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School Nurse Delegation: Do's and Don'ts of the D-Word FAQs

By Robin Shannon, NCSN, RN, DNP posted 08-03-2020 15:29

  

Hello Colleagues,

Thanks so much for attending my session, School Nursing Delegation: Do’s and Don’ts of the D-Word. I wish we could have been together and I could have seen your smiling(?) faces during my presentation. Alas...

Here are my replies to some of the chat questions we didn’t have time to discuss during the conference session. 

Robin Adair Shannon

Download slides from the session.

If a school administrator assigns someone as RN I am not comfortable w/letting them practice under my license what do you advise?

A delegatee must be willing to be trained on the healthcare tack AND must be competent to perform the task after training under your supervision. Use a procedure skills checklist to objectively assess and document the proposed delegatee’s performance. If the skills checklist clearly shows that the individual cannot consistently and safely deliver the required care for the student’s FAPE, then the administrator should assign a new willing and (hopefully) competent person.    

If the school nurse is an LPN, can they delegate tasks to UAPs?

As I tried to emphasize in my talk - you have to look at your state nurse practice act carefully to understand the scope of practice of both the RN and the LPN(LVN). In my state, Illinois, only RNs can delegate care AND an LPN has to practice under the supervision of an RN.

Here is a friendly but emphatic reminder to utilize the NASN position statements to drive effective school health policies and staffing in your district. Please refer to Education, licensure, and certification of school nurses (Position Statement). https://www.nasn.org/nasn/advocacy/professional-practice-documents/position-statements/ps-education : “It is the position of the National Association of School Nurses (NASN) that every school‐age child should have access to a registered professional school nurse … who has a minimum of a baccalaureate degree in nursing from an accredited college or university and is licensed as a registered nurse through a board of nursing” (NASN, 2016).

Also note the NASN (2020) position statement, The School Health Services Team: Supporting Student Outcomes (https://www.nasn.org/nasn/advocacy/professional-practice-documents/position-statements/ps-team): The LPN/LVN performs primarily procedural nursing functions and some shared nursing responsibilities in accordance with their educational preparation and state Nurse Practice Act, which includes working under the supervision of an RN or other designated healthcare professional such as a physician or advanced practice registered nurse (American Association of Occupational Health Nurses [AAOHN], 2017; Benbow, Abel, Benton, & Hooper, 2014). It is important to note how a state Nurse Practice Act defines supervision of the LPN/LVN, which differentiates between on-site (direct) supervision and remote (consultative) supervision. LPNs/LVNs should not be placed in positions in which supervision by a designated healthcare professional is not available (AAOHN, 2017)”.

School nurses and LPNs can work beautifully together on behalf of student health and learning. An LPN/LVN can be a valuable member of the school health team as a ‘nurse in a school’ (not a school nurse) delivering routine care to individual students under their scope of practice. School nurses are responsible for the health and safety of BOTH individual kids AND the whole school community.

Is there a difference between "delegation” and “supervision"?

The ANA & NASN’s School Nursing: Scope and Standards of Practice (2017) defines Delegation (school nurse): The assignment of the performance of a nursing activity to a non-nurse. The school nurse, who, after assessment of the individuals’ capabilities, makes a prudent decision regarding the advisability of delegation (ANA & NASN, 2017, p. 88).

Supervision is a continuum and depends on the student’s health status. It is inherent upon the school nurse as an RN to supervise the delegatee to ensure that the delegated healthcare task is performed accurately and consistently. This means that it is the school nurse’s responsibility to closely monitor the delivery of care by the delegatee. This does not mean that the school nurse has to supervise the delegatee daily, otherwise the purpose of delegation is defeated. Supervision entails dropping in periodically to observe the performance of the procedure, document competency on the procedure skills checklist (Shannon & Kubelka,2013), and assess the student’s status. The delegatee should know what to do in an emergency and when to contact the school nurse to come and assess the child or give immediate advice. For example, if a UAP is delegated to perform routine urinary catheterization and the student misses school due to a UTI, the school nurse needs to re-evalute the UAPs cathing skills. Any time the student’s health status becomes unstable and unpredictable and requires immediate or daily nursing judgement, delegation should stop and a nurse should assume care.

American Nurses Association & National Association of School Nurses. (2017). Definition: Delegation. In School nursing: Scope and standards of practice (3rd ed). (p. 88). Silver Springs, MD: ANA & NASN.

