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Frequently Asked Questions - Delegation

Topics
Board Rule 224 - Delegation of Nursing Tasks by RNs to Unlicensed Personnel for Clients with Active Conditions or in Acute Care Environments Board Rule 225 - RN Delegation to Unlicensed Personnel & Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable & Predictable Conditions.
Overview of Delegation Applicability
Delegation/Assignment Client's Responsible Adult
Advanced Practice Registered Nurses Health Maintenance Activities
Licensed Vocational Nurses Medication Administration
Unlicensed Assistive Personnel Medication or Procedures in an Emergency Situation
Emergency Medical Technicians/Paramedics Hospice
Family Members Delegation for the School Nurse
Nurse Externs  
Documentation  
Supervision  
Physician Orders  
Procedures/Treatments  
Medication Administration  
   
  References
   
   
   

Board Rule 224 - Overview of Delegation

Delegation is an essential nursing skill that RNs use to maximize the nursing care that clients receive.

Delegation is based upon:

  1. The needs of the patient and the stability of the patient’s condition;
  2. The RN assessment of the potential for patient harm;
  3. The complexity of the task;
  4. The predictability of the outcomes;
  5. The abilities of the unlicensed assistive personnel (UAP) staff to whom the task is delegated;
  6. The context of other patient needs to achieve the most benefit from nursing care since the RN is responsible and accountable for safe and appropriate delegation (§224.5, RN Accountability for Delegated Tasks), delegation is utilized at the RN’s discretion.
The delegation process is multifaceted. It begins with decisions made at the administrative level of the organization and extends to the staff responsible for delegating, overseeing the process, and performing the responsibilities (NCSBN, 2016). Employers have a responsibility to ensure that practices specified in job descriptions comply with applicable state and federal laws, regulations and credentialing requirements (e.g., Texas Department of State Health Services; Centers for Medicare & Medicaid Services).Toggle Expand/Collapse Text

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Delegation/Assignment

Delegation & Assignment Defined

The use of terms delegate and assign can be confusing and lead to questions regarding the licensure responsibilities associated with the terms. Delegation is defined as “authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. It does not include situations in which an unlicensed person is directly assisting a RN by carrying out nursing tasks in the presence of a RN.” [§224.4(3)]...Toggle Expand/Collapse Text

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Advanced Practice Registered Nurses

May an Advanced Practice Registered Nurse (APRN) delegate tasks to other nurses or unlicensed assistive personnel?

Under the RN licensure and role, APRNs may only delegate tasks to unlicensed staff or assistive personnel utilizing the applicable RN Delegation Rules 224 or 225 as appropriate and in compliance with Rule 217.11(3)(B). APRNs are not authorized to exceed the delegation criteria in Rules 224 and 225. While APRNs have collaborative working agreements with physicians, APRNs do not have the same delegatory authority as physicians and therefore are limited to delegation of nursing tasks within the RN licensure and role. The BON's delegation rules (§224 & §225) apply to both RNs and APRNs...Toggle Expand/Collapse Text

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Licensed Vocational Nurses

What is the LVN’s scope of practice and role in delegation?

The LVN scope of practice is both directed and supervised [NPA §301.002(2); NPA §301.353; §217.11(2)]. The LVN performs a focused assessment [§217.11(2)]. The delegation decision is based on the comprehensive assessment that is performed by the RN [§217.11(3)]. Since the LVN practice is not autonomous, and the LVN is not educated or licensed to perform a comprehensive assessment, it is beyond the LVN scope of practice to delegate tasks. However, the LVN may assign tasks not requiring delegation and provide supervision to the UAP for assigned tasks...Toggle Expand/Collapse Text

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Unlicensed Assistive Personnel

RNs may be asked to delegate tasks to UAPs with minimal skill levels or skill sets. Organizations may have policies regarding delegation and delegation duties may be included in RN job descriptions. If an RN refuses to delegate based on the assessment, can the RN be required to delegate?

Delegation is widely viewed as an essential nursing skill the RN uses at their discretion based upon the RN assessment. Since the RN is accountable for the delegation process, the decision to delegate belongs to the RN (Rules §224.5 & §225.5 concerning accountability). However, others (e.g., the client, client's family/significant others, the RN's supervisor, the UAP) may have input that the RN needs to consider in the decision making process. The decision to delegate is based on a thorough working knowledge of BON Rules (§224, §225, and §217 .11) and other relevant regulations. When delegating a task, RNs have a duty to maintain patient safety [Rule 217.11(1)(B)] which supersedes other mandates such as facility policy or physician orders (Position Statement 15.14, Duty of A Nurse in any Practice Setting)...Toggle Expand/Collapse Text

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Emergency Medical Technicians/Paramedics

Can an RN delegate nursing tasks to an emergency medical technician (EMT) or paramedic?

