Chapter 3 Professional Regulations of Nursing
PROFESSIONAL NURSING STANDARDS 3:2
The Nevada State Board of Nursing 3:3
STANDARDS OF CARE 3:4
Outcome Identification 3:6
STANDARDS OF PROFESSIONAL PERFORMANCE 3:7
Quality of Care 3:8
Performance Appraisal 3:8
Resource Utilization 3:8
CODE FOR NURSES 3:9
Statutes & Regulations
The previous chapters in this text discussed the legal regulation of nursing. Nursing, however, is not only regulated by Nevada law; like most professions, nursing is also a self-regulating profession. Standards for nurses may be established by a variety of nursing organizations, including, for instance, the American Nurses Association. Nurses are expected, and in some cases are legally required, to meet many of the professional and ethical standards established by these organizations. Significantly, there is a great deal of overlap between professional and legal regulation of the nursing profession. This is in great part because the Nevada State Board of Nursing, a state-governmental organization, has the primary responsibility of monitoring both the professional and legal standards for Nevada nurses. Many of the private organizational guidelines have been adapted and adopted by the Board, and thus have become legally binding standards to which nurses will be held. In some situations, such as those involving advanced practitioners of nursing, the advanced practitioners scope of practice may not be specifically defined by the Board, but may be defined by a professional organization that the Board chooses to recognize (see, for instance, the section on CAN regulation in the previous chapter). Finally, in a malpractice suit against a health professional, it is not unusual for plaintiffs attorneys to introduce or attempt to introduce professional and ethical standards as evidence that the health professional failed to meet these standards. It is, therefore, important for all nurses to be aware of and adhere to all applicable professional standards.
PROFESSIONAL NURSING STANDARDS
This section briefly examines the professional nursing standards established by the Nevada legislature and some important general standards set forth by the American Nurses Association. In general, because the practice of nursing is a learned profession affecting the safety, health and welfare of the public, the regulation of nursing is primarily a function of state law. The first laws applicable to nursing in the United States were passed in the 1890s. These early statutes were elementary, simply stating that the registered nurse (RN) title could be used by individuals who were registered and paid the required fee. By 1923 all states had nurse registration laws (Kozier, Erb, Blais, Professional Nursing Practice, 1997).
Today, state legislatures pass statutes that regulate nursing; these statutes are generally known as nurse practice acts. Nurse practice acts legally define the scope of nursing practice. Although nurse practice acts differ in various jurisdictions, a common purpose is served: to protect the public. Nurse practice acts are administered by state boards of nursing by authority of the governor or the state.
Before more closely examining the professional regulation of nursing, the scope of nursing practice should be defined. The American Nurses Association (ANA) describes nursing practice as the administration, teaching, counseling, supervision, delegation, and evaluation of practice and execution of the medical regimen, including the administration of medications and treatments prescribed by any person authorized by state laws to prescribe (American Nurses Association, Standards of Nursing Practice, 1973. In 1990, the ANA published A Guideline for Suggested State Legislation, based in part on the above definition of nursing practice, to assist state nurse associations in the revision of their nurse practice acts. The publication recommended that a states nurse practice act include the following:
(a) An unmistakable differentiation between professional and technical nursing practice;
(b) Authority for boards of nursing to regulate advanced nursing practice, including the jurisdiction to write prescriptions;
(c) Clarification of nurses accountability for supervising and delegating other personnel; and
(d) Authority of state nursing boards to preside over unlicensed assistive personnel.
Given the broad scope of nursing practice, it is inevitable that most professional standards must be somewhat general. For example, Professional Nursing Practice, (1997), states that nursing standards:
Reflect the values and priorities of the profession of nursing;
Provide guidance for the professional nursing practice;
Provide a framework for the evaluation of the practice of nursing; and
Define client outcomes and describe the profession=s accountability to the public.