(Shameless plug) Shannon, R. A., & Kubelka, S. (2013a). Reducing the risks of delegation: Use of procedure skills checklists for unlicensed assistive personnel in schools, Part 2. NASN School Nurse, 28(5), 222-226. doi:10.1177/1942602X13490030

Shannon, R. A., & Kubelka, S. (2013b). Reducing the risks of delegation: Use of procedure skills checklists for unlicensed assistive personnel in schools, Part 1. NASN School Nurse, 28(4), 178-181. doi:10.1177/1942602X13489886

What if there's a task that can be delegated to the UAP, but parent demands it be done by the RN?  

It’s so hard when there are disagreements with families. Solutions only are achieved through positive trusting relationships with the parent – which I am sure you have tried to establish. I would make sure to clearly lay out the delegation procedures in the 504 plan or IEP. Use the e skills checklist to demonstrate the delegatee’s competence and perhaps have the parent observe the safe administration of the med or procedure by the UAP. Good luck!

Where can we find delegation procedure/ skills check off forms at to implement in our schools?

There are many good sources for procedure skills checklists. They are easy to make once you have a template. Children’s Hospital websites often have great info on procedures (geared to teaching parents – but great for the community setting of school. Ask the Googler! Please feel free to post your favorites. Here are a few of mine: 

  • The Shannon and Kubelka articles in NASN School Nurse referenced above include a sample you can use as a template.
  • (Shameless plug) School Nursing: A Comprehensive Text 3rd ed (Selekman, Shannon, & Yonkaitis (Eds.), 2019) has lots of evidenced-based information on caring for students with special healthcare needs. Especially see Chapter 30: Students supported by medical technology (Porter, Page, Engholm, & Somppi), p. 721.
  • The Wisconsin Department of Public Instruction WISHes Program has a great resource: Nursing procedures: School Health Tasks Training (Thanks to Louise Wilson, WI State School Nurse Consultant – Louise did the terrific 2020 NASN conference presentation on field trips).

https://dpi.wi.gov/sspw/pupil-services/school-nurse/training/nursing-procedures

  • Check out: Porter, S.M., Branowidki, P.A., & Palfrey, J.S. (2014). Supporting students with special health care needs: Guidelines and procedures for schools, 3rd Baltimore, MD: Paul H. Brookes Publishing Co. This book is full of procedures with helpful pictures.

How do you voice your position as a RN when your principal demands you to diaper change a student instead of her one on one assistant that is with her all day?

Unfortunately, this is a common issue. When I was a nursing supervisor, I would often get calls from principals asking about the diapering or changing soiled clothes policy. My answer: There is no poopy pants policy! The school district is paying you to practice at the top of your RN license. If the task doesn’t take a nursing license to preform, then an RN doesn’t need to do it. Diapering does not require nursing judgement. It takes away time from responsibilities that require a registered nurse’s professional knowledge, skills, and abilities. That said, the school nurse should periodically assess students who are diapered to ensure good skin integrity or when there are any bowel or bladder complications. You can recommend that diapering and changing soiled clothes be added to the paraprofessional’s job description so there are no future conflicts.

Can you please clarify which tasks you would delegate for the student to UAP, health aide or LPN? – Really?

Nope. Sorry! Whether, why, what, when and how to delegate is your nursing judgement which is based upon the delegation stipulations of your state’s nurse practice act, your comprehensive assessment of the child’s health condition (is it stable and predictable?), the availability of a nurse, etc. as I tried to outline in the presentation. Use your tried and true friend – the nursing process! These decisions are often complicated and often change as the student’s health status changes. It’s helpful to review the decision trees in the National Council of State Boards of Nursing & American Nurses Association. (2019). National guidelines for nursing delegation. https://www.ncsbn.org/NGND-PosPaper_06.pdf

What if UAP refuses the delegation task?  Even if they have returned demonstration successfully, understand child's needs, etc.?

At any time that a UAP is not comfortable performing the delegated task, then they may refuse. In that case, the principal (with your advice of course) needs to assign a new person for you to train to preform the delegated task. So in other words, don’t be surprised – be prepared to wash, rinse, and repeat. Again, it helps a lot when job descriptions for UAPs or paraprofessionals include the performance of delegated routine healthcare tasks as trained and monitored by the school nurse.

I wish you all the best with your delegation practice and caring for students with special healthcare needs to ensure their right to FAPE. I know you always take good care of your school communities, but please remember to take care of yourself too, especially during these challenging and very contagious times!

Robin

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