Nursing Delegation for the School Setting
Delegation is an everyday occurrence in many work settings including schools. The growing healthcare needs of students, the increased complexity of cares and technology required to meet healthcare needs, along with nursing workforce shortages and limited funding dedicated to providing nursing services and the need to ensure Free and Appropriate Public Education (FAPE) for students makes nursing delegation a valid consideration to meet the healthcare needs of students.
However, delegation comes with challenges and limitations. It requires nurses and school leaders to have a mutual understanding and respect for nursing practice statutory requirements and professional nursing practice standards to avoid suboptimal nursing care and potentially unsafe care for students. It also reduces risks for both the school and the individual licensed nurse.
“Delegation- the act of empowering to act for another; the delegation of responsibilities”. Merriam-Webster.com Dictionary, Accessed 25 March 2024.
A teacher, for example, may delegate to a paraprofessional the task of providing specific learning support to a student. A school leader may delegate to a school employee to monitor the hallway or bathroom during passing times, bus loading, or other education-related tasks and responsibilities.
The words “delegate / delegation /delegated responsibility” have a different meaning based on context particularly in nursing practice.
A school leader may delegate (designate) a paraprofessional as the individual to whom a nursing task or activity may be delegated too, however the final decision to delegate a specific nursing task or activity belongs to the professional nurse who is employed or contracted to provide school nursing services. (Professional nurse includes Registered Nurse, Licensed School Nurse, Advanced Practice Registered Nurse.) Each nursing delegation decision is a unique decision, specific to that individual student and their health condition, and cannot be generalized to every student with a “similar nursing task”.
Why? The Minnesota Nurse Practice Act has specific definitions and requirements for the safe delegation of nursing tasks or activities which the professional nurse must follow and which are designed to protect the public from unsafe and unlawful practice of nursing.
The following sections will provide detailed information to inform school leaders and staff and to guide school nursing practice in Minnesota.
The Minnesota Board of Nursing exists to protect the public's health and safety through regulation of nursing education, licensure, and practice. The Minnesota Nurse Practice Act, Minnesota Statute section 148.171 to 148.285 and MN Rules 6301.0100 - 6321.0500 are the statutory requirements for nursing practice, licensure, and licensure preparation education programs.
MN Statute 148.171 Subd. 7a. defines delegation as the "transfer of authority to another nurse or competent, unlicensed assistive person to perform a specific nursing task or activity in a specific situation."
MN Statute 148.171 Subd. 3a. defines “assignment” means the designation of nursing tasks or activities to be performed by another nurse or unlicensed assistive person.
MN Statute 148.171 Subd. 15 (6) specifically calls out delegation in the professional nurse (RN) scope of practice, “delegating nursing tasks or assigning nursing activities to implement the plan of care;”. This language is not in the legal scope of practice for the Licensed Practical Nurse (LPN), so they do not delegate nursing tasks or activities to others. To learn more about the differences in the legal scope of practice between LPN and RN refer to School Health Services Staffing and the Minnesota Board of Nursing/Nursing Practice Topics including RN and LPN Scope of Practice Chart and the National Council of State Boards of Nursing Scope of Practice Decision-Making Framework and Guidelines.
MN Statute 148.171. Subd. 15 (17) RN and (Subd. 14 (14) LPN have “accountability for the quality of care delivered, recognizing the limits of knowledge and experience; addressing situations beyond the nurse's competency; and performing to the level of education, knowledge, and skill ordinarily expected of an individual who has completed an approved professional nursing education program as described in section 148.211, subdivision 1.”
The Minnesota Nurse Practice Act also describes the grounds for disciplinary action which can include denying, revoking, suspending, limiting, or conditioning the nurse’s license and/or registration to practice nursing. Included in Minnesota Statute 148.261 are:
(5) Failure to or inability to perform professional or practical nursing as defined in section 148.171, subdivision 14 or 15, with reasonable skill and safety, including failure of a registered nurse to supervise or a licensed practical nurse to monitor adequately the performance of acts by any person working at the nurse's direction.
(8) Delegating or accepting the delegation of a nursing function or a prescribed health care function when the delegation or acceptance could reasonably be expected to result in unsafe or ineffective patient care.
(17) Knowingly aiding, assisting, advising, or allowing an unlicensed person to engage in the unlawful practice of advanced practice, professional, or practical nursing.