The standards of education and practice for the vocation are determined by the members of the profession. These standards, in the words of the ANA, apply to all registered nurses regardless of clinical specialty, practice setting or educational preparation. The nursing profession requires integrity of its members to respect the professional judgment of others and to develop nursing standards. Standards of practice delineate nursing functions and the level of excellence required of the nurse. These standards define the nurses ethical and legal obligations to themselves, their clients and support persons, to employees, and to society.
The Nevada State Board of Nursing
In Nevada, the State Board of Nursing has been designated by the legislature to regulate and enforce the provisions of the practice of nursing. NRS 632.005. The legislature very broadly defines the practice of nursing as the general observation, diagnosis and treatment of changes in a persons health. NRS 632.0169. Thus, in Nevada, the Board has broad powers to regulate both the legal and professional aspects of the profession.
The Board establishes professional standards that nurses must meet, and imposes discipline and sanctions, including revocation of license, for those who fail to meet these standards. It maintains a register of all nurses licensed and all nursing assistants certified in Nevada. At least semiannually, the Board publishes a list of names and addresses of persons licensed or certified in Nevada; and of all applicants, licensees and holders of certificates whose licenses or certificates have been refused, suspended or revoked within the preceding year. NRS 632.100. It is the duty of the Board to adopt regulations establishing reasonable standards regarding the qualifications for the issuance of a license for nurses and certificates for nursing assistants. NRS 632.120; NAC 632.155; 632.170. As discussed more fully below, NAC 632.212, sets forth the standards of professional competence to which a nurse is expected to adhere. These areas of minimum competence, or professional standards, are also legally binding on nurses, as they are in the form of regulations prescribed by the Board. For further information, the State Board of Nursing can be reached at the following address and telephone number:
Nevada State Board of Nursing
1755 E. Plumb Lane, Suite 260
Reno, Nevada 89502
Telephone: (775) 688-2620
STANDARDS OF CARE
The nursing profession attempts to ensure that its practitioners are competent and safe to practice by the establishment of standards of practice in all clinical practice settings. These standards are often used to evaluate the quality of care nurses provide. Specific nursing measures that promote safe nursing practice are:
(a) Know your job description;
(b) Follow the policies and procedures of the agency in which you are employed;
(c) Always identify clients before implementing nursing activities;
(d) Report all incidents or accidents involving clients;
(e) Maintain your clinical competence;
(f) Know your own strengths and weaknesses;
(g) Question any order a client questions;
(h) Question any order if a clients condition has changed since the order was written;
(i) Question and document verbal orders to avoid mis-communication;
(j) Question standing orders if you are inexperienced in the specific area.
Professional Nursing Practice.
The purpose of standards of clinical nursing practice is to clarify the responsibilities for which nurses are accountable. Standards of care define the competency of nursing care demonstrated by the components of the nursing process. The standards of clinical nursing practice are generic and provide for the practice of nursing regardless of the speciality area. Distinct specialty nursing organizations have further developed specific standards related to the nursing practice in focused areas.
The nursing professions responsibilities essential in establishing and implementing standards of practice include:
- The establishment, maintenance, and improvement of standards;
Requiring members of the profession to be accountable for the utilization of standards;
iii. The education of the public regarding awareness of the standards;
- The protection of the public from individuals who willfully do not obey nor attain the standards; and
- The protection of individual members of the nursing profession from each other. Professional Nursing Practice.
In 1991, The Standards of Clinical Nursing Practice, a revised version of the 1973 professional standards for registered nurses was published by the ANA. According to the revised edition: Standards are authoritative statements by which the nursing profession describes the responsibilities for which its practitioners are accountable. Consequently, standards reflect the values and priorities of the profession. Standards provide direction for professional nursing practice and a framework for the evaluation of practice. Written in measurable terms, standards also define the nursing professions accountability to the public and the client outcomes for which nurses are responsible. The use of language such as accountability and responsibility remove these standards from the realm of guidelines, and make them potent weapons for a plaintiffs attorney to use in court against a nurse facing a malpractice claim.
The ANA standards describe a competent level of professional nursing care and professional performance common to all nurses engaged in clinical practice. Specifically, nursing standards are established for relevant techniques, such as: Assessment, Diagnosis, Planning/Outcomes; Implementation/Nursing Intervention; and Evaluation of Outcomes.
