Ep11- Penrose-St. Francis Health Services Nursing Services

All official Penrose-St. Francis Healthcare Services guidelines are maintained electronically and are subject to change. No printed guideline should be taken as the official guideline except to the extent it is consistent with the current guideline that is electronically maintained.

EP11- PENROSE-ST. FRANCIS HEALTH SERVICES NURSING SERVICES

SUBJECT: Delegation of Tasks by the Registered Nurse

PREVIOUS DATES: 7/94, 10/95, 1/96, 8/96, 10/98, 11/04, 12/07EFFECTIVE DATE: 11/10

RECOMMENDED BY:Nursing Guideline Committee

NURSING ADMINISTRATION APPROVAL:Katherine D McCord, RN, CNO

GUIDELINES FOR CARE: Using the Five Rights of Delegation, the patient will receive safe care when RNs delegate nursing task to competent ancillary personnel (LPN, CNA, Technician, etc.)

Right task – One that is in the RN’s scope of practice, but could be performed by a non-nurse without risk of injury to the patient.
Right circumstances – The condition of the patient, competence of available staff, and availability of any necessary supervision are considered.
Right person – One who has the skill and/or ability to competently perform the task.
Right directions and communication – A clear, concise description for the task, the objective, and the nurse’s expectations.
Right supervision and evaluation – Timely evaluation of the assistant’s performance of the task(s) during and after completion.

DEFINITIONS:

Delegation: The assignment to a competent individual the authority to perform in a selected situation or selected nursing task included in the practice of professional nursing as defined in section 12-38-132 of the Colorado Nurse Practice Act (2009). As defined by the American Nurses Association, delegation is the transfer of responsibility for the performance of an activity from one person to another while retaining accountability for the outcome. When delegating, the RN retains the accountability for performance of the task.

Delegator: The RN making the delegation; the delegator must hold a current, active license.

Delegatee: An individual receiving the delegation who acts in a complementary role to the RN and whom the RN authorizes to perform tasks which the individual is not otherwise authorized to perform.

PRACTICES:

A. The RN will:

Be knowledgeable about the description of delegation in the Colorado Nursing Practice Act (see ColoradoState Board of Nursing Delegation Decision Tree attachment).
Assume accountability for the quality of nursing care provided directly or through the delegated care provided by others.
Supervise others in accomplishing a nursing task or activity by providing initial direction, periodic inspection, and evaluation of the outcome of the task or activity.
Delegate nursing tasks that meet the following guidelines (see Attachments A&B for list of tasks that CANNOT be delegated):

a)Tasks are within the area of responsibility of the RN.

b)Tasks are within the knowledge, skills and competence of the RN.

c)Tasks are of a routine, repetitive nature and don’t require the delegatee to use nursing judgment or intervention.

d)Tasks are reasonable and other RNs would agree that they are appropriate tasks to assign.

e)Tasks are consistent with the health and safety of the patient.

f)Tasks are limited to a specific delegatee, for a specific patient, at a specific time, on a specific day.

g)Tasks are delegated often enough for the delegatee’s competence to be maintained.

h)Tasks shall NOT require any delegatee to exercise the judgment required of a nurse.

Assure that the delegatee can and will perform the task with the same care and skill that would be expected of a RN. Instruct the delegatee, if necessary, how to perform the task and/or verify skill through review of task performance.
Delegate a task only if the RN has PERSONALLY observed the delegatee’s successful performance of the task. Successful performance means the RN has not verbally coached or otherwise assisted the delegatee.
Assess the following factors before delegating nursing care:

a)Stability of the patient’s condition.

b)Complexity and frequency of the nursing care.

c)Knowledge, skill and abilities of the person to whom the task will be delegated.

d)Nature of nursing tasks being delegated (e.g., invasive nature of the task, the irreversibility of the tasks, the expected outcome, and the potential for harm).

e)Availability and accessibility of resource (equipment, supplies, other health care personnel, etc.) to meet the patient’s nursing care needs.

f)Availability of adequate supervision.

Provide appropriate and adequate supervision based on all the factors listed in #4.
Continually evaluate the needs of the patient, the performance of the delegatee and the need for further instruction, and the need to withdraw the delegation.
Document using the Computerized Information System (CIS).

B. The Health Care Worker who is delegated to (delegatee) will:

Complete routine tasks and duties prior to accepting delegated tasks.
Accept tasks delegated by a RN ONLY if the health care worker has received appropriate training and possesses sufficient knowledge, skills and abilities to

perform the nursing tasks and if the delegating RN has PERSONALLY observed the

health care worker.

Assure that the delegated tasks are performed as directed and not expanded without permission of the RN.
Never delegate the delegated tasks to another person.
Request additional instruction from the RN if necessary.
Provide feedback to the RN concerning patient care issues and outcomes of care provided.
Document using the Computerized Information System (CIS).

C. Care that cannot be delegated by the RN in the BirthCenter(in addition to those tasks listed in Attachments A&B)

Assessment:

a)vaginal exam

b)post delivery recovery

c)interpreting labs and prenatal blood work (maternal and infant blood sugars need for Rhogam or rubella)

d)interpreting fetal monitor strips

e)rupture of membrane assessment (ferning, nitrazine, Amnisure®)

Initial and complex treatments:

a)vaginal cultures

b)speculum exams

c)fetal spiral electrode placement

CNAs/CSTs in the BirthCentercannot be delegated the task of initiating or restarting EFM (External Fetal Monitor).

ATTACHMENT A: Penrose St. Francis delegation limitations for the CNA, technician, housekeeper, or unit secretary.

