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Last modified: June 14, 2006

Long-term care teleconference:
Delegation: What is My Role?

Highlights for March 28, 2006

 

In 2005, the College initiated a series of telephone conference calls to explore the realities of long-term care practice settings and provide opportunities for nurses to collectively problem solve.

The title of the second teleconference in the 2006 series was Delegation: What is My Role? The participants discussed the following four concepts of a nurse's accountability when delegating and working with unregulated care providers (UCPs):

  1. delegating;
  2. performing routine activities of living;
  3. teaching; and
  4. assigning.

Please note that at the time of the teleconference, only RNs and RN(EC)s were permitted to initiate a controlled act procedure. On May 8, 2006, the Ministry of Health and Long-Term Care amended the Nursing Act, 1991, to allow RPNs in Ontario to initiate some procedures. For more information, refer to the article "RPNs can now initiate certain controlled act procedures." The original responses from the teleconference have been enhanced to reflect this recent legislative change. The College has included the original responses as well as inserted information in [square brackets] that reflects the legislative change. By viewing both the original and changed responses, you will be able to see how the Nursing Act amendment affects practice.

 

Delegating

Delegating refers to transferring authority from a regulated health care provider with legislative authority and competence to perform a controlled act procedure to a regulated or unregulated health care provider who does not have the authority and competence. When health care providers require the authority and competency to perform a controlled act procedure that they cannot otherwise legally perform, delegating is necessary.

[Both RNs and RPNs are now legally authorized to delegate, and can delegate a controlled act they are authorized to perform when they have the competency to perform it and provide education. However, there are certain conditions that must be met before a nurse delegates a controlled act.] A delegating RN [or RPN] retains responsibility for the performance of the procedure and client outcome. The care and outcome should be the same as they would be if a nurse was to perform the procedure. An order — either from a physician or RN [or RPN] authorized to initiate — may be required to permit performing the delegated procedure. The requirements of the delegating process are described in the College's Decisions About Procedures and Authority practice standard and Working With Unregulated Care Providers practice guideline, which are available on this website.

Delegating is a formal process that includes:

  • assessing the appropriateness of delegating given the individual client's condition and needs, the competencies necessary to meet those needs and the circumstances of the situation;
  • educating the delegate to achieve competence;
  • determining the delegate's competence;
  • establishing a process for assessing the ongoing competence of the delegate; and
  • maintaining a written record of the delegation process.

Example: A client returns to a long-term care setting after minor surgery to remove a skin lesion. The wound requires simple dressings. After an initial period of assessment and dressing changes by nursing staff, the RN [or RPN] determines that the client's wound is healing properly and it's safe and appropriate for personal support workers (PSWs) to change the dressings.

The RN [or RPN] then establishes and administers an education program which includes both theoretical and practical components. The nurse delegates to each PSW who successfully demonstrates competence for dressing changes the authority to perform the procedure on the specific client.

If other clients require dressing changes, the nurse educator would determine which clients meet the conditions for dressing changes by a PSW and provide additional education so the PSWs can meet the clients' specific needs. The RN [or RPN] would then assign the PSWs to clients accordingly.

 

Routine activities of living

Under the Regulated Health Professions Act, 1991, (RHPA), procedures within nursing's authorized act 2 (administering a substance by injection or inhalation) and act 3 (putting an instrument, hand or finger beyond the opening of body orifices) may fall under an exception that permits someone not authorized to perform the procedures — either directly under the RHPA or through delegation — to assist a client with routine activities of daily living and not be in contravention of the legislation. A procedure is considered a routine activity of living if:

  • the client's condition is well-established, ongoing, stable and predictable;
  • the procedure is part of the client's day-to-day routine; and
  • the need for, response to and outcomes of performing the procedure are well-established over time.

Technically, the routine activities of living exception cancels the need to delegate. However, if a nurse is involved in care that includes procedures falling within authorized acts 2 and 3, and a UCP is being considered for these procedures, the nurse should safeguard client safety and well-being by adhering to the delegation process.

Example: A client with a T5 spinal cord injury cannot reliably empty her bladder and requires intermittent catheterization on a daily basis. While this may be considered a routine activity of living, the RN [or RPN] responsible for coordinating client care recognizes the need to ensure client safety and implements a delegation-type process to determine if, and under what circumstances, PSWs might provide intermittent catheterization.