This entails the collection of patient health data by the nurse. A comprehensive assessment incorporates data from the clients history and physical assessment and addresses the clients support system. Client characteristics influencing the learning process are also considered. The data is validated, organized and recorded.
This involves the analysis of the assessment data by the nurse to formulate diagnoses. The diagnoses are also validated utilizing critical thinking skills to identify client strengths and problems. The term diagnosis refers to the reasoning process (diagnostic reasoning); standardized North American Nursing Diagnosis Association (NANDA) terms are used. NANDA defines nursing diagnosis as a clinical judgement about individual, family, or community responses to actual and potential health problems/life processes. The purpose of nursing diagnoses is to provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. Professional Nursing Practice 262.
The scope of nursing practice as defined by the ANA focuses on the nursing diagnosis and treatment of human responses to health and illness. This core of the clinical practice of nursing is dynamic, and evolves as patterns of human response amenable to nursing intervention are identified, nursing diagnoses are formulated and classified, nursing skills and patterns of interventions are made more explicit; and patient outcomes responsive to nursing intervention are evaluated. The knowledge base of the nurse, the role of the nurse, and the nature of the client population within an environment further define the nurses scope of practice.
This planning phase is a deliberate, systematic part of the nursing process that involves decision making and problem solving. In planning, the nurse refers to the clients assessment data and diagnostic statements for guidance in formulating goals and strategies. The identification of expected outcomes by the nurse are individualized to the patient, to prevent, reduce, or eliminate the clients health problem. This involves developing a care plan of goals for the client that prescribes interventions to attain expected outcomes. Problems and diagnoses are prioritized and nursing strategies are formulated.
This phase consists of reassessing the interventions the nurse identified in the plan of care. The need for assistance is determined and the care plan is carried out. Nursing interventions and client responses are documented. Professional standards support client and family participation, as in all phases of the nursing process.
Evaluation is both an ongoing, intermittent and terminal process in which the client, the nurse and the support persons determine what goals have been achieved. The care plan is reassessed and revised as needed. Care is terminated for clients with achieved goals or resolved problems.
STANDARDS OF PROFESSIONAL PERFORMANCE
The Nevada Revised Statutes contain Nevadas Nurse Practice Act, which sets out the scopes of practice and the nursing standards for various types of recognized nurses in the state. The Administrative Code is more specific, and requires that nurses demonstrate in the performance of their duties competence in:
(a) The diagnosis and treatment of human responses to actual or potential health problems;
(b) Exercising sound judgment;
(c) Making decisions;
(d) Carrying out his duties based on an established plan of care;
(e) Evaluating, assessing and altering, if appropriate, the established plan of care;
(f) Delegating appropriate duties to other nurses;
(g) Supervising a nurse to whom he has delegated nursing duties;
(h) Maintaining accountability in the delegation of care;
(i) Administering medication and carrying out treatments which are properly authorized;
(j) Determining the necessity and appropriateness of health care services for a patient or prospective patient and determining that patient’s eligibility for payment of those health care services by a licensed insurer;
(k) Managing the cases of patients assigned to him by coordinating services and collaborating with other health care professionals in the provision of health care services;
(l) Planning for the discharge of patients; and
(m) Managing risk in the provision of health care services.
Standards of professional nursing performance characterize the competency levels of professional nursing role behaviors. When standards of professional practice are implemented, they serve as measurements utilized in licensure, certification, accreditation, quality assurance, peer review, and public policy.
The ANA Standards of Professional Performance are:
Quality of Care
The systematic evaluation by the nurse of the quality and effectiveness of nursing practice.
The evaluation of the nurses own nursing practice in relation to professional practice standards and relevant statutes and regulations.
The nurse acquires and maintains current knowledge in the practice of nursing.
The interaction and contribution to the professional development of peers, colleagues and other health care providers.
Decisions and actions by the nurse on behalf of patients that are determined in an ethical manner.
