PP 1995 11 9515 Aarp

#9515 November 1995
Delegation of Nursing Activities: Implications for Patterns of Long-Term Care
by Rosalie A. Kane Colleen M. OConnor Mary Olsen Baker
Elizabeth Clemmer, Project Manager

The Public Policy Institute, formed in 1985, is part of the Division of Legislation and Public Policy of the American Association of Retired Persons. One of the missions of the Institute is to foster research and analysis on public policy issues of interest to older Americans. This paper represents part of that effort. The views expressed herein are for information, debate and discussion, and do not necessarily represent formal policies of the Association.
0 , American Association of Retired Persons. Reprinting with permission only. AARP, 601 E Street, N.W., Washington, DC 20049
FOREWORD
In 1993, AARPs Public Policy Institute published a national overview of assisted living, Assisted Living in the United States: A New Paradigmfor Residential Carefor Frail Older Persons?, by Rosalie A. Kane and Keren Brown Wilson. Their research showed that Oregons assisted living facilities were able to provide care to a very impaired group of assisted living residents, many, perhaps most, of whom would otherwise have been in nursing homes. Costs to residents (or to public funding agencies) were about two-thirds of those of nursing homes. Oregons fees were low, in part, because that state has implemented a Nurse Delegation Act that allows unlicensed staff, rather than licensed nurses, to perform routine nursing tasks under carefully prescribed circumstances in assisted living facilities. Recognition of the role that such nurse delegation can play in making assisted living affordable prompted AARP to ask Rosalie Kane and her colleagues at the University of Minnesotas National Long-Term Care Resource Center to examine the status of nurse delegation in Nurse Practice Acts in various states. Dr. Kane, Colleen OConnor, and Mary Olsen Baker have reviewed the statutes and the practices in 20 states, interviewed key informants, and developed case studies for Oregon, Texas, and Colorado. Their analyses and conclusions, and the detailed information they provide in their appendices, should be a valuable resource for those states reviewing nursing practices. Elizabeth C. Clemmer, Public Policy Institute American Association of Retired Persons
Delegation o Nursing Activities f
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TABLE OF CONTENTS
ACKNOWLEDGMENTS
................................................................................
EXECUTIVE SUMMARY ~TRODUCTION
............................................................................
vii
......................................................................................... 1 BACKGRO.UIVD........................................................................................... 1
SIGNIFICANCE TOPIC.................................................................................... OF OREGON EXPERIENCE ....................................................................................... SPECIFYING LEADERSHIP FOR NURSES ........................................................... ROLES DEFINING NURSE DELEGATION ............................................................................
1 4 4 6
8 -8 9 10 12
13 14 16 17 21 21 23 31 37 39 40 47
METHOD RESEARCHQUESTIONS ......................................................................................

SELECTION STATES OF ..................................................................................... SECONDARY ANALYSIS ..................................................................................... KEY INFORMANT INTERVIEWS ............................................................................ SITE VISIT ...................................................................................................
................................................................................................... 7
FINDINGS WHO DELEGATES .......................................................................................... ...................................................................................... WHENTO DELEGATE DELEGATION WHOM ................................................................................... TO DELEGATION WHOM FOR .................................................................................. WHERE DELEGATION DONE Is ............................................................................ TASKS DELEGATION FOR .................................................................................. HOWTASKS DELEGATED ARE ............................................................................ IN LIVING SETTINGS ........................................................... DELEGATION ASSISTED CUSTOMARY PRACTICES ................................................................................... THREE STATE EXAMPLES ................................................................................. OPINIONS ABOUT NURSE DELEGATION ..................................................................
DISCUSSION GENERAL CONCLUSIONS .................................................................................. STEPS TOWARD CHANGE .................................................................................. CONCLUSIONS
.................................................................................................
............................................................................................. 57
57 61
.......................................................................................... 66 REFERENCEs ............................................................................................ 69

NURSE PRACTICE STATUTES REGULATIONS AND .......................................................
71
Delegation of Nursing Activities
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ACKNOWLEDGMENTS
This study of nurse delegation practices was conducted under a contract made in December 1993 by the Public Policy Institute of the American Association of Retired Persons (AARP)to the University of Minnesota's National Long-Term Care (LTC) Resource Center. The study was enhanced by additional finding from the U.S. Administration on Aging (AoA), which finds the National LTC Resource Center. We thank our AARP Project Officer, Elizabeth Clemmer, at AARP for her unflagging encouragement and her keen interest in the substance of the topic. We also thank our AoA Project Oficer, James Steen, who is always supportive and helpfbl in advancing the work of the LTC Resource Center. Many people generously shared their insights for this study. We thank all Board of Nursing personnel, state officials, and other key informants who spoke with us. They were gracious with their time and thoughtfil in their comments. We also thank Robin Fordham, who did a wonderfid job in preparing the numerous tables and the many iterations of drafts of this report. We are especially appreciative of those who reviewed earlier iterations of the report and made helpful comments. Reviewers external to AARP were Ruth Galton Irwin, Oflice of the HHS Assistant Secretary for Planning and Evaluation (ASPE), Division of Disability, Aging and Long-term Care; Phoebe S. Liebig, Ethel Percy Andrus Gerontology Center, University of Southern California; Charles Reed, Assistant Secretary, Aging and Adult Services Division, State of Washington; Charles Sabatino, American Bar Association Commission on Legal Problems of the Elderly; and James Steen, AoA. AAlU? reviewers included Mary J0 Gibson, Robert Jenkens, Donald Redfoot, and Jane Tilly. Of course, we take responsibility for the findings and interpretations, which do not necessarily reflect the conclusions or policies of the reviewers, AARP,the Administration on Aging, or any agencies in any state included in this study. We also note that policies concerning nurse practice are undergoing study and change in many states. Specific descriptive information is, to the best of our ability, accurate as of June 1994. Some policy details probably will have changed in some states before this report appears. It is safe to predict, however, that inter-state variability and considerable ambiguity will still prevail on this issue.
Rosalie A. Kane, Director National LTC Resource Center University of Minnesota Institute for Health Services Research School of Public Health
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EXECUTIVE SUMMARY
Purpose
In this report we review nurse practice statutes, related regulations, and customary professional practices to examine the circumstances by which nurses can and do delegate nursing tasks to unlicensed people. The report was undertaken to explore the reality and the potential for nurses to play an enhanced role as teachers and delegators of care to unlicensed persons working in group settings where elderly people needing care reside, particularly assisted living settings. However, it was necessary to examine nurse practice statutes, regulations, and customs more broadly before considering applications to particular settings. Thus, the report is relevant to those interested in long-term care (LTC) in all settings (e.g. home care, adult day care). Hospital care, other acute care, and nursing homes are outside the scope of this report.
The topic of nurse practice and nurse delegation in LTC is currently being explored for several reasons:
9 LTC costs for a particular consumer are highly sensitive to the need for nursing services, which are expensive to arrange on a routine or unscheduled episodic basis outside of large institutional settings;
9 paid personnel are often already providing personal care and homemaking services to LTC clients in assisted living settings and in their own homes; the efficiency of delegating nursing services to such paid helpers is magnified;
9 if nursing tasks can be safely delegated to unlicensed personnel, the unit costs of care go
down and thus arranging flexible care plans in small group settings and consumers' homes at prices lower than nursing home costs becomes more feasible. Taking into account the need for consumer protections and quality assurance, this report explores the conditions under which it might be desirable and feasible for nurses to teach and delegate nursing tasks to unlicensed personnel in the same way they might teach a family member to assist a relative by performing nursing tasks.
Method
The report presents case studies of nurse delegation in 20 states (Arizona, California, Colorado, Iowa, Florida, Kansas, Maine, Massachusetts, Missouri, Minnesota, Montana, Nebraska, New Jersey, New York, Ohio, Oklahoma, Oregon, Texas, Washington, and Wisconsin). States were selected based on three criteria: they were known or believed to have nurse practice acts that
Delegation o Nursing Activities f page vii
permit substantial nurse delegation; the state was active in developing policies for assisted living programs; and the state had made a substantial investment in client-directed home care. The latter two programs become more feasible and less expensive if some nursing tasks may be delegated, and we, therefore, thought delegation policies were more likely to have been considered in those states.
'
We reviewed the actual nurse practice statutes and regulations in each selected state. We also conducted approximately 130 telephone interviews with key state informants, including: representatives from state boards of nursing; state licensing divisions for assisted living, adult foster care, or group homes; state nurses' associations; state home health associations; state associations for nursing homes and for residential care; and state long-term care ombudsman programs. Most interviews were done between June 1994 and September 1994.
Findings The results of the comparison of the 20 state case studies revealed wide inter-state variation, as well as substantial intra-state ambiguity and confbsion. All but 3 of the 20 states refer to and permit some delegation in their nurse practice statutes and/or regulations. However, although the vast majority allowed some delegation, most provisions were sketchy and amenable to interpretation. The most detailed specification was provided in Colorado, Massachusetts, Oregon, and Texas. Who Delegates > All but 3 of the 20 states permitted registered nurses to do some delegation, and 4 states also allowed for licensed practical nurses to do some delegation. Delegation always had to be within the legal scope of practice (i.e., nurses can only delegate what they were legally permitted to do). Delegation to Whom > The state statutes had three general patterns: 1) nurses could delegate to whomever they view as competent; 2) nurses could delegate to people with specified training or experience, such as nurse's aides; or 3) nurses could delegate only to LPNs or other licensed people.
>
In most states, formal delegation to family members was unnecessary because care by family members was exempted fiom the Nurse Practice Act. Therefore, family members could provide nursing care without being viewed as practicing nursing without a license. Accordingly, nurses could teach family members to provide care without fear that they were aiding and abetting in the practice of nursing without a license. In states that did not exempt family members from the Nurse Practice Act, nurses were required to formally delegate, not merely to teach, nursing tasks to families, who then fell within the scope of the nurse practice act.
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Other variants regarding family members concerned whether a distinction was made between family members who are compensated versus those giving gratuitous care, and how expansively or narrowly family was defined under the act. Delepation for Whom P The majority of states had no restrictions on the characteristics of patients whose care may be delegated. Oregon regulations permitted delegation only if the client had stable and predictable health needs (which was defined broadly to include hospice clients), and Texas had some qualifications that applied only when delegating for a patient with stable conditions and some that applied only with unstable conditions. Where Delegation Is Done > Most state statutes specified no restrictions on the settings where delegation could occur. Exceptions included Kansas, which had some rules that applied only to delegation by school nurses in a school setting; Oregon, where delegation rules applied only in settings where no regularly scheduled nurse was employed; Maine, where delegation was permitted only when a registered nurse was in charge of an organized nursing program; and Texas, which had developed specific provisions that applied only to specified settings. Tasks for Delegation P Broad variation existed regarding what tasks could be delegated, ranging from a general statement that nurses could delegate "nursing tasks," to lists of specific tasks that could or could not be delegated.
>
Oregon and Kansas nurse practice policies recognized a key distinction between delegation and assignment; the former refers to tasks that may only be delegated on a one-by-one basis for each individual patient, whereas the latter refers to tasks that a nurse may delegate (Le., assign) categorically. For example, administration of prescribed oral medications and all personal care tasks could be assigned generally and thus did not need to be delegated on a task-specific and patient-specific basis. Other technical tasks that have more individual variation could not be assigned, but had to be delegated for each patient to whom they pertained. Delegated tasks required a minimum level of supervision by the nurse every 60 days, whereas assigned tasks were supervised at the nurse's discretion. Delegation of administration of medication was a complex area where we found variations in specific permissions or prohibitions. In general, injectable medications were often excluded from the permissible delegation. Some states limited delegation or assignment of medication administration (including oral medications) to people who had completed a specific state training program.
>
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How Tasks Are Delegated 9 States provided relatively few guidelines to nurses about the manner for delegating tasks. The two areas where some rules or guidelines were available concerned documentation and supervision. Only Oregon had extensive documentation rules. All states required some supervision of delegated tasks, but only a subset specified the intensity and type of supervision required, and who must do it. Regarding the latter, the issue was whether the nurse who originally delegated the task must supervise or if a substitute supervisor could be named without the delegation being repeated.
9 Nurses were usually interpreted as accountable for the decision to delegate and the
adequacy of the delegation procedures. They were also generally accountable for the quality of the delegated care, though this issue was not well defined. In only five states was no accountability specified.
9 States that had built their home and community LTC programs with the assumption that
nurse delegation would be used widely tended to have much more specification built into their regulations than those who had not made this explicit policy decision. Thus, Oregon (with more than a decade of policies for nurse delegation) and Texas (a state that incorporated nurse delegation into its planning for community-based long-term care) had developed more guidelines than many other states. Arguably, such guidelines made nurses in these two states feel more secure delegating tasks. Delegation in Group Residential Settings 9 Often state rules for licensure of residential settings restricted nursing delegation practices allowed in those settings beyond the restrictions of the state Nurse Practice Act. This was true if the rules required staff nurses, specifically limited certain tasks to nurses, or required that the settings refhe to admit or discharge people needing certain nursing procedures. As a result, a nurse must know both the state Nurse Practice Act and the restrictions upon the care she or he can provide in different types of settings by state licensing rules.
9 In Oregon and Texas, licensure rules for assisted living and adult foster care are explicitly consistent with state nurse practice acts, and nurses may delegate tasks to unlicensed personnel who work in the settings.
Customary Practices 9 We found considerable intra-state variability in respondents' responses regarding what tasks were appropriate or inappropriate to delegate. Little hard information was available on the extent to which delegation by nurses to unlicensed persons actually occurred in a state.
9 Informants from state boards of nursing expressed reluctance about making lists of tasks that could or could not be delegated, arguing that such lists could remove nurse discretion.
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In some situations, they argued, even the simplest task might be inappropriate for delegation.
Supporting Arguments > In our case study of opinions about nurse delegation, the following views supporting formal, expanded delegation were expressed: delegation offers a way for nurses to assist patients to live in the setting of their choice because of general cost-lowering; delegation promotes equity between people with families (who often give free care that in most states falls outside nurse delegation prohibitions) and those who do not have families; quality of care improves if, through delegation, nurses became involved, providing instruction and some oversight as opposed to being entirely out of the loop, as in some board and care homes; absent delegation, new statutes might permit client self-care or delegated care by physicians in ways that ignore nurses; and delegation offers nurses greater opportunities for leadership and use of their knowledge and skills.
9 Such supportive comments were made by informants in states that permitted substantial nurse delegation and those that did not. Similar positive comments were made by nurses, state officials, and representatives of long-term care providers.
Opposing Arguments and Concerns 9 In our case study of opinions about nurse delegation, the most frequently expressed concerns about delegation included: fears that permission to delegate would glide into "requirements to delegate"; concerns that nurses' education about the why, how, and what of delegation was insufficient; skepticism about the claims to efficiency made by proponents of delegation; fears about encroachment on the prerogatives of the nursing profession; liability concerns; and concerns about risks of poor quality care for the patient.
>
As with the positive comments, these concerns were expressed by informants in states that permitted substantial nurse delegation and those that did not and by informants across disciplines and roles. It should also be noted that many nurses expressing fears and concerns had no direct experience with work in home and community-based care.
Experience and Problems in Practice > Our informants reported few problems associated with delegation of nursing practice. However, except in a few states, notably Oregon, nurse delegation has not been widely implemented. Moreover, no state has a data system to track such problems or, for that matter, to track problems related to delegation of nurse practices under supervised circumstances such as in nursing homes or home health agencies.
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Conclusions
Nurse practice provisions and their interpretations regarding delegation to unlicensed personnel are in flux. Many states are considering these issues as part of overall long-term care planning. The 20 states in the study varied in the details of their policies and practices. Substantial internal ambiguity is also present, with many areas that require interpretation. Strictly speaking, statutory change may not be necessary for nurses to delegate tasks to unlicensed personnel. Often, the broad scope of nurse practice acts permits such delegation. However, in many states, for example, Washington, the state statute would need to be revised in specific ways before meaningful nurse delegation would be possible. For example, even though delegation may be generally and vaguely permitted in a state statute, this authority may be diluted by statutory prohibitions against delegating specific practices such as the administration of medications. Regulatory clarification is also usefil if a state intends to pursue a policy of nurse delegation in community LTC. The mere permission to delegate does not lead to extensive delegation in LTC practice, absent clear policy direction and supportive structures. Although statutory or regulatory change may sometimes be necessary before nurse delegation can be expanded, many informants thought they would be insufficient. Other steps would be needed to respond to nurses' reluctance to delegate, and to provide education, guidelines, and support to nurses who undertake delegation. State regulations governing licensure of LTC settings and state and federal rules regarding vendors or reimbursement might also need modification. States considering amending their provisions to allow more explicitly for nurse delegation to unlicensed people in long-term care need to decide how detailed to be in law and regulation. More general formulations have the virtue of allowing for nurse judgment, but more specific formulationsprovide some initial reassurance for nurses implementingthe policy. State licensure rules for settings and programs often restrict delegation in residential settings regardless of nurse practice acts. Many of nurses' expressed concerns about increased delegation center around the umbrella notion of "liability," though they rarely distinguished between liability related to proper practice of nursing and tort liability (i.e., suits over injuries). There is virtually no case law on this subject. Some of the nurses' concerns about liability would be alleviated with clearer guidelines establishing "non-negligent"ways of performing the teaching and delegation. Some commentators raised concerns about whether consumers would be adequately protected with expanded nurse delegation. They were specially concerned about residents of board-andcare homes and other group living settings where care problems already have been noted. One
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. consumer protection, suggested as essential by nursing leaders, is that the decision about whether to delegate as allowed by the law be completely at the discretion of the nurse. The consumers would also benefit if nurses had guidelines suggesting how characteristics of the consumer's condition and prognosis, the procedure (its difficulty, its riskiness), and the person being delegated (general experience, experience with the task) should inform the nurses' decisions about how and when to delegate and what strategy to adopt for oversight.
Various structural issues are related to the delegation of nurse hnction in LTC. These include:
& considering who will employ the nurse or whether nurses will be self-employed when
conducting delegation fimctions;
P determining the various responsibilities of state case managers, LTC providers, and
consumers for locating and paying the nurse who does the delegation; and
k fixing the price and reimbursement method for this work in a way that does not inflate
costs of overall care or induce demand for nurses to perform delegation tasks once a payment source is in place. Data are not available on the effects of nurse delegation under various systems on either consumer outcomes or costs. Therefore, when and if systems built on nurse delegation are implemented, tracking systems are essential to monitor the activity, evaluate its effects, and provide the capacity to adjust the policy as needed. Also helpfil would be health services research with appropriate comparison groups and outcome measures.
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DELEGATION OF NURSING ACTIVITIES: IMPLICATIONS FOR PATTERNS OF LONG-TERM CARE
INTRODUCTION
"Nurse delegation" is a short-hand term to refer to a variety of practices whereby licensed nurses delegate nursing hnctions to others who are not nurses. In this report, we provide a descriptive overview of statutes, regulations, and customary practices in 20 states as they affect nurse delegation. The report examines the variability and ambiguity of policies and practices regarding state nurse delegation, the impact of nurse delegation on the role of the professional nurse, potential impacts on the quality of care for consumers, and the type of consumer protections that might be appropriate.
BACKGROUND
Significance of Topic LTC consumers typically need a range of assistance. Almost by definition, they require
some assistance with activities of daily living (ADLs), and they are also likely to need routine nursing treatments, such as administration of medications or catheter care. From time to time, or perhaps on a long-term basis, they also may need nursing evaluation and monitoring of their conditions, as well as highly skilled nursing treatments, such as some wound care, skin care, irrigations, tube feedings, ventilation care, or management of complicated medical equipment. For LTC consumers living in their own homes, health-related care is often provided by home health nurses working under medical orders. Such care includes both routine nursing hnctions and time-limited services for particular problems. Examples of time-limited hnctions might include wound care or a regimen of intravenous antibiotics. Routine nursing hnctions
include repetitive direct care such as medication administration, skin care, and catheter changes. Other routine nursing functions that rely on judgment include: observation and assessment of the condition, coordination of a variety of health-related services (e.g., medical equipment), coordination of community senices, supervision of paraprofessional nursing staff such as home health aides, general management and evaluation of the care, and education of patients and family members about the patient's health condition and regimen. Historically nurses have encouraged patients to assist in their own care, providing education and instruction as appropriate. Family members or significant others who participate in the care may also receive instruction from nurses. However, today many older people live alone and lack the physical and cognitive capacity for self-care. Family members, who might have come to the assistance of the disabled older person, may themselves have health problems or disabilities. The average age of people needing LTC is well into the SOs, meaning that the spouses, children, and siblings of LTC consumers are likely to be older people, as well. Some of the conventions governing family care date back many decades to a period when life expectancy was shorter, and much nursing care of adults and children was given within families by its members. Policy and regulations did not anticipate the possibility that a large number of individuals unrelated to the consumer, and not licensed as a nurse, might have a role in providing routine nursing services. At present, society has a strong interest in determining how needed nursing services can be delivered cost-effectively to meet chronic care needs, if self-care or family care are impractical. When an LTC consumer is receiving help from a paid assistant without a nursing license, those unlicensed assistants are not ordinarily empowered to provide the needed nursing help, even
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though, like family members, they might be capable of performing some or all of the needed nursing fhctions with instruction and oversight from a nurse. Thus the policy issue arises: Should explicit policies be developed whereby these helpers who are not relatives can also give medications and perform other nursing finctions? Might it be wise to take advantage of their presence rather than introduce an expensive visit from another provider? Does the fact of the family relationship provide protection to the consumer that justifies treating relatives differently from non-relatives in the delegation of nursing tasks? Of particular interest are policies that apply in non-medical group living settings. Nonmedical settings (such as assisted living, foster care, and various other socially oriented forms of residential care) have developed in response to consumer demand for a form of care that is more user-friendly than the nursing home, where residents (sometimes perceived as tenants) can receive care in settings that offer privacy, choice, dignity, and potential for normal lifestyles (Kane & Wilson, 1993). Typically, such settings are not licensed as health facilities, have more favorable costs compared to nursing homes due to less demanding staffing standards, and have adult staff members on hand who provide a variety of personal care and homemaking services. Presumably, staff in residential settings presumably could achieve the same level of competence to perform repetitive or simple nursing tasks, as do family members without nursing licenses. Again the policy question is whether the benefits of such delegation outweigh the risks and disadvantages. Weighed against the advantages that nurse delegation may have in lowered cost and increased flexibility are concerns about safety of the older person, and liability risks for the nurse, the care program, or the payor.
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Oregon Experience The State of Oregon has been exploring low-cost alternatives to nursing homes since its
adoption of a far-reaching Medicaid waiver in late 1981 (GAO, 1994). The cost-effectiveness of the state's alternative programs (home care, adult foster care, and assisted living) rely on policies permitting nurses to delegate hnctions to unlicensed personnel working in the various care settings. Other states are looking closely at the possibility of creating provisions similar to those of Oregon at the time we initiated our study.
Specifving Leadership Roles for Nurses The nursing literature has recently called for serious attention to defining supervisory
practices (Knollmueller, 1988; Brent, 1993). Although cautious about the implications for quality of care and liability of nurses, Dr. Ruth Knollmueller, Visiting Professor, University of Kentucky, College of Nursing, Division of Community Health Nursing, advises nursing supervisors to be alert to the economics of care. Reshaping supervisory practice in home care, she writes, 9s not
an ifbut a when issue" (p. 362).
Marilyn Harris (1993), Executive Director of the Visiting Nurse Association of East Montgomery County, Willow Grove, Pennsylvania, makes a stronger statement. Referring to delegation as requiring "thoughthl, step-by-step logic that can evolve into an art," and suggesting that competent aides are often more reliable and better trained than other informal caregivers, she writes: To provide high-quality health care to all ages in the 199Os, I believe that specific tasks can be delegated to qualified, competent, unlicensed personnel. . . . The role and responsibilities of qualified, unlicensed caregivers can be expanded, given that the professional registered nurse retains the accountability for delegated tasks. This change has the potential to contribute to the well-being of patients and to improve the over-all quality of in-home health care in the 1990s (p. 56).
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Harris, then, lays out some criteria for such delegation including that the aide has met a general competency evaluation such as that required for Medicare certification, demonstrates ability to follow instructions, and has an interest in assuming additional responsibility. Nurses are clearly key figures in LTC, even when a social (i.e., non-medical) model of care is being sought. Examination of delegation by the nurse requires visiting the entire issue of how to structure LTC programs to incorporate creative leadership roles for nurses. These roles include not only direct practice, but also roles as educators, managers, and designers of programs.
As the LTC labor force expands and new paradigms for LTC with an emphasis on normal
lifestyles are developed, one of the challenges is to find optimal, and perhaps new, ways of drawing upon the expertise of registered nurses. Consequently, leaders in the nursing profession, and some state regulators and policymakers as well, are reconsidering legal and professional requirements that various functions be performed by licensed nursing personnel. This brings to the forefront questions about whether and when nurses should assign or delegate tasks to others. Nursing education, in general, tends to give little attention to teaching RNs how to supervise and delegate functions, although supervision and delegation are a part of most nurses' jobs (Knollmueller, 1988; Minnesota Nurses Association, 1991). If expanded delegation practices were to be encouraged, this would have implications for continuing and basic nursing education. Leaving aside professional orthodoxy, leaders in both nursing and LTC are asking difficult questions about what are the necessary and optimal roles of nurses in LTC, including: What tasks must be done by a registered nurse? What tasks may be safely delegated, but require close supervision? What tasks may be delegated to others with less close supervision? What
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constitutes adequate supervision in residential settings where an on-site nursing staff is not available? How are consumers to be protected and, if nursing tasks are to be delegated, what are the organizational and cost implications of using nurses to provide the necessary instruction and oversight? Proponents of increased delegation suggest that policies permitting more delegation at nurses' discretion would increase consumers' choices of affordable LTC alternatives and allow consumers to remain in home-like settings even without family members to care for them. Opponents argue that the quality of care would be jeopardized, and liability for nurses increased. This debate has proceeded with little systematic attention to what is actually occumng in the field under existing law, regulation, and custom, as well as under purposely amended policies. This report is an effort to provide such information.
Defining Nurse Delegation Nurse delegation, as used in this report, refers to delegation of nursing functions by a
nurse at the nurse's professional discretion to unlicensed persons. Such delegation would be made only to people whom the nurse ascertains are capable of performing the fbnction and the nurse would retain some responsibility for ongoing oversight. One can hardly discuss nurse delegation without grappling with the prior issue of defining nurse practice, which, after all, is the object of the delegation. The topic is complex because nursing is broad and vaned, and the scope of nurse practice includes performance of tasks delegated to nurses by physicians. An old-fashioned view of nursing envisages that nurses largely carry out physician's orders. A more contemporary view, which actually has its roots in the early public health nursing movements of the late nineteenth century, recognizes nurses as independent
~ ~~ ~ ~~
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professionals who use a body of nursing theory, make nursing diagnoses, exercise a wide range of judgments, and supervise paraprofessional workers. But even in this view, nurses also carry out tasks as delegated by physicians. Summarizing state nurse practice statutes, Dombi (1994) suggests that nursing care includes seven fbnctions: nursing assessment; nursing diagnosis; performance of nursing regimen; teaching of patient and family; delegation of tasks; execution of physician's order; and collaboration with health professionals and others. No nurse delegation policy permits the nurse to delegate nursing assessment, nursing diagnosis, or teaching, delegation, and collaboration hnctions. Only the actual performance of the regimen, including that encompassed in "doctor's orders," would be encompassed by nurse delegation policies. The specific tasks that nurses perform range widely in complexity, difficulty, and risk to the patient. This study compares operational definitions of nurse delegation and explores the range of statutory and regulatory policies and customary practices regarding what nursing tasks may be and are delegated in selected states.
METHOD
In this study, we examined nurse delegation policies and practices and interviewed key
informants in 20 states, including Oregon. In so doing, we hoped to shed light on a controversial topic. Using a comparative case study approach, we examined specific statutes and regulations governing nurse practice to determine what rules apply to delegation. Then we carried out a series of semi-structured interviews with key informants in each of the 20 states to learn how these statutes and regulations were interpreted in practice, as well as the key informants' views and concerns regarding nurse delegation.
Delegation o Nursing Activities f Page 7
Research Questions Through comparison of the 20 state case studies, we attempted to explore the following
general research questions: What statutory and regulatory authority exists for the delegation of nurse practice?
To what extent and under what conditions is nurse delegation permitted?

