1 nurse delegation webinar susan c. reinhard senior vice president, aarp public policy institute...
TRANSCRIPT
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Nurse Delegation Nurse Delegation WebinarWebinarSusan C. ReinhardSusan C. Reinhard
Senior Vice President, AARP Public Senior Vice President, AARP Public Policy InstitutePolicy Institute
Chief Strategist, Center to Champion Chief Strategist, Center to Champion Nursing in AmericaNursing in America
DSW Resource CenterDSW Resource Center
February 17, 2010February 17, 2010
OverviewOverview
Why this issue is importantWhy this issue is important Policy approaches to find Policy approaches to find
solutionssolutions State experiencesState experiences
North DakotaNorth DakotaNew JerseyNew Jersey
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Why Important to Why Important to Understand?Understand?
Support consumer’s desire for community Support consumer’s desire for community livingliving
Can find legal solutions in several waysCan find legal solutions in several ways Legal barriers are not always the major Legal barriers are not always the major
barrierbarrier Many state nurse practice acts/ boards of Many state nurse practice acts/ boards of
nursing have enough flexibility to make it nursing have enough flexibility to make it possiblepossible
Other agencies, (public and private) are Other agencies, (public and private) are factorsfactors
Resistance from nurses and othersResistance from nurses and others 3
Finding the regulationsFinding the regulations For nurses, state nurse practice acts For nurses, state nurse practice acts
(statutes) and Board of Nursing regulations. (statutes) and Board of Nursing regulations. Boards of Nursing may also have policies or Boards of Nursing may also have policies or advisory opinions that influence nurses.advisory opinions that influence nurses.
Unlicensed certified assistants (DSW) may be Unlicensed certified assistants (DSW) may be regulated by the board of nursing or other regulated by the board of nursing or other departmentsdepartments
Facility or setting regulations may spell out Facility or setting regulations may spell out the relationship between licensed and the relationship between licensed and unlicensed personnelunlicensed personnel
Settings that are accredited will be influenced Settings that are accredited will be influenced by those requirements (JCAHO, others)by those requirements (JCAHO, others)
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What Kinds of Tasks Might What Kinds of Tasks Might DCWs Perform in DCWs Perform in
Home/Community Settings?Home/Community Settings?Routine health maintenance Routine health maintenance
activities (with predictable activities (with predictable outcomes). Examples of tasks outcomes). Examples of tasks could be:could be: Routine medications, including Routine medications, including
injections (insulin)injections (insulin) Blood glucose monitoringBlood glucose monitoring Bowel and bladder regimes, colostomy Bowel and bladder regimes, colostomy
carecare Tube feedingTube feeding Avoid laundry listsAvoid laundry lists
Policy ModelsPolicy Models(not mutually exclusive)(not mutually exclusive)
Exemption (Consumer Exemption (Consumer Direction)Direction)
Nebraska, Arkansas, New Jersey, Nebraska, Arkansas, New Jersey, North Dakota North Dakota
DelegationDelegationOregon, New Jersey, North Dakota Oregon, New Jersey, North Dakota
UAP CertificationUAP CertificationNorth Carolina North Carolina
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ExemptionExemptionSome categories of persons are Some categories of persons are
exempted from practice regulationsexempted from practice regulations
Most states have some exemptions for Most states have some exemptions for religious orders, religious orders, family membersfamily members, and , and sometimes domestic servants. sometimes domestic servants.
More recently, some states have More recently, some states have included paid personal care aides included paid personal care aides (DCWs) in this category(DCWs) in this category
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ExemptionExemptionIn Practice: In Practice:
The consumer (or his/her non-nurse The consumer (or his/her non-nurse designate) instructs and directs the DCW designate) instructs and directs the DCW in the tasks. in the tasks.
While they may enlist a nurse in teaching a While they may enlist a nurse in teaching a task, and some programs may require task, and some programs may require initial (and periodic) nurse consultation as initial (and periodic) nurse consultation as part of their quality monitoring, there is no part of their quality monitoring, there is no routine nurse involvement with the DCW.routine nurse involvement with the DCW.
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Advantages/Advantages/DisadvantagesDisadvantages
Advantage: maximizes consumer Advantage: maximizes consumer freedomfreedom
Disadvantages: Disadvantages: Does not serve consumers who Does not serve consumers who
cannot or do not want to self direct, cannot or do not want to self direct, or have no one to direct on their or have no one to direct on their behalf.behalf.
No or limited medical or nursing No or limited medical or nursing oversightoversight
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Delegation ModelDelegation Model
““One person, one task”--The nurse One person, one task”--The nurse delegates each task to one DCW delegates each task to one DCW for one consumer.for one consumer. Not transferable to another DCW or Not transferable to another DCW or
another consumeranother consumer Having been taught to perform an Having been taught to perform an
insulin injection for Iris Jones, the insulin injection for Iris Jones, the DSW cannot perform insulin DSW cannot perform insulin injections for other clients without injections for other clients without further delegation for the new client.further delegation for the new client.
