Delegation

Delegation Toolkit for School Nurses

Disclaimer: This toolkit is intended to provide resources for school nursing practice as it relates to delegation of nursing procedures in Oregon Schools. This is not legal, medical, nor nurse practice advice and is not prescriptive as it relates to individual students or individual nursing practice. These resources do not override individual assessment, and clinical judgment. Registered Nurses are responsible for their own assessments, practice, and obligation to the Oregon Nurse Practice Act (NPA).

Delegation

Nursing Delegation is defined as the ability of the registered nurse (RN) to consider the transfer of responsibility of a nursing procedure to an unregulated assistive person (UAP) while the RN continues to be accountable for the outcomes (American Nurses Association [ANA], 2007). The National Council of State Boards of Nursing and American Nurses Association have published National Guidelines on Nursing Delegation (2019) recognizing nursing delegation is an essential skill in nursing practice. The decision to delegate a nursing procedure is based upon:

the judgment concerning the assessment of the student and supporting dynamics
the competence of nursing
the degree of supervision
the procedure to be delegated
the competency of the UAP (NCSBN/ANA, 2019)

The national guidelines on nursing delegation (NCBSN/ANA, 2019) have formulated a model (below) for delegation of nursing procedures that encompass the institutional responsibilities, the nurses responsibilities, and the UAP’s responsibilities.

(NCBSN/ANA, 2019)

Delegation in the School Setting

Delegation of nursing procedures in school settings is a necessity given the number and complexity of school nursing responsibilities, the increasing health needs of students, and the limited number of school nurses available to meet these needs (Resha, 2010).

Nursing delegation is the clinical decision by the RN (not a school administrator) to a competent UAP willing to perform a ttingselected nursing procedure in a selected situation for a selected individual. The school nurse completes the assessment of the student, the UAP training, the evaluation and validation of UAP competence, and provides ongoing supervision of the UAP as well as additional and ongoing evaluation of the student’s health outcomes (NASN, 2018).

Nursing delegation is only allowed in community-based care settings, including schools. Without the structure of a typical clinical setting, the nurse must ensure that this unique environment supports nursing delegation.

Evidence Based Practice

Evidence Based Practice Grid

Basic Information

American Nurses Association ( 2012) Principles of delegation. https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principlesofdelegation.pdf

Legal Practice Standards

At the forefront of nurse case management for school nurses is the understanding of scope of practice as it relates to case management and delegation of nursing procedures in a community setting:

Oregon State Board of Nursing Oregon Nurse Practice Act (Chapter 851)

Chapter 851, Division 47 STANDARDS FOR REGISTERED NURSE DELEGATION PROCESS

Public Access Practice Resources

Note: the following are national or regional resources that serve as a reference; they may or may not be consistent with Oregon law and do not supersede Oregon Nurse Practice Act (NPA).

American Nurses Association

Principles of Delegation

National Association of School Nurses

National Council of State Boards of Nursing

Oregon Health Authority-Oregon Department of Education

School Nurse Manual

Professional Development

Nurses must ensure that they have proficiency in areas of practice in which they delegate. The following include Free Continuing Education resources for Nursing related to delegation skills:

Weydt, A., (May 31, 2010) "Developing Delegation Skills" OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 2, Manuscript 1.

National Association of School Nurses

S081 - Principles for Practice: Nursing Delegation to Unlicensed Assistive Personnel in the School Setting 2nd Edition [Publication] $

Oregon DHS

NurseLearn: Community Based Care for Nurses (Free Modules)

5 courses RN Delegation

Online Home CEU

Mastering the Skill and Art of Delegation: A Critical Step on the Pathway to Nursing Excellence

Tools

Nursing Delegation Resources

OSNA: Understanding Delegation

OSBN Division 47 Interpretive Guidance Document (pdf) UPDATED

(Who/What/When/Where/Why/How Nursing Practice Document)

Delegation Determination (Dichotomous key)

NASN

Templates

The following templates are modifiable for use by school nurses as it relates to their practice and should be used consistently with Oregon State Board of Nursing Delegation Laws, and local school policy.

Delegation Forms: (Documentation of the delegation process) NEW

Step 1. Assessment & Determination: This step includes an assessment of the student and circumstances to determine if delegation is a safe care delivery option. This form should be used to initiate the delegation process with an assessment to determine whether or not to proceed with the delegation. The table format guides the nurse through the assessment of the many elements to be considered. The narrative field form offers a space where a nurse can document an assessment in paragraph form.

Step 1: Assessment and Determination Form: TABLE VERSION (example with prompts)
Single UAP, Single Procedure	Single UAP, Multiple Procedures	Multiple UAPs, Single Procedure
Assessment and Determination Table 1:1 (editable) Assessment and Determination Table 1:1 (fillable PDF)	Assessment and Determination Table 1:3 (editable) Assessment and Determination Table 1:3 (fillable PDF)	Assessment and Determination Table 3:1 (editable) Assessment and Determination Table 3:1 (fillable PDF)

Step 1: Assessment and Determination Form: NARRATIVE FIELD VERSION
Single UAP, Single Procedure	Single UAP, Multiple Procedures	Multiple UAPs, Single Procedure
Assessment and Determination Narrative 1:1 (editable) Assessment and Determination Narrative 1:1 (fillable PDF)	Assessment and Determination Narrative 1:3 (editable) Assessment and Determination Narrative 1:3 (fillable PDF)	Assessment and Determination Narrative 3:1 (editable) Assessment and Determination Narrative 3:1 (fillable PDF)

Step 2. Guidance and Direction: In this step, the nurse prepares and delivers instruction about the procedure to be delegated. Documentation of this step will include artifacts related to training the UAP (e.g. Step-by-step evidence-based documented instructions). There is no form to document this step beyond the artifacts. Validation of the UAPs performance will be based upon this instruction and documented in Step 3: Nursing Delegation: UAP Performance Validation form below. Provision of all required elements, including guidance and direction, will be documented later in Step 4 of the process in the Nursing Delegation: Initial Delegation Authorization Form.