In the views of key informants, what is the impetus for nurse delegation and what are the deterring factors? How has delegation affected the kinds of services available in group residential settings? (Of interest here was whether licensure and regulation of the settings exerted an effect on delegation practices independent of nurse practice provisions.)
To what extent has there been experience in various states with nurse delegation in practice? What, if anything, is known about problems that arose, and how were they solved?
Selection of States States were selected for the case study using four criteria, all of which were designed to
produce a sample of states with a high likelihood of having modified or having considered modifLing the way nursing hnctions are done in LTC to allow more latitude to unlicensed personnel. We included:
1.
States known to have modified policies or practices in the last decade to permit more nurse delegation in LTC. States that the American Bar Association concluded had nurse delegation based solely on a review of statutes in all states (Mattes, 1993). States selected for study by SysteMetrics because they had active consumer-directed attendant care programs (Flanagan, 1994). We reasoned that states with strong consumer-directed attendant programs may have grappled with nurse delegation issues. States known to have made efforts to provide LTC in alternative residential settings, such as assisted living (e.g., Arizona, California, Florida, Minnesota, New Jersey, New York, Ohio, Oregon, and Washington), adult foster care (e.g., Kansas,
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2.
3.
4.
Michigan, Minnesota, Oregon), or other enriched housing settings (e.g., Colorado, Massachusetts, Texas). Moreover, some of these states (e.g., Florida, Minnesota, New Jersey, and New York) had drafted an assisted living policy in the last two years. Table 1 indicates which of the following four criteria each of the 20 states studied met; some states fell into the sample based on multiple criteria.
Table 1. Selection of States for Nurse Delegation Study
Known to delegate ABAstudyof delegation Clientdirected attendant care Active in Assisted Living
IAZ
X X
x x
X
X
.
x x x x x
x x x x x x x
No delegation provision. The Nurse Practice Act stated that "[n]o provision of this chapter shall be constructed to prohibit the rendering of services by nursing assistants acting under the direct supervision nurse." This provision, however, is not interpreted to permit nurse delegation. No delegation provision. But, the Nurse Practice Act stated that "[s]o long as the person involved does not represent or hold himself out as a nurse licensed to practice in this state, [the Nurse Practice Act] shall not be construed as prohibiting the services rendered by technicians, nurses' aides or their equivalent trained and employed in public or private hospitals and licensed long-term care facilities except the services rendered i n licensed long-term care facilities shall be limited to administering medication, excluding injectables other than insulin." There is currently a proposed draft regulation to change the supervision rule to include delegation in any given situation. No delegation provision. The Nurse practice act stated, "it is professional misconduct to permit, aid or abet an unlicensed person to perform activities requiring a license. It is unprofessional conduct to delegate professional responsibilities to a person when the licensee delegating such responsibilities knows or has reason to know that such person is not qualified by training, experience, or by licensure to perform them." These provisions were interpreted as permitting "delegation" by RNs to other RNs and LPNs and prohibiting delegation to anyone with lesser training.
Secondary Analysis
We obtained copies of all 20 states' Nurse Practice Acts and relevant regulations. First, we examined and analyzed the materials from 4 states highly identified with nurse delegation (Oregon, Kansas, Texas, Colorado), and compared them to other states. Although most states
did not have specific delegation laws or regulations, many at least made some reference to delegation either in statute or regulation. Through our review of statutes and regulations, we examined the letter of the law regarding who might delegate nursing fbnctions, to whom they could be delegated, which hnctions could be delegated, and other specific permissions or prohibitions that circumscribed delegation.
Key Informant Znterviews We conducted a series of telephone interviews with key informants from each state to
learn about the history of nurse delegation, applications occurring in practice, and positive or negative reactions to the subject. A set of guiding questions rather than a formal survey was used. (See Appendix A for a list of the guiding questions.) The overall goal of these interviews was to gain an understanding about what, if any, nurse delegation was allowed in each state; what types of nursing tasks were commonly delegated; in what settings delegation was commonly used; and the experiences with, or perceptions regarding, the use of nurse delegation. We attempted to distinguish between a statute on the books and the actual implementation of programs with substantial nurse delegation. (The latter requires behavioral and organizational change, and even payment mechanisms to support the activity.) Approximately 130 telephone interviews were conducted over the course of two months, each lasting an average of 30 minutes. Selection of informants. As Table 2 shows, we talked to a representative from the state board of nursing and the state licensing division for assisted living, board and care, adult foster care, and/or group homes in each state. In addition, we also often spoke to representatives of the State Nurses' Association, State Home Health Association, State Home Health Agency, State Long-Term Care Ombudsmen, State Home Care Association, State Residential Care Association,
page 10
and State Nursing Home Association. Where possible, we contacted and talked with operators of assisted living facilities.
Table 2. Type of Key Informants Interviewed in 20 Selected States
Category includes: State Residential Care Associations and State Nursing Home Associations.
Perspectives of informants. Informants were sought for their particular perspectives and insights regarding the history, actual practice, and reactions regarding nurse delegation in their state. The Board of Nursing representatives provided legal interpretations and clarifications of
the state policy, as well as a historical perspective on the development of nurse delegation in the
state. The State Licensing Division representatives provided information about licensure rules that affected nurse delegation either directly or indirectly in various settings licensed by the state.
~~ ~
page 11
They also provided insight into the amount and type of nurse delegation that is commonly used in each setting. The State Nurses Association representatives provided nurses' perspectives on delegation and an estimate of how prevalent delegation practices were around the state. The State LongTerm Care Ombudsman provided background information about the type of care settings in each state, the use of delegation, and the fi-equency of complaints, if any, received by that office about delegation. In general, the informants for the ombudsman programs also provided a perspective on delegation from the vantage point of a group that is dedicated to consumer protection. Representatives of residential care associations, home health care associations, and nursing home associations reflected on the hands-on experiences of the providers who formed their membership.
In October 1994 we sent a brief survey to all 20 boards of nursing for responses regarding
specific tasks that could or could not be delegated in the state. We did so because various informants within a state offered conflicting views about what was permitted in that state.
Site Visit During the data collection phase, one of the authors (Colleen O'Connor) acted as an
observer at a seminar on nurse delegation in Seattle, Washington, in July 1994. Sponsored by the Aging and Adult Services Administration in Washington State, the seminar consisted of presentations by nurses from Oregon about the dynamics of the Oregon Nurse Delegation Regulations. The attendees included representatives from the nurses' unions, Board of Nursing, Nurses' Association, home health agencies, state licensing divisions, and legislators in Washington. From this seminar, we gained a more thorough understanding of the Oregon program, as well as a better appreciation of the kinds of concerns and issues raised by nurses in a
page 12
state that was considering but had not yet enacted major nurse delegation provisions. This in turn helped us to understand the various positions and opinions of the various state key informants.
FINDINGS
We tabulated and compared the results of the secondary analysis and key informant interviews from each of the 20 states. The results revealed wide variation, ambiguity within states, and confixion in the types of approaches taken by states in granting nurses authority to delegate tasks. In terms of statutory or regulatory language, most of the delegation "provisions" were sketchy, typically consisting of little more than the mention of the term "delegation" in, for example, the definition of professional nursing. Of the 20 states studied, Colorado, Massachusetts, Oregon, and Texas possessed the most detailed specification of delegation. The following sections describe the results of the comparison of the 20 state case studies. Summary tables are used to depict broad distinctions and variations among states. In many instances, more detailed information is provided in the exhibits found in Appendix B. (Note, Kansas has two extremely different provisions, one for school settings and one for other settings, and both are reflected in the summary and appendix tables.) This discussion begins with a presentation of the findings for the following dimensions:
Who may delegate nursing tasks?

0
When is delegation appropriate? To whom may nursing tasks be delegated? For whom may nursing tasks be delegated? Where is delegation permitted? What nursing tasks can be delegated, including the administration of medications?
page 13
How may tasks be delegated, including training, supervision, and documentation requirements and other accountability issues? How do licensure requirements affect delegation in assisted living settings? What are the customary practices regarding delegation? What supporting arguments are cited in favor of nurse delegation? What opposing arguments or concerns are raised about nurse delegation? What problems, if any, are associated with nurse delegation? What benefits resulted from nurse delegation? At the end of the findings section, three state approaches to nurse delegation (Oregon, Colorado, and Texas) are compared. These states represent recent attempts at drafting detailed nurse delegation regulations, and are highlighted because of their contrasting approaches in addressing the dimensions to nurse delegation listed above. (The Massachusetts provisions, also recent and detailed, resemble those in Colorado.)
who Delegates
Delegation by registered nurses (RNs) was permitted in 17 states and another state, Missouri, had a draft rule change in progress that would permit registered nurses to delegate tasks
in specific circumstances (see Table 3). Only Florida and New York had no allowance for
delegation by a registered nurse to non-nurses. The statutory authority to delegate commonly was found within either the description of the RN's scope of practice, or the definition of professional nursing. Four states, Iowa, Kansas, Maine and Oklahoma, also permitted delegation by licensed practical nurses (LPNs). In these states, the authority for LPNs to delegate was found either in
Page 14
the definition of LPN, or by use of the term "licensed nuke" in the delegation provision where ''licensed nurse'' was defined as either a registered nurse or a licensed practical nurse. Delegation by LPN, however, was generally restricted to tasks within the LPNs scope of practice: the LPN could only delegate what he or she was permitted to do. Iowa firther restricted LPN delegation
in two ways: the LPNs who delegated must have (1) additional education and (2) worked in
long-term care settings. (Note that we did not investigate the scope of practice for LPNs other than as it was reflected in statutes and regulations pertaining to registered nurses.)
Table 3. Who May Delegate Nursing Functions in 20 Selected States
CO
FL IA
Yes No delegation provision Yes
No No delegation provision YeS2
MN
M0
NE NJ NY OH OK OR TX WA
WI
Yes Yes YeS Yes No delegation provision3 YeS YeS No delegation provision Yes Yes Yes Yes Yes Yes
No YeS No No No delegation provision No No No delegation provision No YS No No No No
Under the proposed delegation rules, a "professional nurse" may delegate. In long-term patientklient care settings, a LPN with additional education and training was permitted to supervise. Supervision included delegating functions or activities while retaining accountability. Proposed draft to change Supervision Rule to include delegation in any given situation.
page 15
When to Delegate Only eight state statutes and regulations provided any guidelines, or factors, to assist
nurses in determining whether delegation was appropriate (see Table 4). Guidelines commonly identified in these eight state statutes and regulations included: stability of patient's condition; availability of adequate supervision; the delegatee's knowledge, skill, and ability; nature of the delegated task or activity; nature of task; instruction of delegatee; reasonable and prudent nurse standard; availability/proximity of resources (e.g., FINSor LPNs); and the delegatee has documented competencies with employer. As seen in Table 4, two factors, stability of patient's condition and availability of adequate supervision, were listed in six of the eight state statutes and regulations. One other factor, the delegatee's knowledge, skill, and ability, was listed in five state statutes and regulations.
Table 4. Common GuidelinedFactors for Determining When Delegation is Appropriate Identified By 8 of 20 Selected State Statutes
AZ' Stability of patient's condition Availability of adequate supervision Delegate's knowledge, skill, and ability Nature of task Instruction of delegate Reasonable and prudent nurse standard Availability of resources4 Delegate has documented competencies with employer
1
CO
I MA I
MI
1 OK
OR
I TX I WI
X2
x3
X
X X
2
3
Guidelines were in a proposed Board of Nursing Opinion. Monthly assessment of client's needs required in prouosed Board of Nursing Opinion. Annual assessment of the level of supervision and a determination of the level and method of supervision required to assure safe performance required in prouosed Board of Nursing Opinion. Includes the availability and proximity of RN, or other licensed health personnel.
page 16
Delegation to Whom Statutory language regarding the required characteristics of the person to whom tasks
could be delegated varied. Language ranged from provisions permitting delegation to "any person" to provisions that permitted delegation only to other licensed nurses. Broadly stated, state provisions regarding to whom a nurse may delegate tasks fell into one of three categories: anyone he or she deems competent; individuals that possess adequate education, training or experience (such as certified nursek aides); and/or other licensed individuals, usually an LPN. (Table 5 summarizes this information, and Exhibit B-1 in Appendix B provides greater detail, including direct reference to the statutes.) Delegation was commonly defined as the granting of authority by a nurse to a person to practice nursing without a license. In most states, family members fell outside the scope of the nurse practice acts, and thus could perform nursing tasks without being deemed to be practicing nursing. In such cases, a nurse could teach a family member to provide nursing care without this instruction being considered delegation. Further, because delegation restrictions did not apply, no limit existed regarding the extent or type of care a family member could provide. (Indeed, nurse informants commonly stated that they have wide latitude to teach family members nursing tasks.) The following discusses this issue in more detail. Family members and friends. Eighteen of the 20 states exempted family members, and 15 of the 20 exempted friends from the Nurse Practice Act altogether. Exemption from the state nurse practice act means family members could provide nursing care without violating the act and/or practicing nursing without a license. As Table 6 shows, such exemptions were typically limited to family members or friends giving care without compensation, and/or to family members
page 17
Table 5. To Whom T s s May Be Delegated i 20 Selected States ak n

Licensed Practical Nurse Certified Nurse's Aide
Lay Person X
KS - Schools
x3
OK OR
TX
WA
W I
X X
X X X X X
X X
x '
X
Source: Our field notes on this issue were verified by written survey to the 20 boards of nursing, October 1994, with 18 out of 20 responding. Proposed rules: RN may delegate to other licensed nurses, licensed personnel, and qualified personnel. "Qualified personnel" are defined as persons, other than licensed nurses, who function in a complimentary or assistant role to the professional nurse in providing direct patient care or carrying out common nursing functions. "Licensed personnel" are defined as professional and licensed practical nurses. No delegation provision. In New York, it was professional misconduct to permit, aid or abet an unlicensed person to perform activities requiring a license. It is unprofessional conduct to delegate professional responsibilities to a person when the licensee delegating such responsibilities knows or has reason to know that such person is not qualified by training, by experience, or by licensure to perform them. The provision stated that "unlicensed persons" includes, but is not limited to, teachers, secretaries, administrators, and paraprofessionals. Defined as "nursing assistants." In addition, there were proposed rules specifically permitting delegation r "special care providers" of o individuals with developmental disabilities. The Nurse Practice Act did not specify to whom an RN may delegate, and an interpretation by the Board of Nursing was not available.
4 5
page 18
Table 6. Special Provisions/Exemptions in 20 Selected States
self out as nurse

