research paper

14 ViewPoint JANUARY/FEBRUARY 2018

Appropriate Delegation in Ambulatory Care Nursing

Practice Health care has experienced significant changes dur-

ing the past decade. In responding to these demands, healthcare delivery systems are increasingly using a variety of unlicensed assistive personnel (UAP) to work in patient care areas. Evidence suggests that delegation is a skill that nurses generally do not acquire in their educational prepa- ration and yet, in today’s healthcare arena, is highly rele- vant and necessary (Hasson, McKenna, & Keeney, 2012). Appropriate delegation to UAPs is essential in ambulatory care clinics where efficiency and cost containment result in fiscal responsibility. In ambulatory care environments, UAPs such as front desk clerks and patient care technicians may perform multiple tasks under the supervision of the nurse (Mueller & Vogelsmeier, 2013). Nurses must understand and maintain their own scope of practice while collaborat- ing with healthcare practitioners to provide cost-effective, competent, and safe care to multiple patients (Tompkins, 2016). Ambulatory care registered nurses (ACRN) may del- egate certain nursing duties to a licensed practical nurse (LPN) and UAP as long as certain conditions exist, such as evidence of education and training, knowledge and skill to perform the tasks, and the presence of organizational poli- cies and procedures. The intent of this column is to provide a review of important considerations for how the ACRN, LPN, and UAP can work together to provide safe care in the ambulatory care setting.

The majority of UAPs utilized in ambulatory care set- tings are medical assistants (MA). Medication administra- tion is a procedure an MA may perform in a clinic and, in most states, this task is performed under the direct delega- tion and supervision of a licensed medical practitioner. North Dakota is the only state that allows nurses to dele- gate injection administration to specially trained UAPs (McCarty, 2012). This specific task can be delegated to an MA if it is allowed by state medical boards, but there is a wide variation between states on how this topic is addressed (McCarty, 2012; American Association of Medical Assistants [AAMA], n.d.). Some MAs receive on- the-job training while others complete formal training pro- grams with clinical externships. The ACRN frequently observes the UAP skills for the medical staff, verifying and tracking individual competencies, among other things (Jenkins & Joyner, 2013). Examples of legal opinions regarding MA practice in individual states can be found on the AAMA website (Balasa, 2015; Balasa, 2017). Nurses have an ethical responsibility to provide safe care and, beyond knowing what state regulations allow, must also be familiar with their employer’s institutional policies and pro-

cedures. If a nurse feels another nurse or a UAP is not per- forming care safely, including an improperly delegated task, or the person is working beyond the scope of their training, the nurse is ethically obligated to speak with the provider and management about this observation.

Delegation must be based on a fundamental principle of public protection. It is imperative that the MA has obtained the necessary education or training to perform the delegated care. Competency validation should be per- formed and be specific to the knowledge and skill needed to perform the procedure safely for all levels of staff. The ACRN plays an important role in helping to identify and ensure that LPNs and UAPs receive appropriate education to deliver safe, quality care.

Although the ACRN could certainly obtain vital signs, order supplies, and clean equipment, the best use of scarce health care resources is to encourage personnel to work to the full extent of their license or training. The MA scope of practice will vary by state and may be vague, so consult your state medical and nursing regulations for specific allowances in your state (McCarty, 2012). With this in mind, consider the following questions:

Would it possible to teach an interested front office• staff member to obtain basic vital signs? In some locations, with training and practice, this is a skill that could be delegated to the front office staff by a super- vising physician. Performance should be taught, vali- dated, and supervised by licensed staff. Can a nurse train front office staff to provide med-• ical advice over the phone? No, this is not within the scope of the nurse to delegate or supervise, nor would this be appropriate for a physician to hand off to a UAP as it involves assessment and critical thinking beyond the skill of a UAP. If allowed by your state, can a nurse supervise a for-• mally trained MA to administer medications? Yes, if the MA has had the education and validated compe- tency to perform medication administration, and is working under the physician license, the nurse may be delegated oversight responsibility for medication administration. Can a nurse or physician delegate an LPN to initiate• intravenous (IV) therapy in the clinic? Maybe; this will depend on the nurse practice act of your state. If specifically prohibited by your state, the LPN is not allowed to initiate the IV therapy. Can a nurse or a physician delegate an MA to initi-• ate IV therapy? No, the nurse cannot delegate this order. However, the physician may be allowed to del- egate this task depending on the regulations of the state where you reside. As an example, Maryland allows a physician to delegate initiation of a peripheral IV by an MA with onsite supervision (McCarty, 2012)