To determine if delegation to a PSW is appropriate, the RN [or RPN] collaborates with the client's physician and establishes that the client's urinary tract is intact, and that her risk of autonomic dysreflexia is very low and would be offset by the RN [or RPN] assessing the client on a regular basis and being available to manage any untoward outcomes. As part of the education program, the nurse teaches the PSW about untoward outcomes and the expected performance and consultation requirements.

 

Teaching/educating

In this context, educating refers to providing instruction on how to competently perform a procedure; it may or may not include authorization to perform the procedure. When delegation is required under legislation — for example, for UCPs to perform controlled act procedures — teaching is part of the delegation authorizing process (delegating/authorizing including teaching). When delegation is not required — for example, to authorize UCPs to perform routine activities of living or non-controlled act procedures such as taking blood pressure — a delegation process is not legislatively required. To safeguard client safety and well-being, however, the same steps as those for delegation apply (teaching including authorizing). The RN [or RPN] authorizing the performance of the procedure for a particular client, or another resource person may provide the teaching.

Example A: Delegating/authorizing including teaching
An RN at a community college teaches PSWs how to perform urinary catheterization. After successfully completing the course, the RN Educator deems the PSWs competent to perform the procedure. However, the RN Educator does not delegate or transfer the authority to perform the procedure for a specific client. Instead, a delegating RN [or RPN] transfers the authority. The delegating nurse is directly involved with the client, and knows both the client's condition and the health care facility where the PSW works.

Example B: Teaching including authorizing
The Director of Care, RN Educator and Charge Nurse determine that PSWs will administer insulin to clients with diabetes who have stable blood sugars and a set daily dosage. Since these injections qualify as a routine activity of living, delegation is not required. To safeguard client safety and well-being, however, the delegation process is followed.

An RN Educator establishes and delivers an education program that includes both theoretical and practical components. The RN Educator then determines and validates the competence to perform the procedure and authority of the PSWs who successfully complete the program. In collaboration with the Charge Nurse, the RN Educator determines which clients meet the conditions for insulin administration by a PSW. The Charge Nurse then assigns the PSWs accordingly.

 

Assigning

Allocating responsibility to provide care, or aspects of care, for a client may include the need to perform controlled and non-controlled acts. Appropriate assigning takes into account the client's condition and needs as well as the competencies and authority necessary to meet those needs in the situation. In a large organizational setting, assigning generally does not involve, but may rely on, prior delegation or teaching.

Example: A Charge Nurse is responsible for coordinating care for a number of clients, one of whom has been recently admitted and requires intermittent urinary catheterization. The nurse assigns herself to provide catheterization for the recently admitted client and assigns a PSW to assist the client with bathing and dressing. The PSW has been authorized (certified/approved) to provide intermittent urinary catheterization through a delegation process by a regulated health care professional who can delegate, such as an RN [or RPN]. The Charge Nurse assigns the PSW to perform this procedure for a long-term client with a spinal injury who has an established plan of care and whose condition is well-known, predictable and stable.

To Summarize: Regardless of whether nurses are involved in delegating, teaching and/or assigning controlled or non-controlled acts to UCPs, the authorizing nurse applies the rigour of a delegating process to safeguard client safety and well-being. The authorizing nurse is responsible for ensuring that the provider has the competencies to safely, effectively and ethically address client conditions and needs, given the circumstances of the situation. The authorizing nurse is also responsible for ensuring that the care and outcomes of the client will be the same as they would be if a nurse was to perform the procedure. To meet these responsibilities, the nurse must assess the appropriateness of performing a procedure, including the predictability of the client's condition, the needs and the outcomes of performing it. Predictable situations enable UCPs to perform procedures in accordance with pre-set protocols established by a supervising nurse. The nurse retains accountability for the decision to authorize a UCP, supervision and client outcomes. If a nurse does not believe that a UCP can give appropriate care, the nurse is responsible for advocating relevant authorities to safeguard client safety and well-being.

The College recognizes that nurses need guidance on delegating controlled acts. It is working to bring the issue forward to College Council in the near future. Please check The Standard for more information.

 

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