NO special provisions or exemptions. No provision, but according to Board of Nursing, family and client were considered one unit.
and friends who do not hold themselves out as nurses (see Exhibit B-2 in Appendix B for additional detail.) However, in Oregon, where family members were compensated as "clientemployed home care workers" or as "relative foster care providers" by Medicaid waivers; these family members or friends were not exempt from the requirement that they receive formal delegation before performing special nursing tasks. (In Oregon, as described below, routine nursing tasks, may be "assigned" generally without new instructions for each person who will receive the delegated service, whereas special tasks must be delegated.) Special issues concerning delegation to familv members. Three major issues arose pertaining to nurse delegation to family members. The first issue was whether or not a formal
~~
page 19
exemption was made under the state's nurse practice acts. Some informants argued that this issue was an important distinction. If family members were formally exempted from the nurse practice act then technically they were not practicing nursing. Because family members were not practicing nursing, they should, therefore, be able to delegate their tasks to other people without regard to nurse practice acts. If, however, family members were permitted to do some or all services as a stipulation of a nurse practice act, then they were practicing nursing under the conditions permitted in the law. Because they technically were practicing nursing, they could not delegate this authority to another person without violating the nurse practice act. A second issue was whether a family member could be paid for the nursing care without a formally delegated status. In states where the family's authority stems from a provision in the nurse practice act exempting gratuitous care, family members could not get paid and continue to perform nursing tasks without formal delegation. If, however, the nurse practice act simply exempted care given by family members with no mention of payment, then it was unclear whether the family member could be paid. According to the letter of the law, there were no prohibitions of such payment. Nevertheless, disagreement existed between nurse respondents within and across states over this issue. The final issue concerning care permitted by family members was the definition of family. The state statutes varied in how they defined family. Oregon, for example, limited the exemption for care provided by family members to immediate family members providing free care only. Other states, however, extended the definition of family to include significant others and/or fosterparents. Some states interpreted family to include all "family-like"people.
page 20
Delegation f o r Whom Fifteen of the 17 states with a delegation provision had no restrictions on the type of
patient or client who may receive delegated care. Oregon and Texas were the only states to qualify the matter of whose nursing care can be delegated. The Oregon regulations' permitted delegation in home care settings only if the client had stable and predictable health care needs; hospice clients could be considered in that stable and predictable group. The Texas delegation rules' contained some provisions that applied only if the client had a stable and predictable condition, and other provisions that applied only if the client had an unstable or unpredictable condition3. In addition, Nebraska was considering regulations to permit delegation of specified tasks to "special care providers" for individuals with developmental disability.
Where Delegation Is Done Fourteen of the 17 states permitting delegation had no restrictions on the type of
settings in which a nurse could delegate nursing tasks. However, four states (Kansas, Oregon, Maine, and Texas) had delegation provisions that applied only in specific settings (see Table 7). For example, the Kansas Nurse Practice Act contained a set of rules that applied only to registered nurses in school settings. Oregon and Maine illustrated polar opposite approaches to setting-specific restrictions. The Oregon delegation rules applied only in settings where no regularly scheduled nurse was employed and specifically did not apply in acute care or nursing home settings. Conversely, the
2
3
'
OR. ADMIN. R. 851-47-030@)(1993). TEX. ADMIN. CODE tit. 22 218.4(2)(C)(1992), TEX. ADMIN. CODE tit. 22 218.8(2)(1992), and TEX. ADMIN. CODE tit. 22 218.9(b)(1992). TEX. ADMIN. CODE tit. 22 218.4(2)@)(1992).
page 21
Maine delegation rules applied only in settings where a registered nurse was in charge of an organized nursing service, such as a hospital, nursing home, skilled care facility or community health agency.
Table 7. Provisions/Restrictions on Settings i Which Nurse Delegation May Be Performed n in 20 Selected States
No Restrictions
Limited to: Hospital/ Acute Care LTC Facility/ Nursing Home Residential Care/ Assisted Living/ Group Home Hospice School Home Health / community Health No Delegation Provision There were two delegation provisions. One applied to all settings, the other to school settings. School provision used as model by Board of Nursing for all settings. Delegation rules were very setting-specific. See Exhibit B-3 for more detail. Proposed rules: medication administration provision applies only in certain settings. Delegation of medication administration permitted only in assisted living facilities. The delegation rules did not specifically list the permitted settings. However, delegation was permitted only where a nurse was not regularly scheduled and not available to provide direct supervision. The rules specifically did not apply to acute care, long-tern care, and school settings. The delegation rules specifically included hospice clients whose deteriorating condition was predictable.
3
4
The Texas delegation regulations also contained extensive setting specific restrictions. Other provisions applied to clients' residences, which included group homes and foster homes.
page 22
Finally, several of the Texas provisions applied only to "independent living environments," which could also include group homes or foster homes as well as school, work, or church settings. Informants explained that one of the initial barriers to modifLingnurse practices in Texas was the fear that this would pave the way to staffing hospitals with unlicensed personnel. The restrictive language about settings actually facilitated substantial liberalization of the rules. (See Exhibit B-3 in Appendix B for more detail on settings of care, particularly for the complex Texas specifications.)
Tasksf o r Delegation
The constraints on what tasks or fhctions could be delegated to unlicensed persons varied from state to state. At the most permissive and general level of expression were delegation provisions simply stating that nurses could delegate "nursing tasks." At the opposite extreme were delegation provisions that provided lists of tasks that could and could not be delegated. In the following subsection, we present findings regarding what tasks could be delegated as specified
in each of the 17 state statutes and regulations, as interpreted by state boards of nursing. In
addition, unique state restrictions are identified. Finally, state delegation provisions for the administration of medications are outlined. From the statutes and regulations. Four states (Arizona, Minnesota, Nebraska & Ohio) specified no restrictions. In the remaining 16 states, some specific tasks were either explicitly permitted or explicitly prohibited with regard to delegation. As Table 8 shows, eight state statutes permitted specific tasks, five prohibited specific tasks, and three permitted some and prohibited others specific tasks. Nine state statutes or regulations stated (in somewhat tautological style) that a nurse could only delegate activities that did not require nursing judgment, assessment or evaluation. Two of these nine and one other also stipulated that the task
page 23
Table 8. Nursing Tasks That May Be Delegated As Specified in the Statutes and Regulations of the 20 Selected States
Specific tasks permitted
Specific
tasks
prohibited
Task could not require nursing judgment assessment or evaluation
Task could not require the knowledge or skill of an RN
No restrictions specified
X'
I%2
X
X
xs
X6
X X
3
4
However, under proposed rules, the registered nurse could delegate specific nursing functions other than assessment, evaluation, and nursing judgment. The task must be of a routine and repetitive nature. No delegation provision. The proposed delegation le^ for individuals with disabilities listed specific tasks that may be delegated. See Exhibit B-4. Procedures that did not require the education or training of a registered or licensed practical nurse, but that could not be performed by the client independently, need not be delegated and may be assigned by a registered nurse or a licensed practical nurse. Procedures that required the education and training of a registered nurse or a licensed practical nurse could be delegated by the registered nurse. Examples of such procedures included the administration of injectable medications, suctioning, and complex wound care. Texas provided examples of tasks which need not be delegated, tasks which may be delegated, tasks which m a y not be routinely delegated, and tasks which may not be delegated. See Exhibit B-4.
could not require the knowledge or skill of a nurse. In addition, some state provisions specifically identified the collection, reporting, and documentation of simple data, and tasks which meet or
page 24
assist the client in meeting basic human needs, (such as comfort, elimination, socialization, rest and hygiene), as examples of tasks that could be properly delegated to an unlicensed person. (The specific state provisions regarding what tasks can be delegated are provided in Exhibit B-4, Appendix B.)
Table 9. Tasks A Registered Nurse May Delegate As Identified by Board of Nursing Informants i 18 Selected States n
x x x x x x x x
x x
x x
X8
X8
x x
Source: Mailed survey to boards of nursing in 20 states, October 1994, with 18 out of 20 responding.
1
2
3
4
7
8
9
10
11
No delegation provision. What was delegated depended on licensure and qualifications of person. A licensed practical nurse (LPN) or a registered nurse (RN) could assign ADLs, not necessary to delegate. Could be delegated only if clean-technique. T s s requiring sterile-technique may not be delegated. ak Could be delegated to LPNs only. Could not be delegated to certified nurse's aides (CNAs). Could be delegated to unlicensed person in school-setting only. Only school nurses (RNs) could delegate medication administration. Could be delegated to CNA only if CNA completes additional medication course. Permitted by CNAs only. Not permitted in facilities.
page 25
From State Board of Nursing informants' interpretations. As described above, in October of 1994 we sent a brief note and questionnaire to the informants from each state board of nursing to confirm their opinion of specific tasks that could be delegated. (A copy of the letter and questionnaire is provided in Appendix C.) Table 9 shows the responses for the 18 responding states. (An "x" in the table indicates that the state Board of Nursing replied in the affirmative that the task could be delegated.) Restrictions of what can be delegated. The statutes and regulations of four states (California, Colorado, Oregon, and Texas) restricted tasks that could be delegated by a nurse in various ways. Colorado, for example, simply stated that any task delegated must be of a routine, repetitive nature and could not require the delegatee to exercise nursing judgment and intervention. The California delegation provisions, as interpreted by a 1987 Attorney General Opinion (Attorney General Opinion, 1987), restricted the delegation of nursing tasks to medication administration, sterile techniques, and gastrostomy tube feeding. A 1990 California Board of Nursing Legal Counsel Opinion (Department of Consumer Mairs, 1990) hrther restricted delegation in California, allowing the delegation of these select tasks only to other licensed persons. The Oregon delegation regulations had three major distinctions influencing what tasks could and must be delegated. First, the rules stated that basic activities of daily living (ATlLs) could be provided in some settings without the assignment, delegation, or supervision of a licensed nurse. In other words, in some settings an unlicensed person could assist people with activities of daily living without any nurse intervention to delegate the activity. Second, the Oregon rules distinguished between the assignment and delegation of tasks; the former refers to page 26
tasks that can be taught and assigned generally and the latter to tasks that must be delegated individually for each patient who will receive this assistance from an unlicensed person. Third, the Oregon rules distinguished between "basic tasks'' and "special tasks" of clienthursing care. (These distinctions are discussed in more detail in the section highlighting specific state examples [see page 401.) Texas delegation rules listed specific nursing tasks that could be delegated, specific tasks that could not be routinely delegated, and nursing tasks that could not be delegated. The tasks that could be delegated were hrther broken down into tasks that could be delegated in all settings and tasks that could be delegated only in independent living environments. Administration of medications. The delegation of administration of medications has been separated out from the general discussion of what may be delegated, because of the frequency of medication administration in consumers' care plans. Furthermore, in some states (e.g., Washington, Kansas) a major stumbling block to delegation is a specific requirement that registered nurses administer oral medications. Obviously, administration of oral medication is one of the most frequently required LTC tasks, and often is routine and repetitive. In our comparison of the 20 state case studies, as Table 10 shows, six states specifically permitted delegation of medication administration, six states specifically prohibited at least some degree of delegation for medication administration. The remaining nine states neither prohibited nor permitted such delegation; given silence on the subject, one assumes the same provisions applied as to other types of nursing tasks. (Note, the two Kansas provisions were split, one prohibiting delegation and one not specified.) Of the six statutes that specifically permitted delegation of medication administration: two
page 27
Table 10. Delegation of Medication Administration in 20 Selected States

AZ CA CO FL2 IA KS
KS- M ME MI MN MOSNE NJ NY7 OH OK OR TX WA WI School A -
X X
x"
X6 X8
x9 XI0
5
6
10
However, i proposed rules, the delegation of medicatioh administration was permitted to unlicensed persons n who have completed a 40-hour training course. No delegation provision. However, in adult care homes and hospital-based long-term care units, including state operated institutions for the mentally retarded, medication administration was permitted by unlicensed persons who had completed medication administration training programs or is engaged in such a training program. Delegation of medication administration was permitted with restrictions. In LTC facilities and state mental health institutions. CNAs who had completed a medication course could administer non-injectable medications to patients who are 14 years of age and older under the direct on-site supervision of a licensed nurse. Such delegation was prohibited in home-health settings. In boarding homes or adult foster care settings, an unlicensed person who has completed a 24 hour training course could administer oral medications and insulin injections if specifically trained by a RN. No delegation provision In assisted living facilities, "personal care assistants" could administer medications under the delegation of an RN if they had completed a 25 hour course and passed a computerized exam. Although there was no delegation provision in the nurse practice act, the act did contain an exemption for medication technicians in facilities licensed by the Office of Mental Health and the Office of Mental Retardation to pass medications under the supervision of a nurse. This, however, was not considered delegation. State Board of Nursing guidelines specifically prohibit the delegation of medication administration exceDt as authorized by state and/or federal regulations. In settings where a nurse was not regularly scheduled, a registered nurse could delegate the administration of injectable medications. The registered nurse could delegate the administration of non-injectable medications to unlicensed persons in specific facilities, including adult foster care homes and residential care facilities. Board of Nursing interpretations limited such delegation to only subcutaneous injectable medications. The administration of p.r.n. medications could be delegated in limited situations. Delegation of medication administration was permitted only in certain settings with restrictions. For instance, in long-term care settings a registered nurse could delegate to unlicensed persons who held medication aide permits; and in independent living environments where the client's status was stable and predictable and the client had expressed hisher ability and willingness to participate in the management of hisfher care (including hospice if client's deteriorating condition was predictable), the regular presence and assessment, Intervention and evaluation by a registered nurse was not required.
specifically restricted such delegation to oral medications; two specifically permitted the delegation of oral medications and subcutaneous injectable medications, but prohibited all other
page 28
injectable medications; one permitted delegation in school settings of oral medications, subcutaneous injectable medications, and intravenous injectable medications in "an anticipated health care crisis," but prohibited the delegation of the administration of intravenous medications in all circumstances; and 1 permitted medication administration without any specific restrictions.
While the statutory and regulatory policies were conservative toward the delegation of
medication administration, as Table 1 1 shows, survey responses from state boards of nursing revealed much more liberal attitudes toward the subject. Of the 18 states responding to the survey, 13 reported at least some degree of delegation of medication administration was permitted. Of these 13 states, two (Arizona and Iowa) permitted delegation to licensed nurses only.
Table 11. Delegation of Medication Administration As Identified by Board of Nursing Informants in 18 of the 20 Selected States
AZ' CA CO FLZ IA3 KS MA4ME MN M 0 6 NE NJ' NY OK*OR Permitted Delegation of: 0 Oral & Injectable X X X xx5x x Medications ----------------- --_--_-__---___---__-----------------------X Oral Medications Only Prohibited Delegation of X X Medication Administration
x x x
Delegation permitted only to other licensed personnel. No delegation provision. Delegation to LPNs only. Delegation permitted by school nurses only. For Oral Medications, delegation to LPNs and CNAs, if CNA completes an additional medication administration course. For Injectable medications, delegation to LPNs only. No delegation provision. No response. In survey, Board of Nursing noted that what is delegated depends on licensure and qualifications of person. Delegation permitted only for disabled individuals directing their own care in independent living environments when their conditions are stable and medictable.
page 29
Sometimes state statutes distinguished between the "administration of" and "assisting with" medications. "Administration of medications" interpretations ranged from handing a person their medications to putting the medications in the personk body. The interpretations of "assisting with medications" ranged from reminding people to take their medications to handing the medications to the consumers. At least eight states (Colorado, Iowa, Kansas, Maine, Nebraska, New Jersey, New York, and Oklahoma) also had special exceptions for medication administration in various settings. Generally, such provisions did not fall under the domain of the Board of Nursing. Rather, a different department, such as the Department of Health, was granted authority to promulgate regulations about the administration of medication in various facilities. For example, the rules commonly stated that a care provider in a residential care facility could administer medications upon completion of a medication administrator course. In such cases, nurse delegation was not necessary. (The specific distinctions made by the state statutes regarding the administration of medications is provided in Exhibit B-5 in Appendix B.) Two states, Oregon and Texas, had specific rules regarding the delegation of medications.
In Oregon, a registered nurse may choose to delegate the administration of injectable medications
on a case-by-case basis. In contrast, the nurse need not delegate the administration of noninjectable medications, but instead a registered nurse or physician may assign the "various tasks" of the administration of non-injectable medications to unlicensed persons. Further, the administration of p.r.n. (i.e., take as needed) medications and treatments may only be delegated under certain circumstances where no nursing assessment is required in administration, a safeguard that distinguishes management of medications (a professional hnction) from
page 30
administration. Texas regulations generally prohibited delegation of medication administration but permitted delegation in many settings under certain circumstances. For example, Texas rules permitted the delegation of the administration of medications in independent living environments for stable clients who are willing and able to participate in the management of their care. The exceptions in the Texas rules were extensive and setting-specific (see Exhibit B-5in Appendix B, for more specifics).
How Tasks Are Delegated

Few states in the sample provided guidelines for nurses to follow when they delegate tasks, thereby allowing considerable discretion. Some states did require the nurse to instruct the delegate or verify the delegate's competence prior to delegating. In addition, several states warned that a nurse should delegate only in situations where reasonable and prudent. The Oregon and Colorado delegation regulations were more specific and limited delegation to a specific task, by a specific delegate, for a specific client. While the Colorado regulations fhrther limited delegation to a nurse-specified time frame, Oregon provided succinct guidelines that a nurse had to follow prior to delegation, the only state in our sample to do so. The Oregon delegation rules stated that the registered nurse must: teach the unlicensed person the task, observe the unlicensed person performing the task, leave written instructions for performance of the task as a reference, and instruct the unlicensed person that the task being delegated was specific to this client only and not transferable to other clients or to be taught to other care providers Supervision. All 17 states with delegation provisions required supervision of the unlicensed person to whom tasks have been delegated. All but three states (Iowa, Nebraska, and
page 31
Oklahoma) discussed or at least mentioned, in statute, regulation, or guidelines, supervision as it related to delegation. These discussions of supervision varied in three aspects: frequency and degree of supervision required; kind of supervision required; and who must supervise.
In general, the frequency of supervision required by the RN over the delegated tasks was
left to the nurse's discretion. Only two states mandated a minimum level of supervision. In Oregon, the RN was required to supervise, defined as direct oversight, at a minimum of every 60 days with intermittent supervision at the discretion of the nurse. The Texas statute required the
RN to made supervisory visits every two weeks, if the client had an unstable and unpredictable
condition and the nursing care was provided in the client's residence. Also of note are the proposed special care provider regulations in Nebraska, which refer to special care providers for people with developmental disabilities. These proposed regulations would require a RN to directly supervise at least every 30 days. Eight of the 17 states, as Table 12 shows, provided factors for consideration by the nurse in determining what degree of supervision was adequate. The state statutes or regulations commonly included the following four factors: 1) stability of the client's condition; 2) training and capability of the unlicensed person to whom the nursing task was delegated; 3) nature of the nursing task being delegated; and 4) proximity and availability of a qualified licensed nurse to the unlicensed person when performing the nursing task. Five of the eight states providing factors required the nurse to consider all four factors, two state required consideration of the first three factors, and one state required consideration of only the first and the third factors (see Table 12).
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Table 12. How to Determine Appropriate Level of Supervision i 20 Selected States n
'
2
Includes the availability or proximity of RN, or other licensed health personnel. Guidelines entitled "Delegation of Nursing Functions To Unlicensed Persons"provide factors to evaluate.
A second variation among the states was the kind of supervision required, specifically, whether direct or indirect supervision of the delegate was required. Six of the 17 state statutes and regulations with delegation provisions (California, Kansas-general, Nebraska, Ohio, Texas, and Washington) simply required "supervisionll without definition. However, 12 states (Arizona, Colorado, Iowa, Kansas-school, Massachusetts, Maine, Michigan, Minnesota, New Jersey, Oklahoma, Oregon, and Wisconsin) required, at least to some degree, direct observation of the
~~ ~ ~~~ ~
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delegated tasks (e.g., periodic inspection of the actual act of accomplishing the task or activity, observe and monitor task or activity, provide direction and assistance). Moreover, of these 12 state statutes or regulations, five (Colorado, Iowa, Michigan, Minnesota, and Wisconsin) included evaluation as part of their definition of supervision.
Table 13. Supervision Requirements As Specified in the Statutes and Regulations of the 20 Selected States
3
4
However, unprofessional conduct includes the failure to supervise persons to whom nursing functions have been delegated. A RN is consider competent when shelhe effectively supervises nursing care given by subordinates to whom shelhe has delegated tasks. No delegation provision. Alternate nurse is to be designated by the delegating nurse. Further delegating RN must determine whether the task requires RN or LPN supervision. No delegation provision. No delegation provision.
A final variation concerned whether the supervising nurse must be the same nurse who
originally delegated the task to the unlicensed person, or if a substitute supervisor was sufficient. The majority of state statutes and regulations did not directly address this issue, which could have implications for the organization and cost of services. Still, as Table 13 shows, six state statutes and regulations (Colorado, Maine, Michigan, New Jersey, Washington, and Wisconsin) seem to require that the nurse who delegated also needed to supervise. Three other state statutes (Kansas school provision, Oregon, and Texas) indicated that the delegating or an alternate registered nurse
page 34
could supervise the delegate (see Table 13). Only the Oregon delegation rules explicitly addressed this issue. The Oregon rules stated that while it was intended that the registered nurse who delegated the nursing tasks to the unlicensed persons should also provide for supervision of those persons, provided the supervising nurse was familiar with the client, the skills of the unlicensed person, and the plan of care. In addition, the Oregon rules required that the following must occur if the delegating and unlicensed nurses are two different individuals: The reasons for separation of delegation and supervision shall be justified from the standpoint of delivering effective client care, and not only for convenience; The justification shall be documented in writing; the supervising nurse agrees, in writing, to perform the supervision; and The supervising nurse will either be present during the teaching and delegation or will be filly informed of the content of the instruction, approves of the plan for teaching, and agrees that the unlicensed person who is to be taught the task of nursing care is competent to perform that task. Documentation. Of the states studied, only three states (Kansas, New Jersey, and Oregon) had any record keeping requirements. (See Exhibit B-6 in Appendix B.) Kansas had record keeping requirements in school settings: unlicensed persons must be adequately identified by name in writing for each delegated task; and the competency had to be documented in writing. New Jersey delegation rules simply required that there be verifiable training and education of the delegatee. Only the Oregon delegation rules specified what were the exact documentation requirements. (These requirements are discussed in more detail in the section highlighting specific state examples [see page 401.)
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Accountability. Twelve of the 17 state statutes contained provisions that held the nurse accountable for the quality of nursing care provided to the client by the unlicensed person. Five of the 12 also held the nurse accountable for the decision to delegate (see Table 14). The board then had the power to assess whether a reasonable and prudent nurse would have delegated
Table 14. Nurse Delegation Act Accountability/Liability in 20 Selected States

