Delegation Project

INTRODUCTION:

Delegation is a process of authorizing an unlicensed person to provide a nursing service while retaining accountability of how the unlicensed person performs the task. It does not include situation in which an unlicensed person is directly assisting a Registered Nurse by carrying out nursing task in the presence of the Registered Nurse. (BNE Rule 224.4(3))

Delegation is widely viewed as a management tool that Registered Nurses use at their discretion. (BNE, 2005) The Registered Nurse is accountable for the delegation process and the choice to delegate belongs to the Registered Nurse. The Registered Nurse uses good working knowledge of Board of Nurse Examiners Rules and any other relevant regulations in making their decision to delegate. (BNE, 2005). Some hospital policy requires Registered Nurses to delegate some nursing service to unlicensed person but the Registered Nurse still makes the final decision to delegate. Delegation helps the Registered Nurse to get the job done on time and in a more productive way. Generally, delegation frees the Registered Nurse from performing jobs that does not require nursing judgment and hereby save a lot time to attend to other duties.

The scenes below are meant to treat situations where delegation of duties are appropriate or inappropriate according to the BNE's rule.

Independent Living Environment: (CASE I)

The client is a 25 year old home vented patient with severe Multiple Sclerosis, who is bed bound, unable to direct his own care but a parent is available 24/7 either in the home or telephonically and never more than 10 minutes from home; the parent is very willing to participate in care decisions. The unlicensed assistive person (UAP) has been with this client for 2 years and is very mature/reliable in carrying out activities for daily living (ADLs) and health maintenance activities (HMAs), as well as certain delegated nursing tasks (including trach care and suctioning). Up until now, the Home Care RN has been making routine visits every 90 days, and as needed to reassess if there are any changes in the client's condition.

The client developed an obstruction of his G-tube, which required an overnight hospital stay for placement of a new G-tube. At home again, his vital signs are stable, and the RN assesses his condition to be stable and non-fluctuating (i.e. no change from his previous condition).

1. Can the RN delegate the trach care and suctioning?

Yes, the RN can delegate trach care and suctioning to a UAP. BNE rule 225.10(7) specified trach care as one of the activities that can be delegated by a RN. However, before a RN can delegate any activity, BNE rule 225.9 criteria for delegation must be followed, which includes a general assessment of the patient and the stability of the patient among all things. In the above case, the client is in a stable condition based on the RN assessment. This makes this task, one that can be delegated.

2. Is it necessary for the RN to delegate this client's ADLs and HMAs?

No, it is not necessary for the RN to delegate this client's ADLs and HMAs. BNE rule 225.7 and 225.8 specified the rules for delegating the above named activities. The rule provides assessment and functional disability as the two outstanding reasons for exemption of ADLs and HMAs. The case scenarios do not fall into the category for delegation. More over the care giver has been with this patient for two years and has been carrying out these activities. The client's condition is stable; therefore no nursing judgment is needed to carry out these activities.

3. Considering the new G-tube, should the Home Care RN make adjustments to her routine visits? Why and what should they be?

Yes, based on BNE rule 225.14 the rule does not specify what the routine visit adjustment should be in a case like this. The reason been that there are various laws and regulation by different bodies like Medicare and Medicaid, community support services etc that can influence routine visit. The rule specified that when there is a conflict between rules, the most stringent one should apply. The RN should adjust her visit based on her assessment, when there is no law regarding times adjustment. The sound professional judgment of the RN should come to play in a case like this.

Emergency Room: (CASE II)

Mike, an 18 year old male motor vehicle accident victim, was admitted to the ER. Initial assessment indicated that the patient suffered abdominal trauma with sub sternal contusion. BP 88/56; pulse Ð'- weak and thready; respirations - rapid and shallow. Dr. Jackson, ER physician employed by the hospital instructed a paramedic (employed by the hospital) to insert an IV, give the initial dose of an IV medication, and insert a nasogastric tube. The ER's policies and procedures specify that paramedics in the ER are supervised by RNs.

1. What is the responsibility of the RN when another licensed professional delegates to an unlicensed person? Where is this stated in the delegation rules? The responsibility of the RN is as follows:

(1) verifies the training of the unlicensed person;

(2) Verifies that the unlicensed person can properly and adequately perform the delegated task without jeopardizing the client's welfare; and

(3) Adequately supervises the unlicensed person.

(b) If the RN cannot verify the unlicensed person's capability to perform the delegated task, the RN must communicate this fact to the licensee who delegated the task.

The above rule is stated in BNE rule 224.10

2. Could an RN delegate these tasks to a paramedic? Justify your response(s)

No, the RN cannot delegate this task to the paramedic in accordance with BNE rule 224.9 (b) (2). The administration of the initial dose of medication is prohibited from delegation in acute care environment. Also, BNE rule224.9 (b) (3) prohibits administration of medications by an injection route. This is a task that will necessitate the RN to monitor and assess patient initial reaction to medication. Under the present condition of the patient, it is not a prudent and responsible act for a nurse to delegate this task.

3. Would your response to question number 2 be different if the paramedic and physician were not employed by the hospital?

No, my response will still be the same. BNE rule 224.6 which specify