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General Process for Nurse General Process for Nurse DelegationDelegation
State’s Board of Nursing State’s Board of Nursing guidelines generally direct nurse guidelines generally direct nurse toto Make sure task is within nurse’s Make sure task is within nurse’s
scope of practice and can be done scope of practice and can be done with little risk to consumer and with little risk to consumer and without need for nursing judgment without need for nursing judgment
Assess consumer for stability and Assess consumer for stability and DSW for competenceDSW for competence
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General Process for Nurse General Process for Nurse DelegationDelegation
Standard practice: The nurse Standard practice: The nurse instructs the DSW in how to instructs the DSW in how to perform the task and demonstrates perform the task and demonstrates task performance, then the DSW task performance, then the DSW demonstrate the task to document demonstrate the task to document competency. competency.
The nurse provides written The nurse provides written instructions for the DSW and instructions for the DSW and continues to monitor the consumer.continues to monitor the consumer.
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Regulatory SpecificityRegulatory Specificity
Kinds of things states specifyKinds of things states specify Factors to consider when delegating (client Factors to consider when delegating (client
condition, type of task, aide experience)condition, type of task, aide experience) What to verify when delegating (training, What to verify when delegating (training,
task observation)task observation) Instruction to provide (demonstration, Instruction to provide (demonstration,
written--what to include)written--what to include) Monitoring (frequency, in person or phone)Monitoring (frequency, in person or phone) Tasks that can or cannot be delegatedTasks that can or cannot be delegated
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Barriers to DelegationBarriers to Delegation
Though delegation is allowed in Though delegation is allowed in most states, in many cases it most states, in many cases it does not happen. Why?does not happen. Why? Nurse uncertainty about what constitutes Nurse uncertainty about what constitutes
appropriate delegation and fear of losing appropriate delegation and fear of losing her/his license for inappropriate her/his license for inappropriate delegation delegation easier to just perform the easier to just perform the task herself/himself. task herself/himself.
Nurse fears of being forced to delegate Nurse fears of being forced to delegate when he/she feels it is inappropriate to do when he/she feels it is inappropriate to do so.so.
Payer rules may require a nurse to perform Payer rules may require a nurse to perform a task for reimbursement.a task for reimbursement.
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Strategies to Address Strategies to Address UncertaintyUncertainty
Clarifying the delegation process—Clarifying the delegation process—boards of nursing or nurse boards of nursing or nurse employers may address questions employers may address questions like:like: What does the nurse need to verify?What does the nurse need to verify? How does the nurse document How does the nurse document
instructions?instructions? How often should the nurse monitor?How often should the nurse monitor?
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Orientation or TrainingOrientation or Training
Both Oregon and Washington Both Oregon and Washington provide training for contract provide training for contract nursesnurses
Washington also provides training Washington also provides training for DSWfor DSW
New Jersey creating orientation New Jersey creating orientation process through Pilot (Bill Ditto process through Pilot (Bill Ditto will address)will address)
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Liability Liability
WashingtonWashington “Nurses acting within the protocols of their
delegation authority are immune from liability for any action performed in the course of their delegation duties.”
“Nursing assistants following written delegation instructions from registered nurses performed in the course of their accurately written, delegated duties shall be immune from liability.”
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Liability Liability OregonOregon goes beyond the question of goes beyond the question of
professional liability to address civil professional liability to address civil liability:liability:
Nurses who delegate nursing care to an unlicensed person “shall not be subject to an action for civil damages for the performance of a person to whom nursing care is delegated unless the person is acting pursuant to specific instructions from the nurse or the nurse fails to leave instructions when the nurse should have done so.”
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UAP Certification ModelUAP Certification Model
DSW receives a general training and DSW receives a general training and has own “scope of practice,” outlined has own “scope of practice,” outlined in laws/regs, but is generally in laws/regs, but is generally supervised by a nurse.supervised by a nurse.
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UAP Certification UAP Certification ExamplesExamples
North Dakota’s Medication Assistant North Dakota’s Medication Assistant Certification Program Certification Program
North Carolina’s Nurse Aide I and II North Carolina’s Nurse Aide I and II and Medication Aide Programsand Medication Aide Programs
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UAP CertificationUAP Certification AdvantagesAdvantages
May put less of a teaching burden on the May put less of a teaching burden on the nurse by ensuring some common backgroundnurse by ensuring some common background
Formal recognition of UAP skills may be Formal recognition of UAP skills may be beneficial for UAP’s careerbeneficial for UAP’s career
DisadvantagesDisadvantages Costly and time consuming—less flexibility for Costly and time consuming—less flexibility for
consumersconsumers May involve training UAP about things he/she May involve training UAP about things he/she
will never encounterwill never encounter May put nurse too much at ease regarding May put nurse too much at ease regarding
UAP competenceUAP competence
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Message to NursesMessage to Nurses
As states move toward serving As states move toward serving more people in community more people in community settings, they may need to settings, they may need to restructure the way nursing care restructure the way nursing care is delivered and utilize nurses is delivered and utilize nurses more in their teaching and more in their teaching and consulting roles. consulting roles.