Accountable for quality of care AZ
CA
Accountable for decision to delegate
Not specified
X
X
w15
1
2
Provided elaborate standards for the accountability of the delegator.
No delegation provision. The definition of accountability was circular. Accountability included assigning and supervising persons performing those activities or functions which did not require the knowledge and skill level currently
ascribed to the registered nurse. Supervising included delegating functions or activities while retaining accountability. The RN who delegated tasks of nursing care to unlicensed persons was strictly accountable for that delegation. If nursing acts were delegated, the legal principal of respondeat superior was invoked. By that principle, the nursing act undertaken by the LPN or less-skilled assistant was, in a legal sense, the act of the supervising nurse who had delegated.
Delegation oflvursing Activi fies
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in the given situation, and render a decision. Only the Wisconsin Board of Nursing guidelines have an explicit statement that when nursing acts are delegated, the legal principle of
respondeat superior is invoked. Accordingly, the nursing act undertaken by a LPN or lessskilled assistant was, in a legal sense, the act of the supervising nurse who had delegated the task. Presumably this kind of interpretation that would make the nurse vicariously liable for all actions of a delegatee would have the effect of curbing delegation practice. Other commentators do not believe this interpretation is reasonable.
Delegation In Assisted Living Settings Licensure requirements for facilities or settings can restrict the amount and type of nursing
care, if any, provided by a facility and/or whether or not nurses can delegate in a particular setting. Such requirements can, in effect, override in any setting the permission to delegate granted by the nurse practice act. Typically, state informants indicated that no specific licensure requirements existed for a category called ''assisted living facilities." However, through fbrther discussions, we found that settings meeting a hnctional definition of assisted living because hands-on personal care was provided in the setting required to hold some type of license in all 20 states. Where no state specific requirement for assisted living facilities existed, these facilities were licensed using existing residential care guidelines for board and care facilities, personal care homes, and congregate living facilities. Table 15 shows the types of licenses in each state. These rules restricted the use of delegation independent of any other stipulation in each state nurse practice act. For example, some states required that a consumer needing nursing care for a certain number of days, or more, must leave a licensed residential care setting.
~ ~ ~ ~ ~~~ ~ ~
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Table 15. Types of Licenses Commonly Held by Assisted Living Facilities in 20 Selected States
2
3
4
7
8
9
10
11
12 13
Proposed legislation for assisted living licensure. See Appendix B-7. Asshed living will fall under proposed residential care licensure. See Appendix B-7. Legislative mandate, state must license assisted living facilities by January 15, 1995. Licensed as "Boarding Homes. " Licensed under new classification, "Unclassified." Licensed as "Residential Care Facilities," "Family Life Home," "Elder Family Home," "Elder Group Home," and "Continuing Care Retirement Community. " Licensed as "Adult Foster Care" or "Homes for the Aged. " Licensed as "Board and Lodging with Special Services" or "Class E Home Care. " Licensed as "Residential Care Facilities. " Licensed as "Domiciliary Care. " Assisted living facilities must hold an Adult Home license or an Enriched Program license and either: (1) Certified Home Health Agency license; (2) Long Term Care Home license; or (3) Home Care Provider license and contract with (1) or (2). Licensed as "Residential Care Facilities." Wisconsin planned to distinguish between "Community Based Residential Facilities" and "Adult Family Homes" starting November 1, 1994.
At the time of this research, passage of proposed assisted living regulations in Ohio was being held up because of this particular issue. Some groups had lobbied for a rule that would limit the number of nursing visits an assisted living client could receive to 120 days. However, the State of Ohio felt such a limit was too restrictive, particularly if elapsed days between nursing interventions were counted as days, and if each visit, however short, counted as one day. They thought such a policy might preclude retaining residents who needed routine nursing services for more than a few months. In contrast, other state policies did not limit the admission or retention of consumers needing nursing services, but did render their assisted living more costly by
page 38
requiring that the settings employ staff nurses. (For example, in Washington assisted living settings must have staff resources or a nurse contracted for a minimum of five hours per day, which reportedly made smaller assisted living settings less economical.) The state-by-state differences we identified in regard to licensure of residential care settings showed that nurses are constrained not only by the restrictions of the nurse practice act, but also by any restrictions arising from the settings by the setting's licensure requirements in specific settings.
Customary Practices Respondents from state boards of nursing were often reluctant to comment on what tasks
occurs in practice. Rather, respondents from the various state boards of nursing stressed that the appropriateness of delegating a task should be left to the nurses' discretion and that no task could necessarily be delegated in all circumstances. For instance, one respondent noted that even the simplest assistance with daily living, like spoon feeding, could not invariably be delegated. If, for example, the client recently suffered a stroke and had difficulty swallowing, delegation of spoon feeding could be inappropriate. In each situation, it was emphasized, the nurse must assess the condition of the client before making the decision to delegate a particular task. The nurse also must assess and determine the suitability of the person being considered to assume the delegated responsibilities. Nevertheless, some board of nursing respondents were willing to provide examples of commonly delegated tasks. These examples demonstrated wide variation in beliefs about what types of tasks should and should not be delegated, ranging from assistance with activities of daily living, to catheter care, insulin injections, gastrostomy tube feedings, and tracheotomy suctioning.
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Board of Nursing respondents in at least one third of all states reported that delegating activities
of daily living, non-sterile skin care and wound care, and catheter care and catheter insertion to
unlicensed persons occurred in practice.
Three State Examples For policymakers considering implementing legislative or regulatory changes to their
state's current nurse delegation laws, as well as for policy-makers simply curious about how other states address delegation, it is usefbl to compare the subtle, yet pivotal, differences in approaches to nurse delegation among states. To facilitate such a comparison, we highlight in detail three states (Oregon, Colorado, and Texas), which represent relatively recent and somewhat different approaches to implementing increased nurse delegation. A comparison of these states suggests that the subtle differences in the regulations, taken together, lead to or reflect different delegation policies.
Table 16. Comparison of Delegation Regulations in Oregon, Colorado, and Texas