The collaboration by the nurse with the patient, family and other health care providers in providing patient care.
Research findings used in practice by the nurse. Nursing research is an important component to keep standards current and in maintaining a high level of care in the utilization of outcomes. Nursing research provides a scientific foundation for the development and testing of nursing theory; progression of methodology in care implementation and cultivation of nursing practice standards.
The consideration of factors by the nurse related to safety, effectiveness, and cost in planning and delivering patient care.
Standards of Clinical Nursing Practice, 1991.
CODE FOR NURSES
While nurses are held to professional standards promulgated by the Board of Nursing and other organizations, they must also meet the ethical standards of the profession. These ethical standards are set forth in Nevada regulations and in the codes of professional organizations. The Code for Nurses was adopted by the American Nurses Association in 1950 and has been revised periodically. The Code for Nurses is based on the relatively new awareness of the relationship between individuals, nursing, health, and society. Paraphrasing the Code For Nurses (1976, 1985): ANA code of ethics makes explicit the primary goals and values of the profession and indicates a professions acceptance of the responsibility and trust with which it has been invested by society.
Codes of ethics describe the nurses relationships to clients, support persons, colleagues, employers, and society. When an individual becomes a nurse, a moral commitment is made to uphold the values and special obligations expressed in her nurses code. Nursing encompasses the protection, promotion, and restoration of health; the prevention of illness; and the alleviation of suffering in the care of clients, families, groups and communities. When making clinical judgement, nurses base their decisions on consideration of consequences and of universal moral principles, both of which prescribe and justify nursing actions. The most fundamental of these principles is respect for persons. Other principles stemming from this basic principle are autonomy, beneficence, nonmaleficence, veracity, confidentiality, fidelity, and justice.
Code For Nurses (1976, 1985).
Since clients are the primary decision makers in issues concerning their own health, treatment, and well-being, the goal of nursing interventions is to support and enhance the clients responsibility and self-determination to the greatest extent possible. The statements and interpretations of the Code provide guidance for conduct in carrying out nursing responsibilities consistent with the ethical obligations of the professional quality of nursing care. Guidance and assistance in the application of the code to situations may be obtained from the ANA and the state nurses association.
The Code for Nurses with Interpretive Statements is included below:
- The nurse provides services with respect for human dignity and the uniqueness of the client unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
1.1 Respect for Human Dignity
The fundamental principle of nursing practice is respect for the inherent dignity and worth of every client. Nurses are morally obligated to respect human existence and the individuality of all persons who are the recipients of nursing actions. Clients should be as fully involved as possible in the planning and implementation of their own health care. Clients have the moral right to determine what will be done with their own person; to be given accurate information, and all the information necessary for making informed judgements; to be assisted with weighing the benefits and burdens of options in their treatment; accept, refuse, or terminate treatment without coercion; and to be given necessary emotional support. Each nurse has an obligation to be knowledgeable about the moral and legal rights of all clients and to protect and support those rights. Taking into account both individual rights and the interdependence of persons in decision making, the nurse recognizes those situations in which individual rights to autonomy in health care may temporarily be overridden to preserve the life of the human community.
1.2 Status and Attributes of Clients
The need for health care is universal, transcending all national, ethnic, racial, religious, cultural, political, educational, economic, developmental, personality, role and sexual differences. Nursing care should be provided without prejudicial behavior. Individual value systems, culture and lifestyles should be taken into consideration when planning health care for each client.
1.3 The Nature of Health Problems
The nurses respect for the dignity and worth of the individual human being is pertinent, regardless of the nature of the health problem. The nurse doesnt act deliberately to terminate the life of any person. If ethically opposed to interventions in a particular situation, because of the procedures to be used, the nurse may refuse to participate. The refusal should be known in advance so other appropriate arrangements can be made for the clients nursing care. Nursing care for the dying client and support persons should emphasize human contact.
1.4 The Setting for Health Care
The nurse endeavors to promote nondiscriminatory, nonprejudicial care in every encounter. The setting does not determine the nurses ability to respect clients and to render or obtain necessary services.