According to the Colorado Board of Nursing, “It is impossible to create a laundry list of tasks which can never be delegated.” However, an employer may establish policies, procedures, protocol, or standards of care which list or prohibit delegations by nurses in specified circumstances. At Penrose St. Francis, the items in section D, and attachments A& B are limitations or prohibited tasks that cannot be delegated.

The RN will NEVERdelegate responsibility for the following task to anunlicensed staff member such as a nursing assistant, technician, housekeeper, or unit secretary:

Task NOT to be Delegated / Exception
1. / Making patient care assignments.
2. / Evaluating the performance of staff members.
3. / Assessment, diagnosis, planning, or evaluation components of the nursing process.
4. / Health counseling and patient teaching, including evaluation of past patient education. / CNAs may reinforce teaching once completed by professional healthcare provider
5. / Discharge planning
6. / Starting or initiating an IV     / EMTs with IV certification working in an EDT role in the Emergency Dept.
7. / Discontinuing IVs and IV fluids    / May discontinue a peripheral saline lock without fluids infusing on patients 13 years of age or older.
8. / Hanging and caring for IVs or blood products.
9. / Turning off or turning on an IV pump.
10. / Administration of medications by any route with the exceptions listed     / Tap water enemas, cleansing enemas, saline enemas, oil retention enemas, and commercial pre-packaged enemas may be given by CNA.
11. / Titration of oxygen.
12. / Care and removal of epidurals/blocks.
13. / Removal of pacemaker leads, pulmonary artery catheters, and central venous catheters.
14. / Sterile dressings over fresh surgical sites, or over any peripheral or central venous catheter.
15. / Delegation to another person.
16. / Taking telephone/verbal orders from a physician.     / Unit secretaries may accept orders pertaining to diet, activity, routine lab tests, routine x-rays, and care acuity, according to IDP P-01-t, Physician Orders

ATTACHMENT B: Penrose St. Francis delegation limitations for the LPN.

The RN will NEVER delegate responsibility for the following tasks to a LPN:

Dextrose 5%
Normal Saline 0.9%
Lactated ringers
Sodium Chloride 0.45%
Sodium Chloride 0.2%
Pre-mixed IV fluids with electrolyte and vitamins
Pre-mixed antibiotic solutions delivered per labeled instructions.

EXCEPTION: IV Certified LPNs may NOT access large bore catheters (Cordis).
7. / Administration of medications by IV push.    
(See LPN Administration of IV Therapy guideline, Nursing I-01-b) / IV Certified LPNs MAY flush peripheral and central venous access devices designed to maintain venous patency with normal saline or a subtherapeutic dose of heparin.
EXCEPTION: IV Certified LPNs may NOT access large bore catheters (Cordis).
NOTE: for items 8 & 9 The Colorado Board of Nursing defines an adult client as an individual whose chronological age is 13 years or older.
Task NOT to be Delegated / Exception
8. / Regulation of flow rates in all IV access devices for the non-adult patients. / (All LPNs may calculate, observe flow rte, or stop the flow of IVs through venous access devices in ADULT patients ONLY).
9. / Discontinuing IVs and IV fluids from all IV access devices for the non-adult patient. / (All LPNs may remove peripheral short IV catheters in ADULT patients ONLY).
10. / Administration of blood or blood products.
11. / Administration of parenteral nutrition solutions.
12. / Administration of chemotherapy intravenous medication/solutions.
13. / Administration of investigational drugs.
14. / Access or de-access of implanted central venous access ports.
15. / Administration of thrombolytic agent to de-clot a central venous access device.
16. / Insertion of PICC or peripheral midline catheters.
17. / Repair of venous access devices
18. / Removal of a central venous access catheter.
19. / Taking pressure readings from central venous lines.
20. / Hanging IVs and/or adjusting rate of IVs with titrated medications(Examples: Heparin, Aminophylline, Lidocaine, Pronestyl, Magnesium Sulfate).
21. / Hanging IVs and monitoring patients with insulin or vasoactive drugs (Ex: Dopamine or Dobutamine).
22. / Administration of IV medications with narcotics and/or PCAs
23. / Monitoring patients with narcotic infusions or PCAs for the first 24 hours. (Note: It is the responsibility of the RN to administer the PCA infusion and assess the patient per protocol).
24. / Administration of epidural medications.
25. / Monitoring patients with epidurals.
26. / Removal of pacemaker leads, pulmonary artery catheters, and central venous catheters.
27. / Delegation to another person.
28. / Taking telephone/verbal orders from a physician.     / Normal “scope of practice” orders may be accepted by LPNs according to IDP P-01-t, Physician Orders.

REFERENCES:

American Nurses Association. ANA Principles for Delegation. Retrieved 8/26/10 from:

Colorado Board of Nursing Chapter IX, “Rules and Regulations for the Expanded Role of the Licensed Practical Nurse in Relation to IV Therapy and Venous Blood Sampling”, July 2006.

Colorado Nurse Practice Act (12-38-101CRS), 2009. Denver: State Board of Nursing.

Colorado Board of Medical Examiners, “Rules Defining the Duties and Responsibilities of Emergency Medical Services Medical directors and the Authorized Medical Acts of Emergency Medical Technicians”. Retrieved 8/24/10 from:

“Registered Nurses and Unlicensed Assistive Personnel: An Uneasy Alliance”, Journal of Continuing Education in Nursing, July/August 2006 (Volume 37, Number 4), pp. 162-170.

D-02-b