OREGON COLORADO
~~~
TEXAS
R e p ---- _______--______------ l a t ionsjrovided: ----examgles of tasks that could be delegated ----0 examgles of tasks that could not be delegait----- -------------delegation of non-injectable medication administration delegation of injectable medications administration Regulations were setting-specific Regulations were client-specific Regulations mandated minimum supervision Regulations contained documentation requirements
can be delegated yes yes yes Yes
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To facilitate this comparison, we have highlighted these three states' nurse delegation
regulations on the basis of the following factors: How does the regulation address what tasks can be delegated, including the administration of medications? How does the regulation restrict the setting in which clients may receive delegated care? Does the regulation mandate minimum supervision? Does the regulation mandate documentation of the delegation process? (See Table
16 for an overview of the state regulations for each of the above factors.)
How regulations address which tasks may be delegated. In Oregon, the regulations did not limit the tasks a registered nurse could delegate. Unlike any other state studied, Oregon distinguished between "basic tasks" (tasks that did not require the education or training of a nurse, but that could not be performed or directed by the client) and "special tasks" (tasks which required the education and training of a nurse). Examples of "special tasks" included, but were not limited to, suctioning, complex wound care, and administration of injectable medications.
Only ''special tasks" required delegation by a registered nurse. "Basic tasks" could be
assigned by either a licensed practical nurse or a registered nurse. "Delegation"was the specific teaching of a task, to a specific delegate, to be performed on one specific client only whereas "assignment" was merely the general teaching of a task. As discussed below, the level of supervision required by the nurse was dependent on this delegatiodassignment distinction. The delegatiodassignment distinction was also present with respect to the administration of medications. Registered nurses were permitted to assign the administration of non-injectable medications to unlicensed individuals. Delegation was required for the administration of injectable medications. The registered nurse, however, could not delegate the decision to administer p.r.n. medications (Le., medications prescribed by a physician to be given as needed,
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unless the registered nurse supplemented the physician's p.r.n. order with guidelines so specific that the unlicensed person required no discretion in administering the medication.
In Colorado, the delegation regulations limited what nursing tasks registered nurses were
permitted to delegate. A nursing task could be delegated only if the task was routine and repetitive in nature and did not require the exercise of nursing judgment or intervention. The regulations did not provide examples of such tasks. The regulations did, however, limit the delegation of a task to a specific delegatee for a specific client, and within a specific time frame. Finally, although the Colorado regulations did not mention medication administration, the Board of Nursing stated that the delegation of medication administration would be permitted if it met the regulation requirements.
In Texas, the delegation regulations limited what tasks could be delegated by registered
nurses. Registered nurses were prohibited from delegating nursing tasks which required the exercise of nursing judgment or intervention, except in emergency situations. The Texas regulations provided examples of tasks which: Could be delegated in any setting (e.g., non-invasive and non-sterile treatments, collection of data, vital signs, and client comments, ambulation and positioning, and activities of daily living). Could be delegated only in home and community-based, including adult foster care and assisted living environments (e.g., medication administration, tube feeding through permanently placed tubes, and intermittent catheterization). Could not be delegated (e.g., physical, psychological, and social assessment requiring nursing judgment, formulation of plan of nursing care, and tasks that require professional nursing judgment or intervention). Could not be routinely delegated (e.g., sterile procedures, non-sterile dressing or cleansing of wounds, invasive procedures such as inserting tubes in body cavity, and care of broken skin if beyond general first aid).
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The Texas Board of Nursing developed a memorandum that listed tasks that fell outside the practice of nursing and, therefore, could be performed by unlicensed persons without delegation. Specifically, the memorandum states that unlicensed persons can provide personal care to clients in independent living environments who have stable and predictable conditions, without nurse intervention. Additionally, respite services of no more than 30 consecutive days could be provided by unlicensed persons without nurse intervention. The respite services, however, were limited to personal care and the administration of regularly scheduled oral and topical medications normally administered by the primary care giver. This memorandum of understanding also provided scenarios of the proper use of delegation. The Texas regulations specifically prohibited delegating administration of injectable medications, and restricted the delegation of non-injectable medications in certain settings. The delegation of non-injectable medications was permitted in home and community based care settings (including foster cure and assisted living, if the delegatee held a medication aide permit. Delegation of non-injectable medications was also permitted in these same independent living settings if the client had a stable and predictable condition. How regulations restrict the setting in which a nurse mav delegate. The Oregon delegation regulations were setting-specific. The regulations permitted delegation only in settings where there was not a regularly scheduled nurse and a nurse was not available to provide direct supervision. "Regularly scheduled" meant that a licensed nurse was present a minimum of eight hours per day in a setting where client care was continuously delivered. The delegation regulations specifically stated that the delegation rules had no application in settings where the
page 43
application of nursing was continuously performed, such as long-term care facilities or acute care facilities,
In Colorado, the delegation regulations did not restrict the settings in which delegation
was permitted. The Texas delegation regulations did not generally restrict delegation to a specific setting. The regulations did, however, contain setting-specific provisions regarding what tasks could be delegated, whether medication administration could be delegated, and the intensity of supervision required. The provisions distinguished among independent living settings, home health settings, including group homes and foster homes, and long-term care settings. How remlations restrict what clients may receive delepated care. In general the Oregon nurse delegation regulations did not restrict the type of client who could receive delegated care. However, in home health care settings, the RN could delegate nursing tasks only for clients who had a stable and predictable condition and who required minimal nursing supervision. T i hs included hospice clients whose deteriorating condition was predictable. The Colorado nurse delegation regulations did not restrict the type of client who could receive delegated care, except for the requirement that home care clientele for whom tasks were delegated have stable and predictable conditions. (Home hospice clients could be included in those eligible for delegated care if the deteriorating condition was predictable.)
In Texas, the delegation regulations did not generally restrict the type of client who could
receive delegated care. The regulations did, however, contain client-specific provisions regarding what tasks could be delegated, whether medications could be delegated, and the level of
page 44
supervision required. These provisions distinguished between clients with stable and predictable conditions and clients with unstable and unpredictable conditions. How regulations address nurses' supervision of the delegated care? The Oregon nurse delegation regulations mandated a minimum level of supervision. The registered nurse who delegated a task was required to monitor, by direct observation, the unlicensed personk skill and ability to perform the delegated task at a minimum of every 60 days. For assigned tasks (Le., those that did not require teaching on a patient-specific and task-specific basis), however, there was no minimum supervisory requirement. The necessity and frequency of supervision of the assigned task was at the discretion of the RN. The regulations fbrther provided that it was within the R"s discretion to determine whether or not supervision of the assigned task was necessary.
In Colorado, the regulations did not mandate a minimum level of supervision. The
regulations required the nurse to provide "appropriateand adequate supervision." The degree of supervision provided by the nurse was to be based on an evaluation of (1) the clients' nursing care needs, (2) the delegatee's knowledge, skills, and abilities, (3) the nature of the tasks being delegated, and (4) the availability and accessibility of resources, such as other health care personnel to meet the client's nursing needs.
In general, the Texas regulations did not mandate a minimum level of supervision. Rather,
the required level of supervision was dependent upon the setting. In settings where the registered nurse's regularly scheduled presence was required, such as acute care and long-term care settings, the nurse was expected to be "readily available" to supervise the unlicensed person in performance
of delegated tasks. In home care settings, including group homes and foster homes, where the
client had an unstable or unpredictable condition, the nurse was required to make supervisory
page 45
visits every two weeks. If the client had a stable and predictable condition, then the nurse was required to make supervisory visits at his or her discretion to assure that safe and effective services were being provided. When discretion was involved, the degree of supervision was to be determined by the RN after evaluation of factors including, but not limited to, (1) the stability of the condition of the client, (2) the training and capability of the delegate, (3) the nature of the nursing task delegated, and (4) the proximity and availability of the registered nurse to the unlicensed person when the nursing task would be performed. Finally, regardless of setting, the delegating nurse or another equally qualified registered nurse was required to "be available" at all times in person or by telecommunications. How do the regulations in each state address documentation requirement? In Oregon, the following must be documented by the RN when a task is delegated: The rationale to be used to determine that the skill level of the unlicensed person will permit safe teaching and delegating of the special nursing care task, based on the client's condition. How the task was taught and the teaching outcome. The content and type of instructions left for the unlicensed person. Evidence that the unlicensed person understands the risks involved in performing the task and has a plan to effectively deal with any consequences of performing the task. Evidence that the unlicensed person was instructed that the task is client specific and not transferable to other clients or providers. How frequently the client should be reassessed by the registered nurse regarding continuing delegation of the task to the unlicensed person. How frequently the unlicensed person would be supervised. That the nurse takes responsibility for delegating the task to an unlicensed person, and ensures that supervision will occur for as long as the registered nurse is supervising the performance of the delegated task.
Delegation o Nursing Activities f page 46
The Colorado and Texas delegation regulations did not specify documentation requirements.
Opinions About Nurse Delegation

This section reports both supporting and opposing arguments about nurse delegation as
reflected by informants in the 20 states that we studied. These opinions were collected in interviews with key informants. We have made no effort to quantify these remarks, nor do we suggest that they fblly represent the opinions in the state. Rather, our effort was to amass an extensive (though we cannot claim an exhaustive) compilation of views that are held about nurse delegation among key stakeholders in the LTC system. Supporting;arfiments. The majority of informants (i.e., boards of nursing staff, representatives of nursing organizations, regulators, representatives of health care providers and program developers, etc.) supported the use of delegation, at least to some extent. Some saw it as an opportunity for patients to remain in community settings even when no family members were available to care for them. For example, these informants argued that the cost of routine nursing visits that might be needed daily or even more often added to personal care and homemaking, making the cost of community care prohibitive. State program officials particularly cited advantages. This included officials in Oregon where delegation has been in place, Texas where the rules have recently been adopted, and other states (Le., Washington & Arizona) where changes are sought. In Oregon, officials believe that delegation of nurse fbnctions has made possible the state's large programs of home and community based care (including adult foster care) with no loss of quality and no loss of employment for nurses.
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Supporters of nurse delegation, especially nurses, saw properly controlled delegation as a means of improving the quality of care that individuals receive, particularly in community care and home care settings. They argued that when delegation is not allowed and professional nursing cannot be afforded, unlicensed personnel must be already providing the nursing care, because somehow people were receiving care. These informants preferred that nurses be legally empowered to teach such unlicensed personnel how to provide care better. Moreover, they wanted nurses to be the ones making the judgments about when nurses should supervise more intensively, or when a different delegatee should be sought. Some argued that nurses teach people all the time. Nurse delegation, this argument went, makes it legal and official, thus improving the overall safety of residents in home and community care settings. Some supporters also saw delegation related to both consumer empowerment and equity. Regarding empowerment, the argument is that delegation makes real alternatives to nursing home care possible, and reduces the bias against allowing home and community care. Regarding equity, it allows individuals without family caregivers to have the same choices of home and community based care as those with caregiving family members; othenvise some of those individuals without family would need to consider nursing homes because the private and public costs of arranging alternative care, including the nursing component, would be prohibitively costly. In this way, delegation was regarded as enhancing consumer choice and allowing consumers to manage their lives, as well as determine the risks that they will take. Finally, many key informants stated that delegation enables nurses to use their judgment and assessment skills more authoritatively, efficiently, and creatively. In their view, delegation marks an augmentation of the nurse's role of leadership in community care, as well as recognition
page 48
of what has always occurred in some spheres of nurse practice. Their arguments hold that the true distinction of nurses is not their ability to perform tasks, but their ability to make nursing assessments, judgments, and decisions. Thus, these informants thought that delegation would permit nurses to use their unique skills in more practical ways, and spend less time performing tasks that can be done by anyone. It would also open up an expanded clinical teaching and quality assurance role for nurses. Opposing arguments and concerns. Key informants expressed a variety of concerns about nurse delegation. They were stated by respondents who represented a large variety of roles and positions, including nurses, and were mentioned by informants in states with and without nurse delegation. The two most commonly voiced concerns were that (1) nurses might be forced to delegate, and (2) nurses were not sufficiently educated and informed about the details that go into decisions about delegation. Other concerns included worries about the quality of care provided by unlicensed care givers; anxiety regarding the liability of the delegating nurse; fears that delegation was an encroachment on the nursing profession, which could weaken its status; and questions about whether the cost savings believed to result from delegation were real. The following discusses each of these concerns raised by informants.
Fears of coerced delegation. Many informants, particularly nurses, expressed concern

about situations in which they thought nurses might be forced to delegate to unlicensed personnel, either because of employers' orders, or because of reimbursement policies. When an employer forces a nurse to delegate, the nurse is put in an untenable situation, tom between following her or
his licensure requirements or following the requests of the employer. In some situations, nurses
may have to choose between risking their licenses or risking their employment.
page 49
This issue has become one of concern at the national level, which the National Council of State Boards of Nursing explicitly addressed in a 1990 concept paper. The following is an excerpt: Nurses traditionally cany out the role of nurse in an employment context and act as agents of the employer. The relationship is complex and is usually carried out in a setting in which the employer controls the nature of both the work of the nurse and the circumstances of the nurse role enactment. The licensed nurse is responsible to the employer for employment activities. The licensed nurse is accountableto the board of nursing for nursing practice. Employers may attempt to require nurses to delegate, especially when faced with staffing problems. This is inappropriate when the nurse is not willing to delegate. While employers and administrators may suggest which nursing acts should be delegated and to whom the delegation may be made, it is the nurse who ultimately decides and who is accountable for deciding whether the delegation occurs. If the nurse decides that the delegation may not appropriately or safely take place, then the nurse should not engage in such delegation. In fact, if the nurse decides that delegation may not appropriately or safely take place, but nevertheless delegates, hehhe may be disciplined by the board of nursing (National Council of State Boards of Nursing, 1990). Respondents were also concerned about reimbursement policies, public or private, that pressure nurses to delegate to lesser skilled individuals. Several examples of this type of forced delegation consistently emerged in our interviews with the key informants. First, several of the nurse informants reported that some insurance companies could only reimburse for various tasks at rates commensurate with the wages of lesser skilled individuals. Such insurance companies contend that they do not force nurses to delegate, but set a reimbursement rate and the employer may use any employee they desire to perform the task. The employer then may choose one of three options: have a unlicensed person perform the task without any nurse intervention; require a nurse to delegate the task and supervise the unlicensed individual; or have a nurse perform the task and take a loss.
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Secondly, this type of forced delegation was perceived to occur with publicly hnded reimbursement programs. For instance, some state Medicaid programs have lists of tasks that must be done by an aide and by an RN. If an aide or RN performs a task that is not on their respective list, Medicaid will not reimburse the individual or agency for the cost of providing the service. Another example pertains to home health agencies. In some states, before home health agencies could provide care to a Medicaid recipient, they had to present a plan of care to the state agency. The state agency then reviewed the plan of care and indicated which procedures were required to be performed by a licensed person versus an unlicensed person.
In such instances, the state agencies argued that they were not forcing delegation because
the decision to use a higher skilled person always remained with the home health agency. The agencies were simply setting a reimbursement level. Regardless, nurses we interviewed believed they were being forced to delegate in those situations. The nurse respondents expressed concern that policies of the state agencies administering Medicaid and other payment programs undermined nurses' authority to make individualized delegation decisions.
Inadequate education and information. An additional concern frequently raised by

informants, particularly was that nurses, in general, receive inadequate education about delegation and, therefore, do not know what constitutes appropriate or inappropriate delegation with reference to liability risks. The expressed ramifications of the lack of education were threefold: First, because nurses were poorly educated on these issues, they were uncomfortable with delegation and, therefore, reluctant to use it. Second, inadequate education was believed to be the primary reason for inappropriate delegation. The informants stated that when nurses delegate in unsafe situations, they often also fail to verify the competency of the delegate prior to
~~ ~ ~~ ~~~~ ~
page 5 1
delegation, or they inadequately supervise the delegatee. Key informants stated that such lapses were due more to a lack of education than to nurse negligence. Finally, some informants complained that state guidelines were insufficient to ensure that proper delegation procedures had been followed. Other informants recommended that nurses should follow guidelines for delegation provided by the National Council on State Boards of Nursing and the American Nurses Association (see Appendix E). Still, many nurse informants commented that they would choose not to delegate rather than risk losing their license because of improper delegation. The Texas Board of Nurse Examiners took particular pains to develop scenarios for training nurses about delegation decisions (see Figure 1). Also in Oregon, the Senior and Disabled Services Division, which hnds many of the home and community-based services
Figure 1. Scenarios Regarding the Use of Delegation in Texas

L.
A mother who provides around-the-clock care for her child with cerebral palsy plans to spend a long weekend with her husband. An unlicensed, trained provider is hired to provide routine care such as bathing, feeding, dressing, socialization. The child needs an AM and PM dose of Dilantin. The unlicensed person may administer the dose because it is a routine medication for this child and is administered orally.
A young adult released from a bum center three days ago is being cared for by his family. He needs sterile dressing changes three times per day and the administration of pain medication as needed. These skills were taught to the family prior to discharge from the bum unit by a registered nurse. The care givers wish to attend their daughter's wedding but must have someone to bathe, clean the wounds and redress the bums for a three-day period. An unlicensed person could not provide these services without RN delegation. This client does not have a stable, predictable condition.
2.
3.
A client with paraplegia living in his own apartment needs assistance on a daily basis with transferring, bathing, grooming, dressing and exercise. An unlicensed person may provide these personal care services without RN delegation for this client who has a stable and predictable condition.
A client with post traumatic head injury lives in a group home. The client's condition is stable and predictable at this time. The client needs ongoing assistance with meal preparation and grooming. The unlicensed person may provide these services without RN delegation for this client.
1.
5.
A client with cerebral palsy usually has an unlicensed person who assists with feeding, bathing, grooming and transferring. The client developed pneumonia and was hospitalized for IV antibiotic treatment. The client has been discharged but requires continued treatment with antibiotics and respiratory treatments. These services cannot be provided by the unlicensed person.
Source: Texas Board of Nurse Examiners -- Texas Department of Health Memorandum of Understanding.
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programs that rely on nurse delegation, issued a detailed list of conditions for delegation, shown in Figure 2. Respondents indicated that such specific tools were a welcomed security measure, especially if there was an expectation that delegation would be widely practiced.
Quality o care. Some of the informants opposed expansion of nurse delegation on the f
basis of concerns about the quality of care that clients receive. They worried that delegation would be used merely as a cost savings device for facilities and agencies at the expense of consumers. These informants also feared that health care providers would push the delegation legislation to its limits and use as few licensed personnel as possible, leading to reduced quality. At the opposite extreme, however, some consumer advocates representing "disability activists" opposed nurse delegation on the grounds that the clients should be able to direct their own care and should not need intervention by a nurse to delegate tasks to their care givers. (These critics argued against any role for a nurse.)
Nurse IiabiZity. Another common reaction was that delegation was too risky. Nurse
informants did not want the actions of others affecting their licenses. They feared that the board of nursing would hold them liable for the care provided by an unlicensed person, which in some states was true. In addition, some of these respondents believed that unlicensed persons were incapable of providing quality nursing care. Some nurses expressed uncertainty about what could constitute negligence in the way they performed the delegation or in their judgment to delegate in the first place. Although "liability"was a frequent concern of nurse respondents, this tended to be used as an umbrella term to embrace both regulatory liability under the nurse's license and potential for tort liability. Most often the nurses seemed to be worried about the former, but the concerns were not well separated.
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Figure 2. Checklist: Conditions for the Delegation of Nursing Tasks to Unlicensed Persons i Oregon n
- The setting allows delegation. - A regularly scheduled RN is not required.

- The client's condition is stable and predictable.
The client's condition only requires minimal supervision. - The nature of the task to be delegated has been considered, including: - the complexity of the task. - the risks involved in the task. - the skill required to perform the task. - The client's condition has been assessed and a determination has been made that the unlicensed person i capable to perform the task without direct nursing supervision. - A determination of the frequency of client reassessment has been made, to ensure continued appropriatenes of delegation. - The unlicensed person is prepared to effectively deal with the consequences of performing the task a nursing care. - The unlicensed person's ability to perform the nursing task has been assessed. - The frequency of supervision of the unlicensed person has been determined. The rationale for delegating the task to this unlicensed person has been documented. - Prior to delegating the task, the following was done: - teach the unlicensed person the task of nursing care. - observe the unlicensed person performing the task safely and accurately. - leave written instructions for the unlicensed person to use as a reference. - instruct the unlicensed person that the task of nursing care is client specific, is not transferable to an, other client, and may not be taught to other care providers by the unlicensed person. - The following has been documented: - the rationale used to determine that the skill of the unlicensed person will permit safe teaching ani delegation of the specific task of nursing care based on the client's condition. how the task was taught. - the teaching outcome. - the content and type of instructions left for the unlicensed person. - evidence that the unlicensed person understands the risks involved in performing the task. - evidence that the unlicensed person was instructed that the task is client specific and not transferabl to other clients or providers. - how frequently the client should be reassessed by the RN regarding continued delegation c the task of nursing care to the unlicensed person. how frequently the unlicensed person should be supervised. - Written documentation by the RN shows that the RN has taken responsibility for delegating the task to a unlicensed person, and that supervision of the delegated task will occur as long as the RN continues t supervise the performance of the delegated task. by ICompiled from: OSBN, OARS, 851-47-000-851-47-030, Cynthia McDaniel, BSN, RN, Consultant.
page 54
Encroachment on the nursing profession. Delegation legislation was sometimes opposed

by respondents from state boards of nursing and state nurses' unions in the belief that it encroached on the nursing profession. These informants felt that by supporting delegation they were admitting that the unique services nurses provide could be provided by unlicensed individuals, and thereby conceding that the nursing profession was unnecessary.
Skepticism about cost savings. Some informants doubted whether the use of delegation
would result in the anticipated cost savings, raising three arguments to support this skepticism. First, they argued that delegation could compromise the quality of care received by clients. As a result, recipients of delegated care would experience more complications, and thus require additional and more extensive medical attention than would have been required without delegation. Secondly, the respondents argued that because a nurse was accountable for the care given to the client, the amount of supervision provided by the delegating nurse would be so great that any cost savings would disappear. They contended that it would be just as efficient to have the nurse perform the task than to have the nurse supervise at a frequency high enough to ensure safe delegation. Finally, because of the high turnover rate with unlicensed care givers, they argued that the cost of training each new care giver would exceed the cost of a nurse providing the care.
Concerns about system imbalance. As various states move in the direction of

encouraging more nurse delegation in home and community care, some criticisms center around the implication for various providers. For example, several states are currently attempting to pass legislation that would permit such delegation but the proposals face a mix of support and opposition. Washington and Arizona are cases in point. In Arizona, a state that permits
page 55
delegation but prohibits the delegation of medication administration, proposed legislation would allow the administration of medication by individuals who have completed a 40-hour course. The mixed reaction to this proposal is instructive. Some nurses argue that the Arizona legislation is long overdue and will allow nurses to provide supervision of care givers in community care settings. They argue that, currently, nurses are forced to remain out of community care settings because unlicensed care givers are administering medications. If a nurse were involved in such a setting she would be considered to be delegating medication administration illegally. To avoid jeopardizing their licenses, nurses now remain out of these community care settings altogether. Supporters of the proposed legislation also argue that nurses need to be in the loop and supervise the care given by care givers in community care settings. They argue that not only will this legislation increase the overall use of delegation, it will increase the quality of care given to residents in such settings because nurses can and will be involved in the care giving. Opponents of the Arizona legislation are largely nursing home providers who see assisted living as formidable competition if allowed to serve the same market. They argue that medication administration is far too technical to be performed by unlicensed persons even ifthey have a 40hour course. They argue that unlicensed persons cannot and should not assess the side effects of medications and be responsible for making decisions about the administration of medications. One nurse noted that the state requires a person to have more hours of training to cut hair than to administer medications. As demonstrated by this example, when legislative changes are needed to permit delegation, the issue may be mired in controversy.
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In general, states attempting changes in rules governing delegation of administration
reported opposition fiom the nursing home industry. Its interest arises because delegation could permit individuals to stay in community residential settings for longer periods of time. Moreover, delegation would not be permitted in nursing homes because of current federal requirements (which some nursing home industry spokespersons argue are appropriate given the frailty of their residents), and an unequal playing field is thus established. The fear is that other settings will be able to use delegation effectively for care of similarly frail people, thus setting up an unfair competitive situation, and, perhaps, negatively affecting quality.
DISCUSSION
Taken together, this study suggests some general conclusions, summarized immediately below. Then, the final portion of the report draws out implications of these findings for those who might be interested in building LTC programs based on increased delegation of nursing functions.
General Conclusions Current statutes and regulations largelv permit delegation, but statutory change to