- The nurse safeguards the clients right to privacy by judicially protecting information of a confidential nature.
2.1 The Clients Right to Privacy
The nurse is trusted to protect information confidentially. The right to privacy is an unchallengeable human right.
2.2 Protection of Information
Information required for the purposes of peer review, third party payment, or other quality assurance implementations, must be disclosed only under specific policies, mandates, protocols or guidelines assuring the rights, well-being, and safety of the client is maintained.
2.3 Access to records
The individual maintains the right of control over the information in the record, despite the records belonging to the agency where the data was collected. If the clients record is used for research in which anonymity cannot be guaranteed, consent from the client must first be obtained. This ethically ensures the clients right to privacy; and legally protects the client against unlawful invasion of privacy.
- The nurse safeguards the client and the public when health care and safety are affected by the incompetent, unethical, or illegal practice of any person.
3.1 Safeguarding the Health and Safety of the Client
Nurses must be aware of the employing institutions policies and procedures, nursing standards of practice, the Code for Nurses, and laws governing nursing and health care regarding incompetent, illegal or unethical practices.
3.2 Acting on the Questionable Practice
An established process for reporting and handling incompetent, unethical, illegal, inappropriate or questionable practice within the employment setting so reporting can go through official channels without causing fear of reprisal.
3.3 Review Mechanisms
Participation by the nurse in the establishment, planning, implementation and evaluation of review mechanisms serving to safeguard clients is recommended.
- The nurse assumes responsibility and accountability for individual nursing judgements and actions.
4.1 Acceptance of Responsibility and Accountability
Individual professional licensure ensures the basic and minimum competencies of the professional nurse. Individual practitioners of professional nursing must bear primary responsibility for the nursing care clients receive and are accountable for their own practice.
4.2 Responsibility for Nursing Judgement and Action
By accepting nursing responsibilities, the nurse is held accountable for them.
4.3 Accountability for Nursing Judgement and Action
Nurses are accountable for judgements made and actions taken in the course of nursing practice. Neither physicians orders nor the employing agencys policies relieve the nurse of accountability for actions taken and judgements made.
- The nurse maintains competence in nursing.
5.1 Personal Responsibility for Competence
It is the personal responsibility of each nurse to maintain competency in practice. The nurse must be involved in continuing professional education to keep skills and knowledge current.
5.2 Measurement of Competence in Nursing Practice
Participation in the development of objective criteria for evaluation is the nurses responsibility. Additionally, ongoing self-evaluation of clinical competency, decision-making abilities, and professional judgements is part of the nursing commitment.
5.3 Intra professional Responsibility for Competence in Nursing Care
Nurses are required to have knowledge relevant to ethical concepts and principles, the current scope of nursing practice, changing issues and concerns.
- The nurse exercises informed judgement and uses individual competence and qualifications as criteria in seeking consultation, accepting responsibility, and delegating nursing activities to others.
6.1 Changing Functions
Judgement in accepting responsibilities, seeking consultation, assigning responsibilities related to ongoing changes in health services, is the nurses responsibility.
6.2 Accepting Responsibilities
Nurses determine the scope of their practice in consideration of their education, competency, knowledge and extent of experience.
6.3 Consultation and Collaboration
Collaborative efforts encompass the provision of health care. Participation in interdisciplinary teams can be an effective approach to the provision of high quality total health services.
6.4 Delegation of Nursing Activities
Nurses are accountable for the delegation of nursing care activities to other health care colleagues. Assessing competency levels of personnel is essential prior to delegation.
- The nurse participates in activities that contribute to the ongoing development of the professions body of knowledge.
7.1 The Nurse and Development of Knowledge
Each nurse has a responsibility to be involved as an investigator in furthering cognizance, as a research participant or by using empirical and theoretical knowledge.
7.2 Protection of Rights of Human Participants in Research
It is a nursing obligation to maintain vigilance in protecting the life, health privacy, and dignity of human subjects from both anticipated and unanticipated risks and in assuring informed consent.