The BON's rules in Chapter 224 describe the requirements for RN delegation to unlicensed personnel in an acute care environment such as the emergency department. The BON does not regulate practice settings or facility policies, nor does the Board regulate emergency medical technicians or paramedics. Whether certified or licensed, the BON views the EMT or paramedic role within the acute care, inpatient setting or emergency department setting to be equivalent with the UAP for the purposes of RN delegation. While EMTs and paramedics do have out-of-hospital training and licensure/certification applicable to the out-of-hospital setting, within the acute care environment the scope of practice of the EMT or paramedic is limited to the role of the UAP...Toggle Expand/Collapse Text

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Family Members

Patients' families may assist in patient care. When instructing family members in providing care, is this considered delegation?

RNs may be involved in patient/family teaching and this is not delegation. The RN is responsible for providing complete and accurate instructions and oversight, in addition to client assessment (§ 224.6(1) and 225.5(a)). However, the requirements of the rules in Chapters 224 & 225 typically do not apply in this context. Further, the BON defines UAPs as individuals who are "monetarily compensated" to provide health care services. Since families and significant others are not usually compensated for providing care to their loved one, this is not a delegation situation.

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Nursing Students

Many organizations use nursing students (i.e., individuals who are employed in the organization and are currently students in an accredited school of nursing).

  • Is it an acceptable practice for nursing students who provide documented didactic education and demonstration of competence from their nursing program, to perform such duties as urinary catheter placement, sterile dressing changes, and venipuncture in acute care settings?
  • May they perform patient assessments and independently document these assessments in acute care settings?

Employers may hire nursing students to work as UAPs in positions such as aides or nursing assistants. This is a different situation than nursing students who are completing their clinical course work requirements in a facility and are monitored by nursing school faculty. In that scenario, students are authorized to perform nursing tasks as a part of their academic program; therefore, RN delegation is not required. However, nursing students who are employed by a facility as UAPs must function under the delegated authority of a RN to perform nursing tasks [see Rule 224.4(4)(C)...Toggle Expand/Collapse Text

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Documentation

When a RN delegates a task to a UAP, is that UAP responsible for documenting the care provided or is the RN responsible? Does the RN have to co-sign this documentation?

Responsibilities regarding documentation and co-signature are not specified in the delegation rule but may be addressed in facility policies and procedures. The RN's responsibility for complete and accurate documentation is delineated in the Standards of Nursing Practice [BON Rule §217.11 (1)(D)]. As determined by the employing agency/facility with nursing collaboration, UAPs might play a role in the documentation of care they provide. Co-signature indicates that the RN was present or observed all the activities that the UAP is reporting in the record. Without this presence or observation, the BON does not recommend that a RN co-sign others' documentation.

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Supervision

What is the RN's/APRN’s responsibility when s/he supervises an unlicensed assistive person who has been delegated tasks by a physician or other non-RN practitioners?

Board rules §224.10 and §225.14 address situations where the RN is supervising a UAP, yet that RN is not the delegating practitioner because another licensed practitioner is delegating to this UAP. The Documentation Supervision delegation rules allow this practice since delegation, as addressed by BON rule, is not restricted by employment relationships. That is, it is permissible by BON rule for a treating physician or a RN from one employing agency (e.g., a home health agency) to delegate to a UAP from a different agency (e.g., an assisted living facility)...Toggle Expand/Collapse Text

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Physician Orders

In what circumstances is a physician order required for nursing delegation?

Since RN delegation is defined as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task, the BON does not require RNs to obtain physician orders for RN delegation nor can a physician force an RN to delegate. The RN is accountable for the delegation process, therefore the decision to delegate belongs to the RN (Rules §224.5 & §225.5 pertaining to accountability). However, others (i.e., the physician, the client, client's family/significant others, the RN's supervisor, the UAP) may have input into the decision making process. The decision to delegate is based on a thorough working knowledge of BON Rules (§224, §225, and §217.11) and other relevant regulations.

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Procedures/Treatments

Can a RN delegate finger sticks to collect capillary blood for blood glucose testing?

Yes, a RN may delegate finger sticks for blood glucose monitoring [§224.8(a)(2)(A) and §225.10(4)(A)]. In Board Rule §225.12, Delegation of Insulin or Other Injectable Medications Prescribed in the Treatment of Diabetes Mellitus, blood glucose monitoring [§225.12(2)] is an important component of this delegated task...Toggle Expand/Collapse Text

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Medication Administration

Can UAPs administer immunizations?