eliminate specific prohibitions would be needed in some states wishing to implement nurse delegation. For the most part, the nurse practice acts that we reviewed permitted the nurse to delegate tasks to other people. Indeed, nurse practice acts usually incorporate "delegation of nursing tasks" definitionally into the scope of the nurse practice; "teaching of patient and family" is also typically included as another feature of nurse practice (Dombi, 1994). Thus, unless specific qualifications are included, it would seem that nothing in the general provisions of nurse practice acts or regulations in most states prohibits nurses fiom teaching unlicensed personnel and delegating tasks to them. On the other hand, specific roadblocks, particularly prohibitions against
page 57
delegation of medication administration or nurse treatments, may require amendments to state nurse practice acts. Much depends on the opinions of state boards of nursing. Delegation potential is not hlly exercised. Despite the possibility of substantial delegation under law and delegation, such practices are not often integrated into a planned LTC system. The differencebetween states that view themselves and are widely viewed as "having nurse delegation in place'' seems to be as much a matter of policy planning as statutory and regulatory change. Absent clear language in a nurse practice act and consistent interpretations,it is impossible for states to integrate nurse delegation into an LTC system. Consider, for example, the detail developed in Oregon, where nurse delegation has become well established and Texas, where the intent at the time this report was prepared was to incorporate it into a system of home and community-based services. Few states approach this level of detail. Nurse delegation policies and practices vary from state to state. The tables presented in this report and in the appendix show much variation around the theme of nurse delegation. These variations pertain to who may delegate nursing tasks, to whom nursing tasks may be delegated, the settings where delegation is permissible or prohibited, the specific tasks that may or may not be delegated (often including specific rules about administration of medication), and the kind of recording, oversight, and supervision required of the nurse who did the initial delegation. Such variations can affect the cost of the service to the consumer or to third-party payors. For example, frequency and type of supervision needed definitely affects costs, as does the detail about tasks that fall outside the rubric of delegation. The way that medications are handled is especially likely to influence costs. Routine administration of oral medications is one reason why many programs need a licensed nurse. Because this need is so common, a liberalized nurse
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practice act that, nonetheless, is inflexible on medication is unlikely to produce dramatic cost savings. Nurse delegation policies are ambiguous. This study revealed ambiguity about the delegation authority of the nurse. Statutes and regulations are often vague and general. Our respondents within a single state often disagreed about the range of permissible delegation. Much of this ambiguity seems to stem from an understandable reluctance of boards of nursing to clearly define what can and cannot be delegated. Commonly, professional leaders at the state level indicate that the "nurse'sjudgment" is the key indicator as to whether delegation is appropriate in a particular situation. Boards of nursing fear that a list of tasks that may or may not be delegated would eliminate the role of the nurse as the maker of judgments. Ambiguity also arises because of lack of concerted educational and technical assistance efforts. Finally, some ambiguity is inevitable because nursing judgment is and should be at the heart of whether and when to delegate. This means that formulaic solutions are unlikely.
In practice, however, many nurses are reluctant to delegate without clear guidelines to
assure that they are doing so appropriately. Informants from the states told us that many nurses are not educated about delegation and are, therefore, uncomfortable doing it. The various facility and home health licensure rules add to the ambiguity surrounding nurse delegation. Before deciding whether to delegate tasks in a given situation, nurses would have to know the state practice act provisions about delegation, as well as what kinds of nursing services can be provided
in each facility, and whether there are any restrictions about delegating these tasks to unlicensed
personnel. Moreover, regulation of LTC settings and programs is in considerable flux, so that an ongoing effort is needed to keep up-to-date on regulatory policy. However, we were also told by
page 59
some informants that the reluctance to delegate does not pertain to nurses working in private pay arrangements in the home care sector. Familv roles related to nurse delegation are complex and need firther studv. A particularly ambiguous area concerns how family should be treated if formal nurse delegation practices are developed. At present, nurses typically provide instruction to family members without needing to go through a formal delegation process. Whether such exemptions are desirable needs hrther study. Many states are beginning to compensate family members for care with public money. Formal delegation would add accountability and would ensure a level of instruction that might reduce reports of elder abuse and neglect by family members. It would, however, introduce a note of formality into care that is widely known as "informal care." But, if family members are exempted from formal status as a delegated care giver, states that develop formal procedures for delegation will need to revisit the definition of family and decide which arrangement should be excluded. No information svstems have been developed specificallv to track problems. In four states that have made specific recent efforts to encourage delegation of nurse fbnctions (Oregon, Colorado, Texas, and Kansas), our informants reported few untoward experiences. Patients and families were said to be highly accepting of the practices (indeed, not discerning anything different). Despite fears that nurses would be held legally liable for poor processes or results of care rendered by someone they had taught, no such legal challenges have been mounted. But no tracking or monitoring systems are in place to provide systematic data on nurse delegation. Furthermore, little thought has been given about how to interpret any negative incidents that might occur when nursing practices are delegated. Bad results, some inevitable and some
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preventable, occur in health care, regardless of who performs the care. Of concern, however, is the lack of any information system to indicate the effects of nurse delegation. Lacking is the means to uncover problems that should be remedied or to compare delegated nursing to a variety of other circumstances: e.g., care given directly by nurses; care given by family members; and care given by unlicensed personnel without nurse delegation Nurses tend to have some reservations or anxieties about nurse delepation. Although problems have not been seen thus far, nurses have substantial reservations about nurse delegation based on a variety of concerns -- quality of care, liability, losing control over decision-makingand being forced to delegate. Thus, states seeking to modify the delivery of home and community based LTC services in ways that depend on delegation done by nurses may need to develop additional regulations or clarifying instructions. It may also be necessary to launch an informational and educational campaign to inform nurses and others about the provisions and to provide backup support. In particular, nurses need assurance that if they exercise reasonable judgment and attention to their delegation instructions and their assessment of the capability of the person to whom they delegate, they will not be viewed as negligent.
Steps Toward Change In the authors' opinions, models of delegation of nursing functions to unlicensed personnel
should be pursued in the interests of more effective, client-centered, flexible, and efficient LTC, which ultimately permits people to live in preferred, homelike settings. We view Oregon's experience as a promising experiment, deserving of replication in other states, though we also view monitoring systems as vital to any newly implemented nurse delegation programs. In any
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event, if states wish nurse delegation to become established, a deliberate strategy needs to be pursued. The processes potentially required to change nurse delegation practices are multifaceted. The following factors affect the restricted or liberal use of nurse delegation in a given state: the statutory or regulatory provisions permitting or restricting delegation under the Nurse Practices Acts; nurse willingness or reluctance to delegate various tasks; the licensure requirements for facilities or home health agencies; and payor willingness or reluctance to reimburse delegation procedures. The sections below briefly discuss approachesthat may be required to develop workable nurse delegation practices: 1) statutory or regulatory change in nurse practice acts; 2) statutory
or regulatory change in facility licensure; 3) changes in vendor requirements or program
reimbursement rules; 4) structural changes, such as organizational efforts to provide a payment source and a vehicle to help care programs and consumers find nurses to perform delegation; 5 ) information systems and health services research; and 6 ) emphasis on enhancement of nursing roles. Statutorv or regulatory changes in nurse practice acts. As already discussed, most of the states in the sample have provisions for some nurse delegation in statute or regulations or both. Few states specifically restrict what tasks can be delegated and where delegation may be used. Therefore, few statutory or regulatory changes may be necessary. The most common statutory barrier to delegation is restrictions or prohibitions on the delegation of medication administration. Various states have perceived a need to modify provisions that restrict nurse delegation of administration of oral or other medications. Such
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modification may face substantial opposition, not only from practitioners and advocates concerned about quality, but also from provider interest groups alarmed about how delegation permitted in some settings and to some providers might adversely affect the markets of other providers. Changes in statute on regulation affectin? licensure rules of care settings. As stated above, residential care settings (such as foster care homes, assisted living settings, group homes) are often subject to state regulations that require staff nurses. They also often have admission and retention regulations that prohibit people who need nursing care for more than a specified number of days to remain in the setting. If states wish to implement nurse delegation in these settings, related regulations may need to be changed. Education and technical assistance. Even if statutes or regulations permit delegation, nurses must be willing to do so. Education should be directed to making nurses more informed about delegation, better problem solvers, and more comfortable with it. Parallel efforts are needed to inform and train care providers, advocates, and consumers, themselves. In some states that permit delegation, especially those states that provide scant guidance to nurses, the nurses often are reluctant to delegate. A concerted educational approach is needed to change attitudes about delegation. Such a multi-pronged effort might include: continuing education seminars; explanatory pamphlets; a telephone hot-line number where nurses can get advice from a definitive source on a case-by-case basis; an e-mail network development of illustrative case materials where delegation is or is not correct; and (as a long-range approach) incorporation into basic nurse training. Education for nurses must deal not only with provisions of the law and regulations and how to apply them, but also techniques in effective teaching and methods of evaluating
~ ~~~
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competence. The kind of scenarios developed in Texas and the Oregon checklist, shown on page
52 and page 54 respectively, illustrate the kind of concrete help that is needed. Nurses and their
employers are more likely to develop confidence in and comfort with delegating activities if education and technical assistance are available. It is unclear who will pay for such informational services and whether they would be passed on to consumers. The Senior and Disabled Services Division in Oregon certainly has invested in ongoing educational efforts on nurse delegation, seeing them as a necessary cost to build the system. Structural changes. Some attention needs to be given to how nurses will be paid for their delegation activities, including the original instruction and the ongoing monitoring. One cannot assume that nurses are available and positioned to fulfill these functions, nor that some additional costs will not be incurred. Various strategies are possible to acquire the nurse involvement. For example, case management programs that arrange care plans and settings could hire or contract with nurses to perform the delegation. Home care agencies could be hired to do the work on a fee-for-service or Capitated basis. Assisted living settings could themselves employ or contract the nurses and build this into their charges. In that case, public reimbursement would also need to take these costs into account. Smaller residential settings might be able to contract with nurses in a consortium or rely on a registry of nurses who will do delegation. Each solution has implications for costs and accountability. Two points stand out. First, nurse delegation will not increase without some planning for how the work will be structured. Second, planners must guard against introducing perverse incentives that would end up reducing the savings associated with nurse delegation. For instance, if home health agencies were
page 64
encouraged to bill for their delegation activities on a fee-for-service basis, one can anticipate a large induced demand.
In Oregon, several approaches have been mixed and matched. Assisted living programs
usually have a nurse on staff or contract. Foster care homes sometimes hire a nurse for ongoing contact with physicians, and such nurses also perform delegation. Some foster care homes have reported that home health agencies are doing the delegation as a fiee service in homes where they are likely to also do Medicare-reimbursed work (Kane et al., 1989). The Senior and Disabled Services Division has found it most efficient if its local case management programs hire consultant nurses directly to perform delegation to the eight thousand or so client-employed home care workers in the system. (In Oregon, as mentioned earlier, the Medicaid program will pay clientemployed workers selected by the consumer. The state acts as fiscal agent for these personnel, cutting the checks and paying the employer and employee part of Social Security.) It is unclear how a privately paying individual arranging a care plan would gain access to the services associated with nurse delegation. Such individuals might be willing and able to afford to hire a nurse to delegate and oversee the work of an in-home helper, but in all likelihood they have no knowledge of this opportunity. Indeed, home health agencies have an incentive not to inform privately paying clientele of this option. Information systems and research. Virtually no information systems are available to track the effects of nurse delegation and to examine and correct associated problems. A state should put into place some way to monitor the effects of the program and provide a basis for mid-course corrections, if needed. Such a capability engenders confidence for all participants, providers and consumers alike. Furthermore, some operations research and evaluation research might be usefbl
page 65
to determine the extent to which various delegation arrangements are associated with good outcomes for consumers and overall efficiencies in the cost of care. In thinking about tracking the effects and hazards of nurse delegation, however, it will be important to determine the appropriate comparisons. For example, problems with care given by nursing staff members occur in nursing homes and in hospitals where delegation and assignment is controlled and limited. Will a higher standard be demanded of the settings where delegation occurs? Also, should nurse-delegated services be compared to services under direct supervision of a nurse, or to services with no nursing involvement? The methodological problems are compounded because some delegation is part of nurse practice in any event so that distinguishing the "new" approach from "standard" approaches is difficult operationally. Emphasis on enhancement of nursing roles. Although nurses often have concerns about delegation, typically focused on liability or encroachment on the nursing profession, we also found that many nurses see new models of delegation as a way to expand the influence and leadership roles of qualified nurses. This is certainly one of the intents of those who advocate nurse delegation at the policy level. Emphasizing enhancement of nursing roles is also a pragmatic strategy. For nurse delegation to become a vehicle for the improvement of LTC, it must capture the imagination of leaders in nursing as a way for the profession to more fully use a wide range of nursing skills.
CONCLUSIONS
As a result of this study of nurse delegation in 20 states, we conclude that nurse delegation
remains a feasible and promising approach to providing cost-effective LTC in home and community-based care settings, including group residential settings. Supporting and opposing
page 66
forces for such strategies are somewhat balanced, but the nursing profession itself cautiously favors the approach if nurses retain discretion about whether to delegate to an unlicensed person and are never forced to do so. Statutory changes needed to launch nurse delegation may be relatively modest in many states, but state nurse practice acts that prohibit nurses from delegating administration of medications effectively deter delegation efforts and, therefore, require modification. States that presently rely on nurse delegation--notably, Oregon--are generally satisfied with their policies. Oregon's experience might be viewed as a social experiment that other states might decide to emulate, building in the capacity to monitor the effects of the innovation on quality of care, consumer access to care, and cost of care. But, also judging from Oregon's experience, education, technical assistance, and an information system for tracking problems are needed before nurse delegation will become a widespread practice.
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REFERENCES
American Nurses' Association (1992). Position Statement on Registered Nurse Utilization of Unlicensed Assistive Personnel. Washington, DC: American Nurses Publishing Attorney General Opinion (1987), California, A. G. Op. #87-106, June 15,1988. Nurses' Association, Task Force on Unlicensed Assistive Personnel (1994). Registered Professional Nurses and Unlicensed Personnel. Washington, DC: American Nurses Publishing. Brent, N. J. (1993). Delegation and supervision of patient care. Home Healthcare Nurse, fl(4), 7-8. Dombi, W. A. (1994, November). Current Medicare Plan of Care requirements: Issues and problems in care planninp and oversight. Symposium on "The Role of Physicians and other Health Professionals in Planning and Oversight of Medicare Home Health Services, Baltimore, MD. Washington, DC: Center of Health Care Law, 5 19 C Street, N. E., Stanton Park, Washington, D.C., 20002. (Unpublished summary). Flanagan, S. (1994). Payment. Employment-Related Tax, Legal Liabilitv, and Oualitv Assurance Issues Related to In-Home Care Programs That Use Consumer-Directed Attendants (CDCAs). Cambridge, MA: SysteMetrics. Hams, M. D. (1993). Competent, supervised, unlicensed personnel will contribute to highquality, in-home health care. Home Healthcare Nurse, lJ(6), 55-56. Kane, R. A., Illston, L. H., Kane, R. L., & Nyman, J. A. (1989). Adult Foster Care in Oregon: Evaluation. Minneapolis, MN: Division of Health Services Research and Policy, School of Public Health, University of Minnesota. Kane, R. A., & Wilson, K. B. (1993). Assisted Living in the United States: A New Paradigm for Residential Care for Frail Older Persons? Washington, DC: American Association of Retired Persons, Public Policy Institute. Knollmueller, R. N. (1988). Reshaping supervisory practice in home care. Nursing Clinics of North America, 23(2), 353-362. Mattes, R. (1993). Nurse Practice Acts: A Summarv of Findings. An unpublished report of the American Bar Association, Commission on Legal Problems for the Elderly. Washington, DC: American Bar Association.
page 69
Minnesota Nurses Association (1991). The Delegation Issue: What Are Students Taught? St. Paul, MN: Author. National Council of State Boards of Nursing, Inc. (1986). Statement on the Nursing Activities of Unlicensed Persons. (Available from the National Council of State Boards of Nursing, 676 North St. Clair Street, Chicago, IL 6061 1-2921.) National Council of State Boards of Nursing, Inc. (1990). Concept PaDer on Delegation. (Available from the National Council of State Boards of Nursing, 676 North St. Clair Street, Chicago, I 606 11-2921.) L Vick, K. (1995, January 9). Death prompts MD probe of "Assisted Living" facility. The Washington Post, pp. Al, A9. Vladeck, B. (1994). From the health care financing administration:Medicare home health initiative. Journal of the American Medical Association, 271(2), 1556. U.S. General Accounting Office [GAO]. Health, Education, and Human Services Division. Medicaid Low-Term Care: Successkl State Efforts to Expand Home Services While Limiting; Costs (Publication No. GAOiHEHS-94-167). Washington, DC: U.S. Government Printing Ofice, 1994
page 70
Nurse Practice Statutes and Regulations

Arizona Nurse Practice Act, ARIZ.REV. STAT. ANN. $32-1601-1667 (1992). Board ofNursing, ARE. ADMIN. CODE R-4-19-101-504 (1987). Board of Nursing, ARIZ. ADMIN. CODE R-4- 19-402 (Draft, 1991). California Nurse Practice Act, CAL. [BUS. & PROF.] CODE $2700-2837 (West 1992). Board ofRegistered Nursing, 16 CAL. CODE. REGS. tit. 16, $1402-1485 (1992). Colorado Nurse Practice Act, COLO. REV. STAT. $12-38-101-132 (1992). Rules and Regulations Regarding the Delegation of Nursing Functions, 3 COLO. CODE REGS. $716-1-Chapter XI11 (1992). Florida Nurse Practice Act, FLA. STAT. ch. 464 (1993). Nursing, FLA. ADMIN. CODE ANN. r. 59s (1993). Iowa IOWA CODE $152.1-10 (1993). Nursing Practice for Registered NursesLicensed Practical Nurses, IOWA ADMIN. CODE r. 665-6.1-7 (1987).
Kansas Nurse Practice Act, KAN. REV. STAT. $65-1113-1129 (1992).
Performance of Selected Nursing Procedures in School Settings, KAN. ADMIN. REGS. 6015-1010104 (1992). Maine ME. REV. STAT. ANN. tit. 32, $2101-2108-A (West 1985). Regulations Relating to Training Programs and Delegation by Registered Professional Nurses of Selected Nursing Tasks to Certified Nursing Assistants, Code Me. R. $02-380-005 1993).
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Massachusetts MASS. GEN. L. ch. 112, $74-81C (1988).
MASS. REGS. CODE tit. 244, $3.01-05 (1991).

Michi nan MICH. COMP. LAWS ANN.$333.16104 (1992). MICH. COMP. LAWS ANN.$333.16109 (1992). MICH. COMP. LAWS ANN. $333.16215 (1992). Board of Nursing General Rules, MICH. ADMIN. CODE r. 338.10101- 10406 (1992). Minnesota Nurse Practice Act, MI". STAT. $148.171-285 (1992). Board of Nursing Rules, M".R. 6301.O110-2200 (1992). Missouri Nursing Practice Act, MO. REV. STAT. $335.011-259 (1993). Nebraska NEB. REV. STAT. $71- 1,132.04-53 (1992). NEB. REV. STAT. 883-1227 (1991). Regulations Pertair-ng to the Provision of Specia Care Providers, EB. ADMIN. R. & 205 (Draft, 1993). New Jersey N.J. STAT. ANN. $45:11-23-37 (West, 1992). N.J. ADh4IN. CODE tit. 13, $37-6.2 (1992). New York N.Y. VDUC.] LAW $6900-6910 (McKinney 1992). N.Y. COMP. CODES R. & REGS. tit. 8, $64.1-6 (1993). REGS.
Ohio OHIO REV. CODE ANN. $4723.02-99 (1989).

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Oklahoma Oklahoma Nursing Practice Act, OKLA. STAT. ANN. tit. 59, $567.1-16 (West 1989 & Supp.
1995)
Oregon OR. REV. STAT. $678.010-990 (1993). Standards for Registered Nurse Delegation of Nursing Care Tasks to Unlicensed Persons in Settings Where Registered Nurses Are Not Regularly Scheduled, OR. ADMIN. R.
851-47-000-030 (1993).
Texas TEX. REV. CIV. STAT. ANN.art. 4513-4528 (West 1993). Delegation Of Selected Nursing Tasks By Registered Professional Nurses to Unlicensed Personnel, TEX. ADMIN. CODE tit. 22, $218.1-11 (1992). WashinHon WASH. REV. CODE $18.88.005-900 (1992). WASH. ADMTN. CODE $246-839-010-900 (1993). Wisconsin WIS. STAT. $441.01-15 (1992).
WIS. ADMIN. CODE $ [N] 6.01-05 (May 1990).
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Appendix A: Guiding Questions for Nurse Delegation Study
Appendix A Guiding Questions
I.
Development of Nurse Delegation A. How and why did delegation come about? B. If no delegation, is anyone considering it? What modifications are needed to allow delegation? C. What agency is responsible for enforcement? D.
II.
Regulation In Practice--What Is Happening?

A.
B. C.
D. E.
F. G. H. I.
J.
K. L.
M.
What practices are delegated? Who delegates the practices? To whom are the practices delegated? In what kinds of settings does delegation occur? If no delegation, how do nursing fimctions take place in these facilities? 1. How widespread is delegation? 1. Geographical limitations 2. Services limitations 3. Patient limitations Who can arrange to have nursing fbnction delegated? Who is informed about the delegation? Have there been or do you foresee a potential for any problems with the issue of informed consent of the patient? What kind of, if any, training is provided? What kind of, if any, ongoing supervision is provided? Record keeping What type of documentation exists, if any, that a delegation has taken place? 1. Who keeps the records, if any? 2. Liability for care Who is liablehesponsible for care given? 1. What, if any, effect has the delegation of nurse functions to non-licensed 2. persons had on liability? Payment for care How is the delegation paid for? 1. What, if any public payment mechanisms exist to h n d non-nurses delegated to 2. do nursing function? When a nursing task is delegated, is the consumer charged differently 3. compared to non-delegated tasks?
Appendix A
Page I
Appendix A - continued
III.
Perception Questions A. What do you perceive as the pros and cons regarding the delegation of nurse practices to non-licensed persons? What concerns do you have regarding nurse delegation? Considering your actual experiences with delegation . . . 1. Has your experience been positive or negative? 2. What have you found to work and not work? Have there been, if any, problems, concerns, mishaps, drawbacks, or negative 3. aspects to delegation? Does this experience with nurse delegation differ from the experience with 4. certified persons? If so, how? From your perception, what are the underlying goals of nurse delegation to nonlicensed personnel? Have these goals been achieved? 1. 2. Is there documentation?
B. C.
D.
Appendix A
Page 2
Appendix B: Detailed Comparative Tables on Delegation Policies in 20 States
B-1: To Whom Tasks May Be Delegated in 20 States B-2: Special Provisions For Family And Friends B-3: Restriction On The Settings In Which A Nurse May Delegate In 20 Selected States
B-4: What Tasks May Be Delegated In 20 Selected States
B-5: Special Rules For The Delegation Of Medication

Administration B-6: Record Keeping For Nurse Delegation
Exhibit El: To Whom T s s May Be Delegated in 20 Selected States ak

ARIZONA
0
Qualified personnel. (ARIZ. ADMIN.CODE (R4-1942 (C)(l)(a) (1987)). ADMIN. CODE Licensed nurses and/or auxiliary workers based upon their educational preparation. (ARIZ. (R4-19-402(C)(l)(~) (1987)). Interpreted as licensed or unlicensed personnel.
CALIFORNIA
0
A licensed person. (16 CAL. CODE REGS. tit. 16 1443.5(4) (1992) and 1990 California Board of Nursing Legal Counsel Opinion). If a traditional task, can delegate to unlicensed people.
COLORADO
Any person who is not otherwise authorized to perform the task. (3 COLO. CODE REGS. 9716-1-Chapter XIII (1992), 3.6, definition of delegatee). For example, LPN, CNA, other health care professional, or unlicensed person.
FLORIDA
No delegation provision.
IOWA
Not identified.
KANSAS
A person. (KAN. STAT. ANN. 65-1124(n) (1992)).
MAINE
Licensed practical nurses. (ME. REV. STAT. ANN. tit. 32, 2101(2)(C) (West 1985)). Assistants to nurses who have completed or are currently enrolled in a course sponsored by a state-approved facility or a facility licensed by the Department of Human Services. (Me. REV.STAT. ANN.tit. 32, 92 102(2)@)(West 1985)).
MASSACHUSETTS
Unlicensed personnel defined as "a trained, responsible individual other than the qualified licensed nurse who functions in a complementary or assistive role to the qualified licensed nurse in providing direct patientlclient care or carrying out common nursing functions. The term includes, but is not limited to, nurses' aides, orderlies, assistants, attendants, technicians, home health aides, and other health aides. (RN or LPN). (MASS. REGS. CODE tit. 244, 93.05(1) (1991)). Other RNs and/or health care personnel. (RNs only). (MASS. REGS. CODE tit. 244,93.02 (1991)). Other administratively assigned health care personnel. (LPN only). (MASS.REGS. CODE tit. 244, 93.04 (199 l)),
MICHIGAN
A licensed or unlicensed individual who is otherwise qualified by education, training, or experience. (MICH. COMP.LAWS ANN. 9333.16215(1) (1992)). Interpreted as W s , LPNs, and unlicensed individuals.
Appendix B
Page 1
Exhibit B-1 continued

MINNESOTA
Nursing assistant defined as "an individual providing nursing or nursing-related services that do not require the specialized knowledge and skill of a nurse, at the direction of a nurse, but does not include a licensed health professional or an individual who volunteers to provide such services without monetary compensation." (MI". STAT. 148.271(4)(1992)and MINN. STAT. 148.171(7)( 9 2 ) 19). Interpreted as no restrictions.
MISSOURI
NEBMKA
Not specified. (NEB. REV. STAT. 471-1,132.05( 9 2 ) 19). Proposed regulations, "Special Care Providers." (NEB.ADMIN. R. & REGS. 205 (Draft, 1 9 ) . 93)
NEW JERSEY
Licensed practical nurses and ancillary nursing personnel. Ancillary nursing personnel includes, but is not limited to, aides, assistants, attendants, and technicians. (N.J. ADMM. CODE tit. 13, #37-6.2(a) ( 9 2 ) 19).
NEW YORK
No delegation provision. Interpreted, other professionals (registered nurses or licensed professional nurses). It is professional misconduct to permit, aid or abet an unlicensed person to perform activities requiring a license. (N.Y. [EDUC.] LAW 96509(7) (McKinney 1 9 ) . It is unprofessional conduct to delegate 92) professional responsibilities to a person when the licensee delegating such responsibilitiesknows or has reason to know that such person is not qualified, by training, by experience, or by licensure to perform them. (N.Y.COMP. CODES R. & REGS. tit. 8,429 (1993)).
OHIO
Notspecified.
OKLAHOMA
Individual qualified, competent, and legally able (485: 10-1-2),consistent with educational preparation. 95) (OKLA. STAT. ANN. tit. 59,567.3(4) (West and Supp. 1 8 ) .
OREGON
Unlicensed person defined as "an individual who is not licensed to practice nursing, medicine, or any other health occupation requiring a license in Oregon, but who provides basic or special tasks of nursing/client care. A certified nursing assistant as defined by these rules, is an unlicensed person. For the purpose of these delegation rules, unlicensed persons do not include members of the client's immediate family. " (OR. ADMIN. R. 851-47-010(23) ( 9 3 ) "Certified Nursing Assistant" means an unlicensed person who has 19). successfully completed a Board approved training program, has passed the State Competency Evaluation Program and is listed on the nursing assistant registry. (OR. ADMIN. R. 851-47-010(6) ( 9 3 ) 19).
TEXAS
Unlicensed person defined as "an individual who is not licensed as a health care provider, who functions in a complementary or assistive role to the RN in providing direct client care or carrying out common nursing functions. The t r includes, but is not limited to, nurses' aides, orderlies, assistants, attendants, em technicians, home health aides, medications aides permitted by the Texas Department of Health, and other
Appendix B
Page 2
Exhibit B-1 continued

individuals providing personal care/assistance or health related services. ("EX. ADMIN. CODE tit. 22, 8218.2 ( 9 2 ) 19).
WASHINGTON
Competent individuals. WASH.ADMIN. CODE 249-839-010(14)1 9 ) . Interpreted as unlicensed, but (93) regulated, individuals (e.g., c r i i d nurses aides). etfe
WISCONSIN LPN or a less-skilled assistant.

19). 90)
(WIS.
STAT. 8441.1 l 4 (1992)and WIS. ADMIN. CODE #[N] 6.03(3)(May ()
Appendix B
Page 3
Exhibit B-2: Special Provisions for Family and Friends

Special Provisions For Family Limitations Justification Special Provisions For Friends Yes Limitations Justification
Az
Yes
gratuitous
exempted, (ARIZ.REV. STAT. A. #32-1631(1) (1992)). exempted, (CAL. pus.& PROF.] CODE 2727(A) (West 1992)). exempted, (COLO. REV. STAT. g12-38125(l)(a) (1992)). exception, (FLA. STAT. ch. 464.022(1) (1993)). exempted, (KAN. REV. STAT. 4651124(a) (1992)). Board of Nursing considers family and patient considered one unit exempted, (MASS.GEN. L. ch. 112, g80B (1988)). definition of professional nursing, ( I. M STAT. 148.171(3) (1992)).
gratuitous
exempted, (AFUZ. REV. STAT. ANN. g32-1631(1) (1992)). exempted, (CAL. pus.& PROF.] CODE #2727(A) (West 1992)).
~~~ ~
CA
Yes
gratuitous
Yes
gratuitous
CO
Yes
gratuitous
Yes
gratuitous
Yes
without compensation
Yes
without compensation
exempted, (COLO. REV. STAT. 412-38125(l)(a) (1992)). exception, (FLA. STAT. ch. 464.022( 1) (1993)).
IA
Ks
No
Yes gratuitous
No Yes
I
gratuitous exempted, (KAN. REV. STAT. 4651124(a) (1992)).
ME
No
none
No
MA
Yes
gratuitous
Yes
gratuitous
exempted, ( M A S S . GEN. L. ch. 112, SOB (1988)). definition of professional nursing, ( I .STAT M 4148.171(3) (1992)).
MI MN
No
Yes gratuitous Yes gratuitous
Appendix B
Page 4
Exhibit B2 continued
Special Provisions For Family Limitations Justification Special Provisions For Friends Yes Limitations Justification
M0
Yes
does not hold self out as nurse does not hold self out as licensed gratuitous
(Mo.REV.
STAT. 9335.08 l(3) (1993)).
does not hold self out as nurse