7.3 General Guidelines for Participating in Research
Prior to participation in research of any capacity, the nurse should be fully informed of the clients and nurses rights and obligations.
- The nurse participates in the professions efforts to implement and improve standards of nursing.
8.1 Responsibility to the Public for Standards
Only those individuals demonstrating the skills, knowledge, and commitment essential to the professional nursing practice are accepted into the nursing profession.
8.2 Responsibility to the Profession for Standards
Professional standards exist in nursing practice, nursing service, nursing education, and nursing research.
- The nurse participates in the professions effort to establish and maintain conditions of employment conducive to high quality nursing care.
9.1 Responsibility for Conditions of Employment
Conditions of employment that enable the nurse to practice in accordance with the standards of nursing practice and provide a caring environment meeting the standards of nursing service is the individual nurses responsibility.
9.2 Maintaining Conditions for High Quality Nursing Care
The terms and conditions of employment conducive to high quality nursing care is the nurses commitment.
- The nurse participates in the professions effort to protect the public from misinformation and misrepresentation and to maintain the integrity of nursing.
10.1 Protection from Misinformation and Misrepresentation
It is a responsibility of the nurse to advise clients against the use of products that endanger the clients safety and welfare.
10.2 Maintaining the Integrity of Nursing
The nurse may use the title R.N. to act in public interests that are legal and appropriate.
- The nurse collaborates with members of the health professions and other citizens in promoting community and national efforts to meet the health needs of the public.
11.1 Collaboration with Others to Meet Health Needs
Nurses have an obligation to promote equitable access to nursing and health care for all people. This involves collaborative planning at levels that respect the interdependence of health professionals and clients.
11.2 Responsibility to the Public
Promoting the welfare and safety of all people is a commitment of the nursing profession. Active participation in decision making assures fair distribution of health care and nursing resources.
11.3 Relationships and Other Disciplines
A multi disciplinary approach to the delivery of health care services is essential to ensure high quality assistance to all persons.
ANA, Code for Nurses (1985).
According to the ANA, credentialing is the process of determining and maintaining competence in nursing practice. The credentialing process is one way by which the nursing profession maintains standards of practice and accountability for the educational preparation of its members. Credentialing includes licensure, registration, certification, and accreditation.
Licensure is the process by which a government agency grants permission to individuals to engage in the practice of a profession or occupation by certifying that those licensed have attained the minimal degree of competency necessary to ensure that the public health, safety, and welfare will be reasonably well protected.
The Nevada State Board of Nursing is responsible for the examination of applicants and issuance of licenses. NRS 632.150; NAC 632.155. Each applicant who is otherwise qualified for a license to practice nursing as a professional nurse shall be required to write and pass an examination on such subjects and in such form as the board may from time to time determine. Any such written examination may also be supplemented by an oral or practical examination at the discretion of the board. The state board of nursing shall issue a license to practice nursing as a professional nurse in the State of Nevada to each applicant who successfully passes such examinations.
The Board shall also issue a license to practice nursing as a professional nurse, without examination, to any applicant who has been duly licensed or registered as a registered nurse under the laws of any other jurisdiction and otherwise meets the qualifications required of professional nurses in this state. NAC 632.155.
There are two types of licensure as described in Professional Nursing Practice (1997): mandatory and permissive. Under mandatory licensure, anyone practicing nursing must be licensed. Under permissive licensure, the title RN is reserved for licensed nurses, but the practice of nursing is not prohibited to those who are not licensed or registered. Nevada is a mandatory licensing state, and any person who practices nursing must therefore first obtain a license from the Board of Nursing.
In Nevada, the Board may revoke, suspend, or restrict a nursing license, or may place any condition, limitation or restriction on any license or certificate issued if the board determines that such action is necessary to protect the public health, safety or welfare. Unprofessional conduct such as incompetent nursing practice, conviction of a crime, and illicit use or purchasing or selling of illegal drugs are all acts that may result in discipline for a nurse. In each situation, all of the facts are reviewed by a committee at a hearing. NRS 632.350- NRS 632.405; NAC 632.916-NAC 632.940. Nurses are entitled to be represented by legal counsel as a result of the hearing. NAC 632.919. The nurse can request a rehearing or reconsideration of the decision of the court of law or an agency designed to review the decision ten days after receipt of an order of the Board. NAC 632.928.
