Chapter 8 Unlicensed Assistive Personnel and the Registered Nurse

1. Chapter 8 Unlicensed Assistive Personnel and the Registered Nurse

2. Terminology • Unlicensed assistive personnel (UAP) includes • Nurse aides, nurse extenders • Health care aides • Technicians • Patient care technicians • Orderlies • Assistants or attendants • Nursing assistive personnel (NAP): replacement term by ANA in 2007

3. Motivation to Use UAP • Arguments • Maximize human resources: free professional nurses from tasks and assignments not requiring independent thinking and professional judgment (nonnursing tasks and functions) • Cost savings: conflicting findings in research • Controversy • UAP are not supplements but replacements of professional RN staff • Variation in scope of practice and lack of minimum educational and training requirements

4. Top Reasons for Being Pulled Away from Patient Care • Documenting information in multiple locations • Completing logs, checklists, and other unnecessary paperwork/data collection • Filling out regulatory documentation • Entering/reviewing orders • Walking to equipment/supply areas, utility rooms, etc.

5. Educational Requirements • OBRA regulations for certified nurse’s aides • Minimum of 75 hours of state-approved theory and practice • Successful completion of competency exam in both areas • Most UAP training in employing facility with no formal certification • Formal training at vocational schools and community colleges; focus on long-term care; certification only to meet state requirements • Education for acute care settings facility-based; no required educational standards or guidelines

6. Question #1 Is the following statement true or false? • Currently, strict standards related to the educational requirements are in place for UAP.

7. Answer to Question #1 False • Wide variations exist in the educational requirements for UAP. For example, OBRA regulations require a minimum of 75 hours of theory and practice, and successful completion of an exam in both areas, while in other cases, training occurs in a facility with no formal certification.

8. Certified Medicine Aides • Have worked in licensed nursing home settings, residential care settings, and adult day services in this country for almost four decades • RNs reported feeling pressured to delegate medication administration to UAPs because of inadequate organizational personnel and finances • “Handing over a crucial nursing responsibility under jeopardizing circumstances” (see Research Fuels the Controversy 8.1)

9. UAP Scope of Practice #1 • ANA: 6 actions necessary to create a national and/or state policy agenda for education of UAP or NAP and competencies for safe practice (see Box 8.1) • No universally accepted scope of practice for UAP • Some states with task lists • Most facilities allowing a broader scope of practice than advocated by professional nursing organizations or state boards of nursing • UAPs completing tasks traditionally reserved for licensed practitioners, that is, medication administration

10. UAP Scope of Practice #2 • In many settings, UAPs perform functions within the legal scope of nursing • Certain activities NEVER to be delegated to UAP • RN ultimately responsible for: • Analyzing information using highly developed critical thinking skills • Then using the nursing process to achieve desired patient outcomes • Regulatory oversight: regulation varied by state and jurisdiction

11. UAP and Patient Outcomes • Effect of increased use of UAP not fully known • Studies show direct link between decreased RN staffing and decline in patient outcomes. • Increased incidence of falls • Increased incidence of nosocomial infections • Increased physical restraint use • Higher medication errors

12. Question #2 Which of the following would be appropriate for a nurse to delegate to a UAP? A. Vital sign measurements B. Care planning C. Patient assessment D. Patient teaching

13. Answer to Question #2 A • A UAP may perform vital sign measurements because this task does not require independent thinking or professional judgment. Activities that should never be delegated include those that require the RN to analyze information using highly developed critical thinking skills and then use the nursing process to achieve desired patient outcomes.

14. RN Liability for Supervision and Delegation of UAP #1 • RN responsible for adequate supervision of person to whom assignment has been delegated • RN liable if negligent in supervision of employee at the time the employee committed negligent act • Supervisor’s failure to determine which patient needs could be safely assigned to a subordinate • Failure to closely monitor subordinate requiring supervision

15. RN Liability for Supervision and Delegation of UAP #2 • RN awareness of UAP’s job description, knowledge base, demonstrated skills • “Mindful” communication between the RN–UAP dyad • RN is always: • Accountable for care given • Responsible for instructing UAP as to who needs care and when

16. RN Liability for Supervision and Delegation of UAP #3 • UAP accountable for knowing: • How to perform care properly • When others need to be called in for tasks beyond limits of knowledge and training • Marquis and Huston (2017) • Bottom line: RNs are always accountable for care given and instructing NAPs to perform care properly • ANA general principles for delegating to NAP (see Box 8.2)

17. RNs Working as UAP: Liability • New graduates being hired as UPAs • Issues of legality • RN not able to provide care to level of expertise—violation of statues • Possible charges of negligence or malpractice if providing care only to the level of the assumed position • Role discrepancy

18. Creating a Safe Work Environment • Health care organization activities to increase likelihood that UAP used effectively and appropriately • Clearly defined organizational structure • RN recognized as leader of health care team • Clear job descriptions defining roles and responsibilities • Uniform training and orientation programs for UAPs • Adequate program development in leadership and delegation for RNs

19. Question #3 Is the following statement true or false? • The RN is responsible for instructing UAP in how to properly perform the assigned care.

20. Answer to Question #3 False • The RN is responsible for instructing UAP as to who needs care and when. The UAP is accountable for knowing how to properly perform the assigned care and when to call in others for tasks beyond limits of knowledge and training. The RN must know if UAP has knowledge and skills to perform assigned task. If not, then the RN should not delegate the task.

21. UAP Shortage #1 • Demand for UAP growing; persons typically filling these positions declining • Graham (2017): Acute shortages occurring across the United States, but in some states, the problem is worse than others • Current nationwide shortage of well-trained UAP in all settings—high turnover rate • Long hours, inadequate staffing, physical and emotional job demands, low pay • Negative messages from managers, supervisors, coworkers

22. UAP Shortage #2 • Current nationwide shortage (cont.) • Lack of employer-paid benefits • Limited career paths • Less-than-ideal working conditions; high turnover rate leaving others short-handed • Outdated federal regulations for minimum standards for staffing in nursing homes • Hazards related to exposure to infectious diseases and drug-resistant infections • Emotional exhaustion brought on by occupational fatigue

23. UAP Shortage #3 • Possible solutions • Financial incentives • Addressing the barriers to incorporating UAP into modes of care • Making sure UAP is successfully recognized as a delegated clinical role • Doing more to recruit and retain UAPs

24. End of Presentation