

Situation 1: The NP or CNM is practicing in "independent" practice according to the statute and rules of the MSBON. The Boards agree that this individual may prescribe Schedule II drugs.

Situation 2: The NP or CNM who chooses to practice under the delegation of a physician, in accordance with 32 MRSA 2205-B(3) may NOT prescribe Schedule II drugs because of the limitation of delegation placed upon the physician by the BOLIM. The BOLIM's rule provides for petition for an exception on a case by case basis.

Situation 3: NPs and CNMs who work under delegation at a health care institution as required by the rules governing membership or employment at the facility whose rules or bylaws prohibit Schedule II prescribing by other than fully licensed physicians or appropriate delegated licensed staff, the scope of practice may be made more restrictive, but not less. That institution may be a clinic, hospital, nursing home or other health care provider. When the NP or CNM accepts a contract, real or implied, to abide by the rules of the institution, the NP or CNM may NOT prescribe Schedule II substances.

In the instance where a NP or CNM works in multiple settings which include multiple categories, the NP or CNM may prescribe Schedule II drugs only when working in "independent" practice settings.

Signed by chairmen of both the MSBON and BOLIM December 11, 2001

Telephone Orders

Purpose:

1. To clarify the roles and responsibilities of physicians and nurses regarding telephone orders.

2. To insure public protection and assure quality of care.

Physicians, nurses and other health care providers rely on the professional skills and integrity of all participants in the health care delivery process.

Physicians are responsible to assure that the orders communicated are appropriate to the situation, and that orders are accurately relayed from the physician's office.

Nurses may accept physician orders via telephone from office personnel designated by the physician. In receiving orders from physician offices, nurses are responsible for recognizing the appropriateness of the order with respect to the plan of care, and for implementing the order or obtaining clarification.

Dated: February 1995

The Use of Prehospital Personnel in the Hospital

Purpose:
1. To provide clarification of the role of the registered professional nurse in the supervision and training of prehospital personnel (EMT through paramedic).

2. To provide clarification of the role of the prehospital provider in the hospital.

Opinion:
The registered professional nurse may participate as an instructor or preceptor for prehospital personnel who are in the hospital to receive initial or refresher training.

The registered professional nurse may not delegate nursing functions to prehospital personnel.

The registered professional nurse who delegates nursing functions to prehospital personnel will be in violation of 32 MRSA Sections 2102(C) and (D) and 2105-A (2) (D).

Prehospital personnel are not licensed by the Board of Emergency Medical Services to perform any skills in the hospital other than during their training and in completing the transfer of their patient to the hospital staff.

Prehospital personnel will be functioning in direct conflict with 32 MRSA Section 2106(3) (Law Regulating the Practice of Nursing) if they are employed by the hospital to perform nursing functions.

Approved by Board of Nursing and Board of Emergency Medical Services

Dated: February 11, 1992

Delegation Guidelines

Delegation: Concepts and Decision-Making Process

Introduction

To meet the public's increasing need for accessible, affordable, quality health care, providers of health care must maximize the utilization of every health care worker and ensure appropriate delegation of responsibilities and tasks. Nurses, who are uniquely qualified for promoting the health of the whole person by virtue of their education and experience, must be actively involved in making health care policies and decision; they must coordinate and supervise the delivery of nursing care, including the delegation of nursing tasks to others.

Issues related to delegation have become more complex in today's evolving health care environment, creating a need for practical guidelines to direct the process for making delegatory decisions. Accordingly, this paper expands and builds upon the National Council's 1987 and 1990 conceptual and historical papers on delegation by presenting a dynamic decision-making process and practical guidelines for delegation.

Purpose

The purpose of this paper is to provide a resource for Boards of Nursing, health policy makers, and health care providers on delegation and the roles of licensed and unlicensed health care workers. The paper emphasizes and clarifies the responsibility of Boards of Nursing for the regulation of nursing, including nursing tasks performed by unlicensed health care workers, and the responsibility of licensed nurses to delegate nursing tasks in accord with their legal scopes of practice. It provides a decision-making tool which can be used in clinical and administrative settings to guide the process of delegation. This paper also describes the accountability of each person involved in the delegation process and potential liability if competent, safe care is not provided.

Premises

The following premises constitute the basis for the delegation decision-making process.

1. All decisions related to delegation of nursing tasks must be based on the fundamental principle of protection of the health, safety and welfare of the public.
2. Boards of Nursing are responsible for the regulation of nursing. Provision of any care which constitutes nursing or any activity represented as nursing is a regulatory responsibility of Board of Nursing.
3. Boards of Nursing should articulate clear principles for delegation, augmented by clearly defined guidelines for delegation decision.
4. A licensed nurse must have ultimate responsibility and accountability for the management and provision of nursing care.
5. A licensed nurse must be actively involved in and be accountable for all managerial decisions, policy making and practices related to the delegation of nursing care.
6. There is a need and a place for competent, appropriately supervised, unlicensed assistive personnel in the delivery of affordable, quality health care. However, it must be remembered that unlicensed assistive personnel are equipped to assist - not replace - the nurse.
7. Nursing is a knowledge-based process discipline and cannot be reduced solely to a list of tasks. The licensed nurse's specialized education, professional judgment and discretion are essential for quality nursing care.
8. While nursing tasks may be delegated, the licensed nurse's generalist knowledge of patient care indicates that the practice-pervasive functions of assessment, evaluation and nursing judgment must not be delegated.
9. A task delegated to an unlicensed assistive person cannot be redelegated by the unlicensed assistive person.
10. Consumers have a right to health care that meets legal standards of care. Thus, when a nursing task is delegated, the task must be performed in accord with established standards of practice, policies and procedures.
11. The licensed nurse determines and is accountable for the appropriateness of delegated nursing tasks. Inappropriate delegation by the nurse and/or unauthorized personnel may lead to legal action against the licensed nurse and/or unlicensed personnel.