All registered nurses are licensed by the board of nursing of the state. The requirements for licensure vary by state. In Nevada, the qualifications for licensing are described in NAC 632.150. All nursing candidates must write the National Council Licensure Examinations (NCLEX) for registered nursing or practical nursing. NAC 632.155.
In Nevada, an advanced practitioner of nursing means a registered professional who has specialized skill, knowledge and experience obtained from an organized formal program of training and who is authorized according to the conditions set forth in NAC 632.255 to NAC 632.295. The term includes a nurse midwife, a nurse psychotherapist, a nurse practitioner and a clinical nurse specialist. The ANAs position is that the function of the professional association establishes the scope of practice for advanced nursing practice and the state boards of nursing can regulate advanced nursing practice within each state.
Accreditation is a process by which a voluntary organization, such as the National League for Nursing (NLN), or a governmental agency, such as the state board of nursing, appraises, evaluates, recognizes and grants accredited status to institutions, universities, colleges or programs that meet predetermined structure, standards, processes and outcome criteria. Minimum standards for basic nursing education programs are established. State accreditation is granted to schools of nursing meeting the minimum criteria. According to the NLN, accreditation reflects a program that is flexible and progressive, meeting the changing needs of the society it serves through sound educational methods and a humanistic approach.
In Nevada, an accredited school of nursing means a school of nursing which is accredited by the Board or another body or agency authorized by law to accredit or approve schools of nursing in the state in which the school is located. NRS 632.011. The Board sets forth standards and approves curricula for schools of professional nursing in Nevada. NRS 632.430-632.460; NAC 632.615-632.625.
Delegation and supervision by nurses are both significant aspects of the nursing profession as proper patient care often involves the assimilation of colleagues with various levels of expertise and capabilities. Delegation is defined as the transfer of responsibility for the performance of an activity from one person to another while retaining accountability for the outcome. The ANA recognizes the appropriate utilization of assistive personnel by describing the following concepts:
- a) The nursing profession determines the scope of nursing practice;
- b) The nursing profession defines the roles of assistive personnel involved in providing direct patient care;
- c) The nursing profession defines the education, training and utilization for any unlicensed assistive roles;
- d) The RN is responsible and accountable for the provision of nursing practice;
- e) The RN supervises and determines the appropriate utilization of any unlicensed assistant involved in providing direct patient care; and
- f) The purpose of unlicensed assistive personnel is to enable the professional nurse to provide nursing care for the patient.
Nevada law specifically sets out the requirements for the delegation and supervision of nursing care. Section 632.222 of the Administrative Code states that:
1) A registered nurse may delegate nursing care to other nurses and supervise other personnel in the provision of care if those persons are qualified to provide that care.
2) A registered nurse shall perform or supervise any act necessary to ensure the quality and sufficiency of the nursing care of a patient which is delegated to or by other nurses under his supervision.
3) Before delegating the care of a patient to another nurse, a registered nurse shall consider the following:
The amount of direction required by the nurse to whom the care is being delegated;
The complexity of the nursing care needed by the patient, recognizing that simple care may be performed by following an established policy while more complex care requires greater knowledge and a higher level of judgment, direction and supervision;
The educational preparation and demonstrated competency of the nurse to whom the care is delegated; and
The established policies and procedures relating to the care of the patient and the procedures used to communicate to other providers of health care the patient’s symptoms, reactions and progress.
4) A registered nurse who delegates nursing care to another nurse or assigns duties relating to that care to other personnel is responsible for the actions taken by those persons in carrying out the duties delegated or assigned.
Similarly, a licensed practical nurse who delegates nursing care to another LPN or other person is responsible for the actions taken by those persons in carrying out the duties delegated or assigned. NAC 632.230.