does not hold self out as licensed gratuitous
(Mo.REV. STAT. 335.081(3) (1993)).

(NEB.REV.
STAT. 4711.132.06(1) (1992)).
NE
Yes
(NEB. REV.
STAT. 9711.132.06(1) (1992)). (N.J. STAT. ANN. p45:ll23@) (West, 1992)).
Yes
NJ
Yes
Yes
(N.J. STAT. ANN. 945111230) (West, 1992)). (N.Y. BDUC.] LAW 96908(a)(l) (McKinney 1992)).
NY
Yes
does not hold self out, or accept employment as a person licensed to practice nursing. If remunerated, the person does not hold self out as one who accepts employment for performing such care. none
(N.Y. [EDUC.] LAW 6908(a)(1) (McKinney 1992)).
Yes
does not hold self out, or accept employment as a person licensed to practice nursing. If remunerated, the person does not hold self out as one who accepts employment for performing such care.
OH
Yes
(OHIO REV.
CODE ANN. 44723,320 (1989)).
No
(OHIOREV.
CODE ANN. p4723.320 (1989)).
OK
Yes
gratuitous
exempted, (OIUA. STAT. ANN. tit. 59, @67.11(1) (West 1989 & Supp. 1995)). immediate family exempted from delegation rules, (OR REV. STAT. 9851-47-
Yes
gratuitous
exempted, (OIUA. STAT. ANN. tit. 59, 9567.11( 1) (West 1989 & Supp. 1995)).
OR
Yes
none
No
If special task
of nursing care, must be delegated.
Appendix B
Page 5
Exhibit B2 - continued
Justification Special Provisions For Friends Limitations Justification
020 (1993)). exclusion from delegation rules,
1
Yes
1
gratuitous
I
excluded form delegation rules, RN may supervise or instruct others in the gratuitous nursing care of the sick.
RN may supervise or instruct others in the gratuitous nursing care of

the sick.
(TEX. ADMIN.
(TEX. ADMIN.
CODE tit. 22, 4218.11 (1992)).

~
CODE tit. 22, 4218.11 (1992)).

Yes
gratuitous does not hold self out as a registered nurse
~ ~ ~ ~
(WASH.REV. CODE
418.88.030 (1992)).
~ ~
(WASH.REV. CODE
#18.88.030 (1992)).
exception,
Yes
(WIS. STAT.
4441.115 (1992)).
doesnot represent self as registered nurse
exception,
( W I S . STAT.
p441.115 (1992)).
Appendix B
Page 6
Exhibit B-3: Restriction On The Settings In Which A Nurse May Delegate In 20 Selected States
ARIZONA None. CALIFORNIA None.
COLORADO
None.
FLORIDA No delegation provision.
IOWA
None.
KANSAS
General - None. School: KAN. REV. STAT. 965-15-102 (1992): applies only to the Registered Nurse in school settings.
MAINE
ME. REV. STAT. ANN. tit. 32,9 1 2 2 ( ) & (D) (west 1 8 ) none. 20()C 95: CODE Me. R. w2-380-005 (1993): applies only to the Registered Nurse in charge of an organized nursing service, e.g., hospital, nursing home, skilled care facility, community health agency. MASSACHUSETTS None.
MICHIGAN
None.
MINNESOTA
None.
MISSOURI
NEBRASKA NEB. REV. STAT. 871-1,1 2 0 ( ) g (1992): none. 3.54() 19) NEB. REV. STAT. 483-1227(3)( 9 1 : applies only to Registered Nurses delegating to Special Care
Providers.
NEW JERSEY
None, except delegation of medication administration permitted only in assisted living facilities.
NEW YORK No delegation provision.
Appendix B
Page 7
OHIO
None.
OKLAHOMA
None.
OREGON Delegation rules apply only in settings where a registered nurse is not regularly scheduled and not available to provide direct supervision. (OR. ADMIN. R. 851-47-000(1) (1993)). The rules have no application in acute care or long term care or any other setting where the regularly scheduled presence of a registered nurse is required. (OR. ADMIN. R. 851-47-000(2) (1993)). TEXAS Some provisions apply only to specific settings:
Where the RN's regularly scheduled presence is required; settings include, but are not limited to acute care, long term care, rehabilitation centers and/or clinics providing public health services where the R " s presence is regularly scheduled. (TEX. ADMIN. CODE tit. 22, 4218.4(2)(A) (1992)). Client's residence where the RN is required to assess, plan, intervene and evaluate the client's unstable and unpredictable condition and need for skilled nursing services; settings include, but are not limited to group homes, foster homes and/or the client's residence. (TEX. ADMIN. CODE tit. 22, 4218.4(2)@) (1992)). Client's residence or independent living environments and the client has stable and predictable health care
needs; settings include, but are not limited to, hospice care, groups homes, foster homes, the client's residence, school and place of work. ( TEX. ADMIN. CODE tit. 22, $218.4(2)(C) (1992)).
Where registered nurse is regularly scheduled; long-term care setting (TEX.ADMIN. CODE tit. 22, 4218.8(1)(A) (1992)), and home health setting (TEX. ADMIN. CODE tit. 22, 4218.8(1)(B) (1992)). Independent living environments where the client's clinical and behavioral status is stable and predictable, does not require the regular presence and assessment, intervention and evaluation by an RN and the client has expressed hisher ability and willingness to participate in the management of hisher care, including hospice settings where the client's deteriorating condition is predictable. (TEX. ADMIN. CODE tit. 22, 4218.8(2) (1992)). Independent living environments, where the client has stable and predictable health care needs. (TEX. ADMIN. CODE tit. 22, $218.9@) (1992)). "Independent living environment" is defined as "a client's individual residence which may include group home or foster home as well as other settings including, but not limited to school, work or church where the client participates in activities. (TEX. ADMIN. CODE tit. 22, $218.2 (1992)).
WASHINGTON None. WISCONSIN None.
Appendix B
Page 8
Exhibit B-4: What Tasks May Be Delegated In 20 Selected States
ARIZONA
0
No specific task requirements.
CALIFORNIA
The following tasks are the only nursing tasks technically delegated and may only be delegated to other licensed persons: 3 medication administration (including insulin); 3 sterile technique; 3 gastrostomy tube feedings. 1987 Attorney General Opinion and 1990 California Board of Nursing Legal Counsel Opinion. ADLs/personal care can be performed without RN assessment but may be delegated.
COLORADO
Any task delegated: 3 must be of a routine, repetitive nature; 3 may not require the delegatee to exercise nursing judgment and intervention. (3 COLO. CODE REGS. 8716-1-Chapter Xm (1992)).
FLORIDA
0
IOWA
0
Notspecified.
KANSAS
In general-Cannot delegate task that requires nursing judgment (per Kansas Board of Nursing Delegation Tree, (1992)). In School setting: Basic caretaking (bathing, dressing, grooming, routine dental, hair and skin care, preparation of food for oral feeding, exercise including occupational therapy and physical therapy procedures, toileting including diapering and toilet training, handwashing, and transfer and ambulation) may be performed without delegation. Specialized caretaking (catheterization, ostomy care, preparation of food and tube feedings, care of skin with damaged integrity, administering medications and performing other procedures requiring nursing judgment) shall be assessed and delegated as appropriate. The selected nursing task shall not require the exercise of nursing judgment or intervention. (KAN. ADMIN. REGS. 60-15-102 (1992)).
MAINE No task shall be delegated that is not listed on the Skills Checklist of the PRESCRIBED CURRICULUM
FOR NURSING ASSISTANT TRAZNING PROGRAMS. (CODE Me. R. 02-380-005 (1993)).
MASSACHUSETTS
By way of example, and not in limitation, the following nursing activities are usually considered within the scope of nursing practice to be delegate, and may be delegated provided the delegation is in compliance with MASS. REGS. CODE tit. 244 3.05(2) (1991):
Appendix B
Page 9
Nursing activities which do not require nursing assessment and judgment during implementation. The collection, reporting, and documentation of simple data. Activities which meet or assist the patientklient in meeting basic human needs, including, but not limited to: nutrition, hydration, mobility, comfort, elimination, socialization, rest and hygiene. (MASS. REGS. CODE tit. 244, 43.05(4) (1991)). By way of example, and not in limitation, the following are nursing activities that are not within the scope of sound nursing judgment to delegate: Nursing activities which require nursing assessment and judgment during implementation. Physical, psychological, and social assessment which requires nursing judgment, intervention, referral or follow-up. Formulation of the plan of nursing care and evaluation of the patient's/client's response to the care provided. Administration of medications except as permitted by MASS. REGS. CODE tit. 244, 43.05(5) (1991).
= =
MICHIGAN
A licensee may not delegate: 3 Herhis entire scope of practice, but may select certain acts, tasks, or functions to delegate. An act, task, or function which, under standards of acceptable and prevailing practice, requires the level of education, skill, and judgment required of a licensee under this article. (MICH. COMP. LAWS ANN. 4333.16215(1) (1992)).
MINNESOTA
MISSOURI
NEBRASKA
NEB. REV. STAT. 471-1, 132.05(g) (1992): NO
NEB. REV. STAT. 483-1227 (1991): Yes

Gastrostomy tube-feeding Urine and blood glucose testing Clean intermittent catheterization Continuous nondiscretionary oxygen administration Routine colostomy and ileostomy care excluding imgation Care of tracheostomy stoma excluding ties, and oral pharyngeal suctioning.
In addition, the proposed rules, NEB. ADMIN. R. & REGS. 205 (Draft, 1993), include:
3
3
Enema/suppository bowel evacuants Administration of medication via a gastrostomy tube Administration of p.r.n. oral and topical medications
NEWJERSEY No task may be delegated which is within the scope of nursing practice and requires:
*
3
The substantial knowledge and skill derived from completion of a nursing education program and the specialized skill, judgment and knowledge of a registered nurse; An understanding of nursing principles necessary to recognize and manage complications which may result in harm to the health and safety of the patient. (N.J. ADMIN. CODE tit. 13, 437-6.2 (1992)).
Appendix B
Page 10
The following are guidelines delineating the contributions ancillary persome1 may make in the delivery of care: Taking vital signs, temperature, pulse, respiration and blood pressure. Measuring height, weight, and intake and output. Monitoring blood glucose. Collecting specimens; urine, stool, and sputum. Recording information. Reporting to the registered professional nurse changes in the condition of the patient. Providing personal hygiene and activities of daily living. Assisting with ambulation, positioning and turning. Assisting with psychosocial activities. Providing for a safe environment. Assisting with feeding. Transporting patients. Performing elimination activities; enemas- cleansing and treatment, established ostomy care. Setting up traction equipment. Performing vaginal irrigations. Maintaining oxygen administration. ak Providing post mortem care. (Board of Nursing Guidelines for the Delegation of Selected Nursing T s s to Ancillary Nursing Personnel in all Health Care Settings (Sept. 18, 1990)). (In practice, delegation to ancillary personael not limited to list)
NEW YORK No delegation provision.

There is an exclusion for services given by attendants in institutions under the jurisdiction of or subject to the visitation of the state department of mental hygiene if adequate medical and nursing supervision is provided. (N.Y. WDUC.] LAW 86908(b) (McKinney 1992)).
OHIO
0
OKLAHOMA
By way of example, and not in limitation, the following nursing tasks may be considered within the scope of nursing practice to be delegated and may be delegated provided the delegation is in compliance with OKLA. STAT. ANN. tit. 59, p567.1-16 (West 1989 & Supp. 1995). 3 Nursing tasks that may be delegated are those which do not require nursing assessment, judgment, evaluation and teaching during implementation, such as: + The collecting, reporting, and documentation of simple data; + Tasks which meet or assist the client in meeting basic human needs, including, comfort, elimination, socialization, rest and hygiene. (Oklahoma Board of Nursing Guidelines, "Delegation of Nursing Functions to Unlicensed Persons" (4), (March, 1993)). By way of example, and not in limitation, the following nursing tasks that are not within the scope of sound nursing judgment to delegate: =$ Nursing tasks which require nursing assessment, judgment, evaluation and teaching during implementation; such as: + Physical, psychological, and social assessment which requires nursing judgment, intervention, referral or follow-up. + Formulation of the plan of nursing care and evaluation or the client's response to the care provided.
Appendix B
Page 11
Administration of medications except as authorized by state and/or federal regulations. (Oklahoma Board of Nursing Guidelines, "Delegation of Nursing Functions to Unlicensed Persons" 4(5), (March, 1993)).
OREGON
Basic activities of daily living can be provided in some settings without the assignment, delegation, or supervision of a licensed nurse. OR. ADMIN. R. 851-47-000(7) (1993). "Basic T s s of CliedNursing Care" need not be delegated and may be assigned by a registered nurse or a ak licensed practical nurse. OR. ADMIN. R. 851-47-010(2) (1993). "Basic T s s of ClientMursing Care" ak means procedures that do not require the education or training of a registered nurse or licensed practical nurse, but that cannot be performed by the client independently. Basic tasks of clientlnursing care also means procedures that may be directed by the client. These basic tasks include, but are not limited t , activities of o daily living. Basic tasks will vary from setting to setting depending on the client population served in that setting and the acuity/complexity of the client's care needs. OR. ADMIN. R. 851-47-010(5) (1993). "Special Tasks of CliedNursing Care" must be delegated by the registered nurse. "Special tasks of cliednursing care" means procedures that require the education and training of a registered nurse or licensed practical nurse to perform. Special tasks will vary from setting to setting depending on the client population served in that setting and the acuity/complexity of the client's care needs. Examples of special tasks include, but are not limited to: a Administration of injectable medications; suctioning; a Complex wound care. OR. ADMIN. R. 851-47-010(18) (1993).
The registered nurse may delegate tasks of nursing care, including the administration of subcutaneous injectable medications and the administration of non-injectable medication to one unlicensed person, specific to one client. OR. ADMIN. R. 851-47-030(1) (1993). Under no circumstance may the registered nurse delegate the nursing process in its entirety to an unlicensed person. Selected interventions of nursing care may be delegated. OR. ADMIN. R. 851-47-030(2) (1993).
TEXAS
The nursing task must not require the unlicensed person to exercise nursing judgment or intervention except in emergency situations. E X . ADMIN. CODE tit. 22, p218.3(4) (1992). SDecific Nursing Tasks Which Mav Be Delegated: By way of example, and not in limitation, the following nursing tasks are ones that are within the scope of sound professional nursing practice to be delegated, regardless of the setting: 3 non-invasive and non-sterile treatments unless otherwise prohibited by 218.10 of this title. 3 the collecting, reporting and documentation of data including, but not limited to: + vital signs, height, weight, intake and output, clinitest, and hematest results; + changes from baseline data established by the RN; + environmental situations; + client or family comments relating to the client's care; and + behaviors related to the plan of care; 3 ambulation, positioning, and turning; transportation of the client within a facility; 5 personal hygiene and elimination, including vaginal irrigations and cleansing enemas; 3 feeding, cutting up of food, or placing of meal trays;
Appendix B
Page 12
socialization activities; activities of daily living; reinforcement of health teaching planned andlor provided by the registered nurse. (TEX. ADMIN. CODE tit. 22, 218.9(a)(1992)). way of example, and not in limitation, in an independent living environment, where the client has stable and predictable health care needs, the RN may delegate activities of daily living and nursing tasks required for maintenance of the client's status. Delegatable tasks, in addition to those identified in subsection (a) of this section, include: 3 medication administration in compliance with #218.8(2); assistance with feeding, including tube feeding through permanently placed tubes; 3 assistance with elimination, including intermittent catheterization; a assistance with other activities necessary to maintain the independence of the client such as maintenance ADMIN. CODE tit. 22, 218.9@)(1992)). of skin integrity. (TEX.
Nursing Tasks That Mav Not Be Routinelv Delegated: By way of example, and not in limitation, the following are nursing tasks that are not usually within the scope of sound professional nursing judgment to delegate and may be delegated only in accordance with subsection (b) of this section: sterile procedures - those procedures involving a wound or an anatomical site which could potentially become infected; non-sterile procedures, such as dressing or cleansing penetrating wound and deep bums; invasive procedures, inserting tubes in a body cavity or instilling or inserting substances into an indwelling tube, unless allowed in #218.8(2), #218.9(a)(5) or 4218.9(b); care of broken skin other than minor abrasions or cuts generally classified as requiring only first aid treatment; (TEX. ADMIN. CODE tit. 22, 8218.10 (1992)). Nursing Tasks That Mav Not Be Delerrated: By way of example, and not in limitation, the following are nursing tasks that are not within the scope of sound professional nursing judgment to delegate: physical, psychological, and social assessment which requires professional nursing judgment, intervention, referral, or follow-up; formulation of the plan of nursing care and evaluation of the client's response to the care rendered; specific tasks involved in the implementation of the plan of care which require professional nursing judgment or intervention; the responsibility and accountability for client health teaching and health counseling which promotes client education and involves the client's significant others in accomplishing health goals; and administration of medications, including intravenous fluids, except as permitted by 5218.8 of this title. (TEX. ADMIN. CODE tit. 22, 4218.7 (1992)). Nursing Tasks That Need Not Be Delegated: According to the Personal Assistance Services Guidelines of the Texas Department of Human Services (June 1994), personal care (feeding, preparing meals, transferring, toileting, ambulation and exercise, grooming, bathing, dressing, routine care of hair and skin and assistance with medications that are normally self administered) may be provided for clients who have stable and predictable conditions by qualified unlicensed persons in independent living environments. An "independent living environment" is a client's individual residence which may include a group home or foster home as well as other settings including, but not limited to, school, work or church were the client participates in activities. (TEX.ADMIN. CODE tit. 22, 8218.2 (1992)).
Appendix B
Page 13
Short term respite services of no more than thirty (30) consecutive days in which the primary care giver acts as the client's advocate and is being relieved of the care giver role by a qualified unlicensed person. In this setting the following nursing services may be provided by the qualified unlicensed person when: 3 the task provided to the client is limited to the provision of personal care (feeding, preparing meals, transferring, toileting, ambulation and exercise, grooming, bathing, dressing, routine care of hair and skin, and assistance with medications that are normally self administered). (See Personal Assistance Services Guidelines, Texas Department of Human Services, June 1994). a for those clients receiving regularly scheduled oral or topical medication normally administered by the primary care giver the qualified unlicensed person may administer these agents based on specific instructions from the primary care giver. + These tasks do not include: 9 calculation of any medication doses except for measuring a prescribed amount of liquid medication and breaking a tablet for administration as instructed by the primary care giver; 9 administration of medications by any injectable route; 9 administration of medications used for intermittent positive pressure breathing or other methods involving medication inhalation treatments; 9 administration of medications by way of a tube inserted in a cavity in the body. ("EX. ADMIN. CODE tit. 22, 218.8(3) (1992)). The provision of (a) and (b) above is limited to a thirty (30) day period for the purpose of respite. If the need for these respite services is greater than fourteen (14) days, then a registered nurse must make an assessment to determine that the client's condition continues to be stable and no changes in the delivery of services are required. No other nursing functions may be provided by the unlicensed person without the delegation and supervision of an RN.
WASHINGTON Nursing acts delegated by the licensed registered nurse shall not require the unlicensed person to exercise nursing judgment nor perform acts which must only be performed by a licensed nurse, except in an emergency situation (WASH. REV. CODE 18.88.280(2) (1992), WASH. ADMIN. CODE P246-839010(14)(a)(iii) (1993)).
The following are tasks that require a license, whether or not severing or penetrating of tissues is involved and whether or not a degree of independentjudgment and skill is required: 3 Administration of medications Administration of treatments a Administration of tests and inoculations (WASH. REV. CODE 18.88.285(1) (1992) and 1993 Attorney General interpretation). It is the opinion of the Board of Nursing that sterile techniques should not be delegated.
WISCONSIN While nursing acts may be delegated, the functions of assessment and evaluation may not. The LPN and lessskilled assistant may assist the RN in these functions, but may not perform them in their entirety. (Board of Nursing, "Delegation of Nursing Acts" (October 1990)).
Appendix B
Page 1 4
Exhibit B-5: Special Rules For The Delegation Of Medication Administration

