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Case Study, Chapter 8, Unlicensed Assistive Personnel and the Registered Nurse
The increased use of unlicensed assistive personnel presents both opportunities and challenges for the American health care system. The nurse manager has to deal with the challenge that unlicensed assistive personnel only be used to provide personal care needs or nursing tasks that do not require the skill and judgment of the RN.
1. The nurse manager reviews the national effort to define the scope of practice for unlicensed assistive personnel. In 2007, the American Nurses Association made recommendations for a national and/or state policy for nursing assistive personnel. What are the six actions that should be taken to create a national and/or state policy agenda about the educational preparation of unlicensed assistive personnel and the competencies they should have for safe practice?
2. The need in health care today is for today’s nurses to have highly developed delegation skills in working effectively and efficiently with unlicensed assistive personnel. This is critical to ensure the clients’ needs are met and their safety is not jeopardized. What are the key general principles that the nurse manager needs to review with professional registered nurses in delegating to unlicensed assistive personnel?
Chapter 8 Unlicensed Assistive Personnel and the Registered Nurse
Copyright © 2016 Wolters Kluwer Health | Lippincott Williams & Wilkins
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Terminology
Unlicensed assistive personnel (UAP) includes
Nurse aides, nurse extenders
Health care aides
Technicians
Patient care technicians
Orderlies
Assistants or attendants
Nursing assistive personnel (NAP): replacement term by ANA in 2007
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Motivation to Use UAP
Arguments
Maximize human resources: free professional nurses from tasks and assignments not requiring independent thinking and professional judgment (nonnursing tasks and functions)
Cost savings: conflicting findings in research
Controversy
UAP are not supplements but replacements of professional RN staff
Variation in scope of practice and lack of minimum educational and training requirements
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Top Reasons for Being Pulled Away from Patient Care
Documenting information in multiple locations
Completing logs, checklists, and other unnecessary paperwork/data collection
Filling out regulatory documentation
Entering/reviewing orders
Walking to equipment/supply areas, utility rooms, etc.
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Educational Requirements
OBRA regulations for certified nurse’s aides
Minimum of 75 hours of state-approved theory and practice
Successful completion of competency exam in both areas
Most UAP training in employing facility with no formal certification
Formal training at vocational schools and community colleges; focus on long-term care; certification only to meet state requirements
Education for acute care settings facility-based; no required educational standards or guidelines
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Question #1
Is the following statement true or false?
Currently, strict standards related to the educational requirements are in place for UAP.
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Answer to Question #1
False
Wide variations exist in the educational requirements for UAP. For example, OBRA regulations require a minimum of 75 hours of theory and practice, and successful completion of an exam in both areas, while in other cases, training occurs in a facility with no formal certification.
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Certified Medicine Aides
Have worked in licensed nursing home settings, residential care settings, and adult day services in this country for almost four decades
RNs reported feeling pressured to delegate medication administration to UAPs because of inadequate organizational personnel and finances
“Handing over a crucial nursing responsibility under jeopardizing circumstances” (see Research Fuels the Controversy 8.1)
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UAP Scope of Practice #1
ANA: 6 actions necessary to create a national and/or state policy agenda for education of UAP or NAP and competencies for safe practice (see Box 8.1)
No universally accepted scope of practice for UAP
Some states with task lists
Most facilities allowing a broader scope of practice than advocated by professional nursing organizations or state boards of nursing
UAPs completing tasks traditionally reserved for licensed practitioners, that is, medication administration
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UAP Scope of Practice #2
In many settings, UAPs perform functions within the legal scope of nursing
Certain activities NEVER to be delegated to UAP
RN ultimately responsible for:
Analyzing information using highly developed critical thinking skills
Then using the nursing process to achieve desired patient outcomes
Regulatory oversight: regulation varied by state and jurisdiction
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UAP and Patient Outcomes
Effect of increased use of UAP not fully known
Studies show direct link between decreased RN staffing and decline in patient outcomes.
Increased incidence of falls
Increased incidence of nosocomial infections
Increased physical restraint use
Higher medication errors
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Question #2
Which of the following would be appropriate for a nurse to delegate to a UAP?
A. Vital sign measurements
B. Care planning
C. Patient assessment
D. Patient teaching
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Answer to Question #2
A
A UAP may perform vital sign measurements because this task does not require independent thinking or professional judgment. Activities that should never be delegated include those that require the RN to analyze information using highly developed critical thinking skills and then use the nursing process to achieve desired patient outcomes.
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RN Liability for Supervision and Delegation of UAP #1
RN responsible for adequate supervision of person to whom assignment has been delegated
RN liable if negligent in supervision of employee at the time the employee committed negligent act
Supervisor’s failure to determine which patient needs could be safely assigned to a subordinate
Failure to closely monitor subordinate requiring supervision
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RN Liability for Supervision and Delegation of UAP #2
RN awareness of UAP’s job description, knowledge base, demonstrated skills
“Mindful” communication between the RN–UAP dyad
RN is always:
Accountable for care given
Responsible for instructing UAP as to who needs care and when
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RN Liability for Supervision and Delegation of UAP #3
UAP accountable for knowing:
How to perform care properly
When others need to be called in for tasks beyond limits of knowledge and training
Marquis and Huston (2017)
Bottom line: RNs are always accountable for care given and instructing NAPs to perform care properly
ANA general principles for delegating to NAP (see Box 8.2)
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RNs Working as UAP: Liability
New graduates being hired as UPAs
Issues of legality
RN not able to provide care to level of expertise—violation of statues
Possible charges of negligence or malpractice if providing care only to the level of the assumed position
Role discrepancy
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Creating a Safe Work Environment
Health care organization activities to increase likelihood that UAP used effectively and appropriately
Clearly defined organizational structure
RN recognized as leader of health care team
Clear job descriptions defining roles and responsibilities
Uniform training and orientation programs for UAPs
Adequate program development in leadership and delegation for RNs
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Question #3
Is the following statement true or false?
The RN is responsible for instructing UAP in how to properly perform the assigned care.
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Answer to Question #3
False
The RN is responsible for instructing UAP as to who needs care and when. The UAP is accountable for knowing how to properly perform the assigned care and when to call in others for tasks beyond limits of knowledge and training. The RN must know if UAP has knowledge and skills to perform assigned task. If not, then the RN should not delegate the task.
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UAP Shortage #1
Demand for UAP growing; persons typically filling these positions declining
Graham (2017): Acute shortages occurring across the United States, but in some states, the problem is worse than others
Current nationwide shortage of well-trained UAP in all settings—high turnover rate
Long hours, inadequate staffing, physical and emotional job demands, low pay
Negative messages from managers, supervisors, coworkers
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UAP Shortage #2
Current nationwide shortage (cont.)
Lack of employer-paid benefits
Limited career paths
Less-than-ideal working conditions; high turnover rate leaving others short-handed
Outdated federal regulations for minimum standards for staffing in nursing homes
Hazards related to exposure to infectious diseases and drug-resistant infections
Emotional exhaustion brought on by occupational fatigue
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UAP Shortage #3
Possible solutions
Financial incentives
Addressing the barriers to incorporating UAP…