When supervising another nurse, be aware of potential problems before they surface. If staffing shortages force you to make assignments of unqualified or minimally qualified persons, document your actions and the reasons for them. Send a memo to the appropriate supervisor and administrator stating that you were forced to assign unqualified individuals to tasks unsuited to their skills. If appropriate, communicate to other personnel that a unqualified individual will be performing a task and will require additional supervision and assistance.
In addition to legal liability for negligent selection (assignment) and negligent supervision, nurse managers and supervisors face disciplinary action from the Nevada State Board of Nursing. Even if a patient is not harmed, a nurse may be disciplined for assigning or delegating functions, tasks or responsibilities to unqualified persons. Another section of the same regulation states that failing to supervise a person to whom functions of nursing are delegated or assigned will be considered unprofessional conduct that will be disciplined. NAC 632.890.
An important and often overlooked facet of the delegating process is the ethical responsibility of delegatees to refuse any responsibilities for assignments of activities they dont have the expertise to perform safely and competently. This is applicable even if hospital policies, physicians, and nurse colleagues request these tasks be completed. Nurses should therefore ensure that they are competent to complete a task before accepting a delegation. For more information see the chapter in this text on delegation, assignment, and supervision.
A nurse may need to delegate certain responsibilities to an assistant. Nurses may require assistance to give client care quickly in certain situations and to ensure the clients safety. The function of delegating in the health care field is often complex because of the number and diversity of caregivers, the amount of knowledge and clinical skills necessary to provide care, and the intricacy of the relationship among staff, client, and environment.
In delegating, the nurse must also determine how many and what type of personnel are needed for the procedure or situation. After establishing that assistance is required, the nurse must be able to identify what type of support is needed, the length of time help will be required, and what assistance is available. The nurse should arrange for assistance by asking the appropriate person before initiating the nursing procedure.
Delegation requires the nurse to be aware of colleagues knowledge and level of expertise. An important aspect of delegation is the evaluation of nursing and support personnel. By knowing the experience, background, skill level, and strengths of each person, a nurse can delegate responsibilities that help develop each individuals competence. Nursing personnel to whom aspects of care have been delegated need to be supervised and evaluated. The amount of supervision is highly varied and is dependent on the knowledge and capability of each individual. The nurse contributes to the evaluation process by being the person who assigns the activity and observes the performance.
The National Council of State Boards (1995) summarizes the following five rights of delegation:
1) The Right Task: Tasks that are appropriate for delegation include those:
- a) which frequently reoccur in the daily care of a client or group of clients
- b) which do not require complex or multi-dimesional application
- c) for which the results are predictable and the potential risk is minimal; and
- d) which utilize a standard and unchanging procedue.
2) The Right Circumstances: A somewhat generic standard that includes the appropriate patient setting, and takes into account the available resources, preparation for the task, complexity of the task, and the ability to monitor the person to whom the task is delegated.
3) The Right Person: The person delegating the task should ensure that the nurse performing the task is properly trained and adequately assessed. The nurse accepting the delegation should also assess her own performance in order to ensure that she can perform the given task. In other words, the right person should delegate the right task to the right person to be performed on the right person.
4) The Right Direction/Communication: The supervisor should convey a clear, concise description of the task including objectives, limits, and expectations. The nurse accepting the delegation should ensure that she knows what specific data will be collected and the method and timelines for reporting, what specific activities will be performed and any instructions or limitations specific to the client, and what the expected results are, any potential complications, and the time lines for communicating such information.
5) The Right Supervision/Evaluation: The persons responsible for supervision of tasks should be clearly identified. Appropriate monitoring, evaluation, intervention, documentation, and as needed, feedback, should be provided.
In sum, delegation is an important tool of professional nursing, but one that brings with it a need to adhere to professional and legal guidelines in order to minimize potential liability. To delegate effectively, the nurse must be aware of the needs and goals of the client and support persons, the nursing activities helping the client to meet goals, and the skill level and knowledge of various nursing and support personnel.