The laws regarding immunizations are not within the BON’s authority. With regard to vaccines of any kind, an Attorney General opinion in 1981 (MW-318) determined immunizations are preventative, thus no medical diagnosis is required or made when a person receives an immunization.

However, RN/APRNs may not delegate the administration of immunizations under the delegation rules. Where allowed by state law, appropriate non-physician personnel may provide vaccinations under a physician-approved standing order without the need for physician examination and a client-specific order. An additional document that may provide guidance is the FAQ: Seasonal Influenza, and Vaccinations available on the Board’s website as well as the Board’s Position Statement 15.5 Nurses with Responsibility for Initiating Standing Orders.

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Board Rule 225 - Applicability

In relation to delegation, what types of clients and settings should a RN refer to Chapter 225? In relation to delegation, what types of clients and settings should a RN refer to Chapter 225?

There are three criteria that must be met in order for a Registered Nurse to apply the delegation rules from Chapter 225. The criteria is 1) the client is in an independent living environment such as a home a group home, foster home, assisted living facility or school; (2) the client, if 16 or older, or client's responsible adult is willing and able to participate in decisions about the overall management of the client's health care; and (3) the task is for a stable, predictable condition as defined by §225.4. [Board Rule 225.1(a)]Toggle Expand/Collapse Text

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Client's Responsible Adult

Who is eligible to serve as the "client's responsible adult" (CRA)? Is it possible for the CRA and the unlicensed assistive person (UAP) to be the same person? Can the CRA be an employee of the facility/agency providing the services?

BON Rule 225.4(5) defines CRA as “an individual, 18 or older, normally chosen by the client, who is willing and able to participate in decisions about the overall management of the client's health care and to fulfill any other responsibilities required under this chapter for care of the client. The term includes but is not limited to parent, foster parent, family member, significant other, or legal guardian.”...Toggle Expand/Collapse Text

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Health Maintenance Activities

RNs in independent living environments such as, home and community-based settings or school health while caring for clients with stable and predictable conditions must utilize the rules in Chapter 225, RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions when making decisions that pertain to delegation...Toggle Expand/Collapse Text

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Medication Administration

Is drawing up a required dose of insulin a delegated task?

According to Rule §225.12, the RN may delegate administration of insulin or other injectable medications prescribed in the treatment of diabetes mellitus subcutaneously, nasally or via an insulin pump. As part of the medication administration process, the UAP may be required to draw up the insulin or other injectable medications utilizing a sliding scale to determine the required dose of insulin or medication. These are generally permissible tasks and should be specified in the RN's instructions and physician's order. The RN may not delegate these activities if s/he will have to make decisions that require professional nursing or medical judgment. The calculation of insulin doses may not be delegated. The BON does not consider the application of a sliding scale to be of the same complexity of calculating a dose based on carbohydrate-to-insulin ratios.Toggle Expand/Collapse Text

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Medication or Procedures in an Emergency Situation

Are there any medications or procedures that may be delegated in an emergency situation in independent living environments such as in home health or school health?

Planning for emergencies in independent living environments requires the RN to utilize both Chapter 224, Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments and Chapter 225, RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions...Toggle Expand/Collapse Text

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Hospice

Is a client receiving hospice care considered stable & predictable?

Yes, according to Rule §225.4(11). Stable and predictable is defined as “a situation where the client's clinical and behavioral status is determined to be non-fluctuating and consistent. A stable/predictable condition involves long term health care needs which are not recuperative in nature and do not require the regularly scheduled presence of a registered nurse or licensed vocational nurse. Excluded by this definition are situations where the client's clinical and behavioral status is expected to change rapidly or in need of the continuous/continual assessment and evaluation of a registered nurse or licensed vocational nurse. The condition of clients receiving hospice care in an independent living environment where deterioration is predictable shall be deemed to be stable and predictable.”

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Delegation for the School Nurse

Can RNs delegate medication administration via envelopes or sealed plastic bags and give it to the teacher or another UAP when s/he accompanies students on field trips?

According to Board Rule 225.11(1), a RN may delegate the administration of medications from a daily reminder pill container. This rule section also applies to RNs who delegate medication administration to UAPs in the school setting when there is from a properly labeled unit dosage container filled by a registered nurse or another qualified district employee...Toggle Expand/Collapse Text

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References

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For more information on these and other topics, use the sear ch field at the top right corner of the page. Should you have further questions or are in need of clarification, please feel free to contact the Board.