Step 3. Validation: After the UAP has been trained, this tool should be used to guide the nurse’s assessment of the UAP.

Step 3: UAP Performance Validation Form
Single UAP, Single Procedure	Single UAP, Multiple Procedures	Multiple UAPs, Single Procedure
UAP Performance Validation 1:1 (editable) UAP Performance Validation 1:1 (fillable PDF)	UAP Performance Validation 1:3 (editable) UAP Performance Validation 1:3 (fillable PDF)	UAP Performance Validation 3:1 (editable) UAP Performance Validation 3:1 (fillable PDF)

Step 4. Authorize: In this step, the nurse considers the initial assessment and the UAP competency to decide whether or not to delegate. This form is used to document the initial agreement with the UAP to deliver care in the delegated procedure.

Step 4: Initial Delegation Authorization Form
Single UAP, Single Procedure	Single UAP, Multiple Procedures	Multiple UAPs, Single Procedure
Initial Delegation Authorization 1:1 (editable) Initial Delegation Authorization 1:1 (fillable PDF)	Initial Delegation Authorization 1:3 (editable) Initial Delegation Authorization 1:3 (fillable PDF)	Initial Delegation Authorization 3:1 (editable) Initial Delegation Authorization 3:1 (fillable PDF)

Step 5. Inspection and Evaluation: This form is used to document the periodic inspection, the re-evaluation, of the delegation.

Step 5: Periodic Inspection and Evaluation Form
Single UAP, Single Procedure	Single UAP, Multiple Procedures	Multiple UAPs, Single Procedure
Periodic Inspection and Evaluation 1:1 (editable) Periodic Inspection and Evaluation 1:1 (fillable PDF)	Periodic Inspection and Evaluation 1:3 (editable) Periodic Inspection and Evaluation 1:3 (fillable PDF)	Periodic Inspection and Evaluation 3:1 (editable) Periodic Inspection and Evaluation 3:1 (fillable PDF)

Step 6. Ending Delegation: This form should be used when the RN makes a determination to end the delegation. It could be supported by updated Assessment and Determination and/or UAP Performance Validation Forms.

Step 6: Ending Delegation Form
Single UAP, Single Procedure	Single UAP, Multiple Procedures	Multiple UAPs, Single Procedure
Ending Delegation 1:1 (editable) Ending Delegation 1:1 (fillable PDF)	Ending Delegation 1:3 (editable) Ending Delegation 1:3 (fillable PDF)	Ending Delegation 3:1 (editable) Ending Delegation 3:1 (fillable PDF)

Authors: Jan Olson, Lori Perkins, Wendy Niskanen

Peer Reviewers: Denise Cardinali, Tamara Bow, Corinna Brower, Kristiina Gagner, Tanya Martin, & Jamie Smith

Editorial Reviewer: Wendy Niskanen

References

American Nurses Association. (2007). Assuring safe, high quality health care in the pre-K through 12 educational settings. (Position Statement).

American Nurses Association. (2012). The principles of delegation. Silver Springs, MD: ANA.https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principlesofdelegation.pdf

Barrow JM, Sharma S. Five Rights of Nursing Delegation. [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519519/

Bifarin O., Stonehouse D.(2017) Clinical supervision: an important part of every nurse’s practice. Br. J. Nurs.;26(6):331–335. - PubMed

Blay N., Roche M. (2020). A systematic review of activities undertaken by the unregulated

National Council of State Boards of nursing (2016) National guidelines for nursing delegation. Journal of Nursing Regulation 7(1) 5-14

National Association of School Nurses. (2018). The role of the 21st century school nurse (Position Statement). Silver Spring, MD: Author.

National Association of School Nurses (2019). School-sponsored trips - The role of the school nurse (Position Statement). Silver Spring, MD: Author.

Nursing Assistant. J. Adv. Nurs;76:1538–1551. - PubMed

National Institutes of Health (2017). What are competencies? https://hr.nih.gov/about/faq/working-nih/competencies/what-are-competencies

Joint Position Paper from ANA and NCBSN on the National Guidelines for Nursing Delegation

https://www.ncsbn.org/public-files/NGND-PosPaper_06.pdf

Resha, C., (2010) Delegation in the School Setting: Is it a Safe Practice? OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 2, Manuscript 5.

Shore CB, Maben J, Mold F, Winkley K, Cook A, Stenner K. (2022). Delegation of medication administration from registered nurses to non-registered support workers in community care settings: A systematic review with critical interpretive synthesis. Int J Nurs Stud.;126:104121. doi: 10.1016/j.ijnurstu.2021.104121. Epub 2021 Oct 29. PMID: 34896760; PMCID: PMC8803545.

Stenner K, Shore CB, Maben J, Mold F, Winkley K, Cook A. Delegation of insulin administration to non-registered healthcare workers in community nursing teams: A qualitative study. J Adv Nurs. 2023 Apr 2. doi: 10.1111/jan.15662. Epub ahead of print. PMID: 37005976.

Zheng J, Tayag J, Cui Y, Chen J. Bloom's Classification of Educational Objectives Based on Deep Learning Theory Teaching Design of Nursing Specialty. Comput Intell Neurosci. 2022 Jul 21;2022:3324477. doi: 10.1155/2022/3324477. PMID: 35909830; PMCID: PMC9334097.