Medication Administration Justification Restrictions Excations Medication Administration Justification Restrictions
COLORADO Medication
Prohibited
ARE
ADMJN.CODE R419402(CXlXb) (1987): the registered nurse may assign the administration of medication to other licensed nurses only.
FYoDosed rules would allow delegation of non-iniectable medications to unlicensed mode. Prohibited A 1987Attorney General Opinion: medication administrationis a function requiring a license and therefore cannot be delegated to unlicensed persons, only other licensed nurses.
Not specified
Exceptions
Exclusion in the Nurse Practice Act: the administration of medications in personal care boarding homes falls under the jurisdiction of the Department of Health. (COLO. REV.STAT. $12-381 2 5 0 (1992)). Personal care boarding homes: trained medication aides may administer oral, not injectable, medications. The aides may not fill medications minders. They may be filled only by RN, LF, family member or fiend. No delegation provision.
Medication Administration Justification Restrictions Exceptions
Mdcl eia
Administration Justification Restrictions Exceptions
Not justified
Long-term care facilities: oral medication may be administered by a medication manager or a CertifiedMedication Aide. Board of Nursing may issue a declaratory ruling permitting the delegation of medication administration to an unlicensed person. Not specified
nt, Adult care homes and hospital-based long term care u i s including state operated institutions for the
Appendix B
Page 15
KANSAS
Exceptions, (cont'd) mentally retarded: medication administration permitted by unlicensed person who has completed medication administration programs or is engaged in such program. (KAN. REV. STAT. 865-1 124(n) (1992)). School settings: (a) A registered nurse may delegate the administration of medications to unlicensed persons if: (1) The administration of the initial dose of a mediation has been previously administered to the student. No subsequent administration shall require medication dosage calculation. Measuring a prescribed amount of liquid medication or breaking a table for administration is not calculation of medication dosage; (2) the nursing care plan requires administration by subcutaneousroute; or (3) an anticipated health crisis requires administration by intramuscular route. (b) The following acts shall not be delegated to unlicensed persons: (1) The administration of intravenous medications; (2) the administration of medications through intermittent positive pressure breathing machines; or (3) the administration of drugs, as defined by K.S.A. 1990 Supp. 65-1626, through any tube inserted into the body except through an established feeding tube directly inserted into the abdomen (KAN. ADMIN. REGS. 60-15-104 (1992)).
MAINE Medication Administration Justification Restrictions Exceptions
Permitted
Long-term care facilities and state mental health institutions: CNAs who have completed a medication course may administer non-injectable medications to patients who are 14 years of age and older only under the direct on-site supervision of a licensed nurse. Code Me. R. 802-380005(4) (1993). Home health setting: CNA may administer medications in the home health setting. Code Me. R. 02-380-005(1)(A)(l) (1993). Boarding home or adult foster home: an unlicensed person can administer medications ifhdshe takes a 24 hour trainingprogram and clinical. Can put pill in client's mouth, take a written order and administeraccording to the order. Can give insulin injections if specificallytrained by the RN for a specific client.
I Medication
MASSACHUSETTS
Prohibited Administration of medications except as permitted by MASS. GEN. L. ch. 94C (1991) is a nursing activity that is not within the scope of sound nursing judgment to delegate. (MASS. REGS. CODE tit. 244, #3.05(5)(1991)).
Restrictions Level IV nursing homes, residential care settings: unlicensed persons may administer medications.
MICHIGAN
I Medication
Not specified
Appendix B
Page 16
Medication Administration Justification Restrictions Exceptions Not specified
Medication Administration Justification Restrictions Exceptions Medication Administration Justification Restrictions Exceptions
No delegation provision
Not specified
Residential care facility: medication assistant can assist with medications. Nursing homes: CertifiedMedication Aides can administer medications. Home care: CertifiedMedication Aides are not allowed. Not specified
Assisted living facilities: "Personal care assistants"(PCA) can administer medications under the delegation of an RN if they have a 25 hour course and pass computerized exam. PCA can give orals and predrawn insulin. No other injectables allowed. Can give any p.r.n., but
No delegation provision
I
elh fie Exemption for medication technicians in facilities licensed by the Ofice of Mental Hat and Ofc of Mna Retardation. Medication technicians can pass medications under the supervision of a nurse. etl This is not delegation. (N.Y. [EDUC.] LAW 46908(b) (McKinney 1992)).
Not specified
Appendix B
Page 17
Prohibited OklahomaBoard of Nursing Guidelines Delegation of N r i g Functions to Unlicensed Persons usn (March 1993). Except as authorized by state andor federal regulations. (Guidelines 45(c)). Residential care homes: Medication Assistant Technicians can administer medications. N r i g homes: Certified Medication Aides can administermedications. usn Home health: Home Health Aides cannot administer medications.
v,
Appendix B
Page 18
OREGON Medication Administration Justification Restrictions
Permitted OR. ADMIN. R. 85147-010(18) (1993). A registered nurse may delegate the administration of injectablemedications. (OR. ADMIN. R. 85147OlO(18) (1993)). P.r.n. medications and treatmentsmay not be delegated except under special circumstances. (OR. ADMIN.R. 85147-01O( 15) (1993)).
A registered nurse may assign the various tasks of administration of non-injectable medications to u l c n e persons in the following specific facilities. This does not include su~utaneous niesd injectable medications which must be specificallydelegated by the registered nurse.
(a) Local correctional facilities, lock-ups, and juvenile detention facilities. (b) Juvenile training schools. (c) Facilitiesoperated by a public agency for the purpose of detoxification of persons who use alcohol excessively. (d) Homes or facilities licensed for adult foster care. (e) Residential care, training or treatment facilities. (OR. ADMIN. R. 851-47-O20( (1993)). 1) "Assignment" means that the registered nurse, or licensed DraCtical nurse, directs an unlicensed person to perform a basic task of client care with knowledge that the unlicensed person has previously been taught the task and remains competent in performing the task. Assignment may require that a licensed nurse supervisethe unlicensed person performing the basic task of client care. The need for supervision is at the discretion of the registered nurse. (OR. ADMIN. R. 85147-010(2) (1993)).
rm n V a r i ~Tasks of the Administration of Medications" means removal of an individualdose f o a u~ previously dispensed, properly labeled container (including a unit dose container), v g it with the physician's order, giving the individual doses to the proper client at the proper time by the proper route and promptly recording the time and dose given. Teaching the correct administrationof non-injectable medications does not fall under one to one delegation and can be accomplished through initial direction, procedural guidance and periodic inspection by a registered nurse (or physician). (OR. ADMIN. R. 85147-010(25) (1993)).
"Non-injectableMedication" means any medication, including controlled substances, which is not

administered by the intradermal, subcutaneous, intramuscular, or intravenous route. (OR. ADMIN. R.
85147-010(11) (1993)). "P.r.n. (pro re nata) medications a d treatments" means those medications and treatmentswhich have been ordered to be given as needed. The usual meaning of any p.r.n. order is that an assessment of the client is required prior to carrying out the order. Therefore, the decision to administerp.r.n. medications and treatments cannot be delegated because the client assessment requires the skill of a licensed nurse. There are situations, however, in which administering p.r.n. medications and treatmentscan be accomplished without directly involving the registered nurse prior to each administration. The decision to administer p.r.n. medications and treatments cannot be delegated in situationswhere an on-site assessment of the client is required prior to administration. The decision regarding whether an on-site assessment is specific to an individual client's care may be written by the registered nurse for use by the unlicensed person when an on-site assessment is not required prior to administrationof a medication or treatment. These Written parameters supplement the physician's p.r.n. order by providing the unlicensed person with guidelines which are so specific regarding the p.r.n. medication or treatment that the unlicensed person uses no discretion in administering the medication or treatment. The steps in the decision-making to administer the p.r.n. medication or treatmentare contained within the instructions left by the registerednurse. (OR. ADMIN. R. 85147-010(15) (1993)). Exceptions
Appendix B
Page 19
TEXAS
Medication Administration Justification Restrictions Exceptions Prohibited Administration of medications, including intravenous fluids, except as permitted by TEX.ADMIN. CODE tit. 22,4218.8 (1992) maynot be delegated. TEX. ADMIN. CODE tit. 22, 218.7(5) (1992).
TEX.ADI". CODE tit. 22,4218.8 (1992): The administration of medications may be delegated only
in accofdance with this section: (1) In settings where the registered professional nurses' regularly scheduled presence is required to perform ongoing assessment, intervention and evaluation of the client's health statudstabfiity,the RN may only delegate in compliancewith subparagraphs (A) and (B) of this section.
(A) A RN may delegate the administration of medications to unlicensed persons working i a longn term care setting and holding valid medication aide permits issued by the Texas Department of Health under the Health and Safety Code, Chapter 242, SubchapterF. The RN shall be knowledgeable regarding the rules of the Texas Department of Health governing medication aides and shall assure that the medication aide is in compliancewith the statute.
(B) A RN may delegate the administration of medications to unlicensed persons working in a home health setting and holding valid home health medication aide permits issued by the Texas Department of Health under the Health and Safety Code,Chapter 142, Subchapter B. The RN shall be knowledgeable regarding the rules of the Texas Department of Health governing home health medication aides and shall assure that the home health medication aide is in compliance with the statute. The RN shall make a supervisory visit while the medication aide is in the client's residence at least weekly or when any change in medication regimen is ordered.
(2) In independent living environmentswhere the client's clinical and behavioral status is stable and predictable, does not require the regular presence and assessment, intervention and evaluation by a RN and the client has expressed hislher ability and willingness to participatein the management of hidher care, including hospice settings where the client's deteriorating condition is predictable, the RN may delegate the administration of medications. The delegation may only occur after the RN has trained or verified the training of the unlicensed person to administer the medication. The RN may only delegate medications which are administered orally or via permanently placed feeding tubes, sublingual, or topically, including eye, e r and nose drops and vaginal or rectal suppositories. a
(3) A RN shall not delegate the following tasks to any medication provider: (A) calculation of any medication doses except for measuring a prescribed amount of liquid medication and breaking a tablet for administration, provided the RN has calculated the dose; (B) administration of the initial dose of a medication that has not been previously administered to the
client; (C) administration of medications by any injectable route; (D) administration of medications used for intermittent positivepressure breathing or other methods involving medication inhalation treatments; administration of medications by way of a tube inserted in a cavity of the body except as stated in paragraph (2) of this section; (F)responsibility for receiving verbal or telephone orders from a physician, dentist, or podiatrist; and (G) responsibility for ordering a client's medication from the pharmacy.
e)
I Medication
WASHINGTON
I Prohibited
WASH. REV.CODE. 18.88.285 (1992) and 1993 Attorney General Interpretation
Appendix B
Page 20
I Medication
WISCONSIN
Permitted
WIS. STAT. p44 1.1l(4) (1992) and Board of N r i g "Position On Medication Administration By usn Unlicensed Personnel", (September, 1989).
Administration Justification
Appendix B
Page 21
Exhibit B-6: Record Keeping For Nurse Delegation

ARIZONA None.
CALIFORNIA
0
None.
COLORADO
None.
FLORIDA 0 No delegation provision. IOWA None. KANSAS General - None. In school setting: unlicensed person must be adequately identified by name in writing for each delegated task. (KAN. ADMIN. REGS. 60-15-102(f) (1992)). 3 unlicensed person's competency must be documented in writing. The unlicensed person shall Co-sign the documentation indicating the person's concurrencewith this competency evaluation. (KAN. ADMIN.
REGS. 60-15-102(g) (1992)).

MAINE
None.
MASSACWSETTS None.
MICHIGAN
0
None.
MINNESOTA 0 None.
MISSOURI
0
NEBRASKA
None. Proposed le^: The RN must submit documentation to the Department of Health, Board of Nursing, every six months, which identifies: number of individuals receiving special care services. 3 number of individuals providing special care services. 3 specific procedures being provided. a setting(s) in which the services are being provided. (NEB.ADMIN. R. & REGS. 205 @=fit 1993)).
Appendix B
Page 22
NEWJERSEY
There must be verifiable training and education of delegatee. (N.J. ADMIN.CODE tit. 13, 376.2(b) (1992)).
NEW YORK
OHIO
None
OKLAHOMA Oklahoma Board of Nursing Guidelines "Delegation of Nursing Functions to Unlicensed Persons" 92(d),
(March 1993): The unlicensed person shall have documented competencies necessary for the proper performance of the task on file with the employer. Written procedures shall be made available for the proper performance of each task.
OREGON Prior to delegating the task, the registered nurse must document the following: The rationale used to determine that the skill of the unlicensed person will permit safe teaching and delegation of the specific task of nursing care based on the client's condition. How the task was taught. The teaching outcome. The content and type of instructions left for the unlicensed person. Evidence that the unlicensed person understands the risks involved in performing the task and has a plan to effectively deal with any consequences of performing the task. Evidence that the unlicensed person was instructed that the task is client specific and not transferable to other clients or providers. How frequently the client should be reassessed by the registered nurse regarding continued delegation of the task to the unlicensed person. How frequently the unlicensed person would be supervised. (OR. ADMIN. R. 851-47-000-030(1)(i)(E) (1993)).
0
Following teaching and delegating the task, the registered nurse must document, in writing, that he/she takes responsibility for delegating the task to an unlicensed person, and ensures that supervision will occur for as long as the registered nurse is supervising the performance of the delegated task. (OR. ADMIN. R. 851-47OOO-O30( l)(i)Q (1993)).
TEXAS
None
WASHINGTON None WISCONSIN None
Appendix B
Page 23
Appendix C:
Brief Questionnaire to Boards of Nursing
Appendix C Nurse Delegation Letter and Questionnaire

November 8, 1994 Addressee
Dear
Thank you for agreeing to ver@ the information that we have collected about nurse delegation in your state. Your answers to the following questions will be checked against our research. Please complete and return the following questionnaire to us by Friday, November 11, 1994 via f w (612) 624-5434. Again, thank you for your cooperation and assistance with this research project. Cordially, Colleen OConnor and Rosaiie Kane
1.
There is a spec& provision in my state's Nurse Practice Act or regulations that permits nurse delegation. - N o Yes Provided the nurse feels delegation is appropriate, hdshe may delegate to: Registered Nurses (RNs) - N o Yes Provided the nurse feels delegation is appropriate, hdshe may delegate: Activities of daily living; (ADLs: grooming, bathing, etc) Yes N Yes Intermittent Catheterization - N Foley Catheterization - N Yes Non-sterile dressing changes - N Yes Suctioning Yes N Non-injectable medications - N Yes Injectable medications Yes N
2.
3.
o o o o o o o
4. Activities of daily living (ADLs) (bathing, grooming, etc. may be performed by non-nurses without delegation. - N o Yes
Appendix C
Page 1
Appendix D:
Addresses of State Boards of Nursing in the 20 States
Appendix D: Addresses of State Boards in 20 States Used for the Study

Arizona State Board of Nursing 2001 W. CamelbackRd., Ste. 350 Phoenix, AZ 85015
(602) 255-5092
Massachusetts Board of Registration in Nursing Leverett Saltonstall Bldg. 100 Cambridge St., Rm.1519 Boston, MA 02202
(617) 727-9960
California Board of Registered Nursing 400 R St., Ste. 4030 Sacramento, CA 94244-2 100
(916) 322-3350
Colorado Board of Nursing 1560 Broadway, Ste. 670 Denver, CO 80202

(303) 894-2430
Michigan Board of Nursing Ottawa Towers N. 611 W. Ottawa Lansing, MI 48933

(517) 373-1600
Florida Board of Nursing 111 E. Coastline Dr., Ste. 5 16 Jacksonville, FL 33202

(904) 359-633 1
Minnesota Board of Nursing 2700 University Ave. W., Ste. 108 St. Paul, MN 55 114
(6 12) 642-0567
Iowa Board of Nursing State Capitol Complex 1223 E. Court Ave. Des Moines, IA 503 19
(515) 281-3255
Missouri State Board of Nursing 3605 Missouri Blvd. P.O. Box 656 Jefferson City, M 0 65 102
(3 14) 75 1-0073
Kansas Board of Nursing Landon State Office Bldg. 900 SW Jackson, Ste. 430 Topeka, KS 66612-1256
(9 13) 296-4929
Nebraska Board of Nursing 301 Centennial Mall S. P.O. Box 95007 Lincoln, NE 68509
(402) 47 1-2115
Maine State Board of Nursing State House Sta. 158 Augusta, ME 04330-0158
(207) 624-5275
New Jersey Board of Nursing 124 Halsey St., 6th F1. P.O. Box 45010 Newark, NJ 07101
(201) 504-6430
Appendix D
page 1
Appendix D continued New York State Board for Nursing Cultural Education Center, Rm. 9B30 Albany, NY 12230 (5 18) 474-3843
Ohio Board of Nursing Education and Nurse Registration 77 S. High St., Ste. 504 Bismarck, ND 58504-5881 (614) 466-3947
Oklahoma Board of Nurse Registration and Nursing Education 2915 N. Classen Blvd., Ste. 524 Oklahoma City, OK 73 106 (405) 525-2076 Oregon State Board of Nursing 800 N.E. Oregon Street, #25 Portland, OR 97232 (503) 73 1-4745 Texas Board of Nurse Examiners 9101 Burnet Rd. P.O. Box 140466 Austin, TX 78714 (512) 835-4880 Washington State Board of Nursing 1300 SE Quince St., EY-28 Olympia, WA 98504 (206) 753-2686 Wisconsin Board of Nursing 1400 E. Washington Ave. P.O. Box 8935 Madison, WI 53708-8935 (608) 266-0257
Appendix D
Page 2
Appendix E: The National Council on State Boards of Nursing and the American Nurses Association Guidelines for Delegation
Appendix E. The National Council on State Boards of Nursing and The American Nurses Association Guidelines for Delegation
The National Council on State Boards of Nursing (1990) states that the decision to delegate should be based on the following: Determination of the task, procedure or function that is to be delegated.
Staff available.
Assessment of the client needs. Assessment of the potential delegate's competency. Consideration of the level of supervision and determination of the level and method of supervision required to assure safe performance.
The American Nurses' Association (American Nurses' Association, 1992) has similar guidelines and states that nurses should not delegate nursing activities that include the core of the nursing process (assessment, diagnosis, planning, and evaluation) and require specialized knowledge, judgment, and/or skill. Examples of these activities are:
The iiil nursing assessment and any subsequent assessment that requires professional nursing nta knowledge, judgment, and skill; The determination of the nursing diagnoses, establishment of the nursing plan of care, and evaluation of the client's progress in relation to the plan of care; and
Any nursing intervention which requires professional nursing knowledge, judgment, and skill.
Nursing judgment is the intellectual process that a RN exercises in forming an opinion and reaching a conclusion by analyzing the data.
In addition, the American Nurses' Association (American Nurses' Association, 1994) suggests that nurses use the following grid to evaluate activities being considered for delegation:
Appendix E
Page 1
Figure 1. Decision Grid for Registered Professional Nurse to Delegate Five Factors Affecting Decision to Delegate
Reprinted with permission of the American Association of Critical Care Nurses from Nursing and Non-Nursing Activities
in Critical Care: A Frameworkfor Deckwn Making. Copyright 1990 by the American Association of Critical Care
Nurses. (American Association of Critical Care Nurses, 1990).
Appendix E
P W2
A publication of the
Public Policy Institute
American Association of Retired Persons

601 E Street, N.W. Washington, DC 20049

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#9515 November 1995

Delegation of Nursing Activities: Implications for Patterns of Long-Term Care

by Rosalie A. Kane Colleen M. OConnor Mary Olsen Baker

Elizabeth Clemmer, Project Manager

Delegation o Nursing Activities f

EXECUTIVE SUMMARY ~TRODUCTION

METHOD RESEARCHQUESTIONS ......................................................................................

.......................................................................................... 66 REFERENCEs ............................................................................................ 69

Delegation of Nursing Activities

Delegation of Nursing Activities

Delegation o Nursing Activities f

Delegation o Nursing Activities f

Delegation o Nursing Activities f

Delegation o Nursing Activities f

conducting delegation fimctions;

Delegation o Nursing Activities f

DELEGATION OF NURSING ACTIVITIES: IMPLICATIONS FOR PATTERNS OF LONG-TERM CARE

Delegation o Nursing Activities f

Delegation o Nursing Activities f

Delegation of Nursing Activities

Delegation of Nursing Activities

To what extent and under what conditions is nurse delegation permitted?

Delegation o Nursing Activities f

Table 1. Selection of States for Nurse Delegation Study

Table 2. Type of Key Informants Interviewed in 20 Selected States

Delegation o Nursing Activities f

Who may delegate nursing tasks?

Delegation o Nursing Activities f

Table 3. Who May Delegate Nursing Functions in 20 Selected States

Yes No delegation provision Yes

No No delegation provision YeS2

No YeS No No No delegation provision No No No delegation provision No YS No No No No

Delegation of Nursing Activities

Delegation o Nursing Activities f

Delegation of Nursing Activities

Table 5. To Whom T s s May Be Delegated i 20 Selected States ak n

Delegation of Nursing Activities

Table 6. Special Provisions/Exemptions in 20 Selected States

self out as nurse

Delegation o Nursing Activities f

Delegation o Nursing Activities f

Delegation o Nursing Activities f

Delegation of Nursing Activities

Specific tasks permitted

Task could not require nursing judgment assessment or evaluation

Task could not require the knowledge or skill of an RN

Delegation o Nursing Activities f

Delegation o Nursing Activities f

Delegation o Nursing Activities f

Table 10. Delegation of Medication Administration in 20 Selected States

KS- M ME MI MN MOSNE NJ NY7 OH OK OR TX WA WI School A -

Delegation o Nursing Activities f

Delegation o Nursing Activities f

Delegation o Nursing Activities f

How Tasks Are Delegated

Delegation o Nursing Activities f

Table 12. How to Determine Appropriate Level of Supervision i 20 Selected States n

Delegation o Nursing Activities f

Delegation of Nursing Activities

Delegation o Nursing Activities f

Table 14. Nurse Delegation Act Accountability/Liability in 20 Selected States

Accountable for decision to delegate