Definitions

Accountability ..... Being responsible and answerable for actions or inactions of self or others in the context of delegation.

Delegation ........... Transferring to a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains accountability for the delegation.

Delegator ............ The person making the delegation.

Delegatee ............ The person receiving the delegation. (a.k.a. Delegate)

Supervision ......... The provision of guidance or direction, evaluation and follow-up by the licensed nurse for accomplishment of a nursing task delegated to unlicensed assistive personnel.

Unlicensed Assistive Personnel (UAP) .. Any unlicensed personnel, regardless of title, to whom nursing tasks are delegated.

Regulatory Perspective: A Framework for Managerial Policies

Boards of Nursing have the legal responsibility to regulate nursing and provide guidance regarding delegation. Registered Nurses (RNs) may delegate certain nursing tasks to Licensed Practical Nurses/Vocational Nurses (LPN/VNs) and unlicensed assistive personnel (UAP). In some jurisdictions, LPN/VNs may also delegate certain tasks within their scope of practice to unlicensed assistive personnel. The licensed nurse has a responsibility to assure that the delegated task is performed in accord with established standards of practice, policies and procedures. The nurse who delegates retains accountability for the task delegated.

The regulatory system serves as a framework for managerial policies related to the employment and utilization of licensed nurses and unlicensed assistive personnel. The nurse who assesses the patient's needs and plans nursing care should determine the tasks to be delegated and is accountable for that delegation. It is inappropriate for employers or others to require nurses to delegate when, in the nurse's professional judgment, delegation is unsafe and not in the patient's best interest. In those instances, the nurse should act as the patient's advocate and take appropriate action to ensure provision of safe nursing care. If the nurse determines that delegation may not appropriately take place, but nevertheless delegates as directed, the nurse may be disciplined by the Board of Nursing.

Acceptable Use of the Authority to Delegate

The delegating nurse is responsible for an individualized assessment of the patient and situational circumstances, and for ascertaining the competence of the delegatee before delegating any task. The practice-pervasive functions of assessment, evaluation and nursing judgment must not be delegated. Supervision, monitoring, evaluation and follow-up by the nurse are crucial components of delegation. The delegatee is accountable for accepting the delegation and for his/her own actions in carrying out the task.

The decision to delegate should be consistent with the nursing process (appropriate assessment, planning, implementation and evaluation). This necessarily precludes a list of nursing tasks that can be routinely and uniformly delegated for all patients in all situations. Rather, the nursing process and decision to delegate must be based on careful analysis of the patient's needs and circumstances. Also critical to delegation decisions are the qualifications of the proposed delegatee, the nature of the nurse's delegation authority set forth in the law of the jurisdiction, and the nurse' personal competence in the area of nursing relevant to the task to be delegated.

Delegation Decision-Making Process

In delegating, the nurse must ensure appropriate assessment, planning, implementation and evaluation. The delegation decision-making process, which is continuous, is described by the following model:

I. Delegation criteria

A. Nursing Practice Act
1. Permits delegation
2. Authorizes task(s) to be delegated or authorizes the nurse to decide delegation

B. Delegator qualifications
1. Within scope of authority to delegate
2. Appropriate education, skills and experience
3. Documented/demonstrated evidence of current competency

C. Delegatee qualifications
1. Appropriate education, training, skills and experience
2. Documented/demonstrated evidence of current competency

Provided that this foundation is in place, the licensed nurse may enter the continuous process of delegation decision-making.

II. Assess the situation
A. Identify the needs of the patient, consulting the plan of care
B. Consider the circumstances/setting
C. Assure the availability of adequate resources, including supervision

If patient needs, circumstances, and available resources (including supervisor and delegatee) indicate patient safety will be maintained with delegated care, proceed to III.

III. Plan for the specific task(s) to be delegated
A. Specify the nature of each task and the knowledge and skills required to perform it
B. Require documentation or demonstration of current competence by the delegatee for each task
C. Determine the implications for the patient, other patients, and significant others

If the nature of the task, competence of the delegatee, and patient implications indicate patient safety will be maintained with delegated care, proceed to IV.

IV. Assure appropriate accountability
A. As delegator, accept accountability for performance of the task(s)
B. Verify that delegatee accepts the delegation and the accountability for carrying out the task correctly

If delegator and delegatee accept the accountability for their respective roles in the delegated patient care, proceed to V.

V. Supervise performance of the task
A. Provide directions and clear expectations of how the task(s) is to be performed
B. Monitor performance of the task(s) to assure compliance to established standards of practice, policies and procedures
C. Intervene if necessary
D. Ensure appropriate documentation of the task(s)

VI. Evaluate the entire delegation process
A. Evaluate the patient
B. Evaluate the performance of the task(s)
C. Obtain and provide feedback

VII. Reassess and adjust the overall plan of care as needed
The Five Rights of Delegation provided an additional resource to facilitate decisions about delegation.

______________________________________________________________________________

  • The Five Rights of Delegation
    One that is delegable for a specific patient.
  • Right Circumstances
    Appropriate patient setting, available resources, and other relevant factors considered.
  • Right Person
    Right person is delegating the right task to the right person to be performed on the right person.
  • Right Direction/Communication
    Clear, concise description of the task, including its objective, limits and expectations.
  • Right Supervision
    Appropriate monitoring, evaluation, intervention, as needed, and feedback.

______________________________________________________________________________

Conclusion

The guidelines presented in this paper provide a decision-making process that facilitates the provision of quality care by appropriate persons in all health care settings. The National Council of State Boards of Nursing believes that this paper will assist all health care providers and health care facilities in discharging their shared responsibility to provide optimum health care that protects the public's health, safety and welfare.