The Minnesota Nurse Practice Act provides the foundational requirements for nursing practice including nursing delegation however the practice of both Professional Nursing (RN) and Licensed Practical Nursing (LPN) also “incorporates caring for all patients in all settings through nursing standards recognized by the Board”. In the next section Nursing Delegation: Professional Standards and Guidance provides additional detail to those standards that guide nursing delegation.
Nursing practice standards are guidelines and criteria established by professional nursing organizations to ensures that nurses provide safe, competent, and ethical care to patients. Nursing Practice Standards provides additional information.
The National Association of School Nurses (NASN) which is the professional nursing organization for the specialty practice of school nursing, with the approval of American Nurses Association developed the School Nursing Scope and Standards of Practice, 4th Edition (2022) which specifically addresses delegation.
The Minnesota Board of Nursing supports the NCSBN and ANA Joint Position Paper on Delegation and National Guidelines for Nursing Delegation to facilitate and standardize the nursing delegation process. These guidelines provide further definitions important to nursing delegation.
Delegated Responsibility: A nursing activity, skill, or procedure that is transferred from a licensed nurse to a delegatee.
Delegatee: One who is delegated a nursing responsibility by the professional nurse and is competent to perform the task and verbally accepts the responsibility.
Delegator: One who delegates a nursing responsibility. The delegator in Minnesota is the professional nurse (RN, LSN, APRN).
Accountability: To be answerable to oneself and others for one’s choices, decisions and actions as measured against a standard (NASN School Nursing Scope and Standards of Practice, 4th Edition).
Assignment: The routine care, activities and procedures that are within the authorized scope of practice of the RN or LPN or part of the routine functions of the UAP.
Assistive Personnel (AP): Any assistive personnel trained to function in a supportive role, regardless of title, to whom a nursing responsibility may be delegated. This includes but is not limited to certified nursing assistants or aides (CNAs), patient care technicians, CMAs, certified medication aids, and home health aides (formerly referred to as ‘‘unlicensed” assistive personnel [UAP]).
The National Council for State Boards of Nursing (NCSBN) and American Nurses Association(ANA) have published a Joint Position Paper on Delegation. Delegation can be summarized as follows:
- A delegatee is allowed to perform a specific nursing activity, skill or procedure that is outside the traditional role and basic responsibilities of the delegatee’s current job.
- The delegatee has obtained the additional education and training, and validated competence to perform the care/delegated responsibility. The context and processes associated with competency validation will be different for each activity, skill or procedure being delegated. Competency validation should be specific to the knowledge and skill needed to safely perform the delegated responsibility as well as to the level of staff to whom the activity, skill or procedure has been delegated. The licensed nurse who delegates the “responsibility” maintains overall accountability for the patient. However, the delegatee bears the responsibility for the delegated activity, skill, or procedure.
- The licensed nurse (RN) cannot delegate nursing judgment or any activity that will involve nursing judgment or critical decision making.
- Nursing responsibilities are delegated by someone who has the authority to delegate (in MN this the RN) and delegated responsibility is within the delegator’s (RN’s) scope of practice.
- Clinical reasoning, nursing judgment and critical decision making cannot be delegated by the RN.
The next section will highlight the process of nursing delegation to others, training, supervising, and monitoring required for safe nursing delegation.
Process of Nursing Delegation
The professional nurse (RN, LSN, PHN) has sole responsibility to determine and make decisions related to nursing delegation. NCSBN describes this as the nurse transferring authority which directs another individual to do something that that person would not normally be allowed to do. The individual is responsible to perform the activity as trained by the professional nurse however, the nurse retains accountability for the delegation.
Prior to delegating a nursing activity, the professional nurse must use the nursing process to complete an assessment and develop the plan of care to meet the student’s health needs.
The National Guidelines for Nursing Delegation outline The Five Rights of Delegation which are the steps in the delegation process.
| NCSBN Language | Implementation Guide | |
|---|---|---|
| Right task | The activity falls within the delegatee’s job description or is included as part of the established written policies and procedures in the school setting. |
|
| Right circumstance | The health condition of the patient must be stable. If the student’s condition changes, the delegatee must communicate this to the licensed nurse, and the licensed nurse must reassess the situation and the appropriateness of the delegation. |
|
| Right person | The licensed nurse along with the employer and the delegatee is responsible for ensuring that the delegatee possesses the appropriate skills and knowledge to perform the activity. |
|
| Right directions and communication |
|
|
| Right supervision and evaluation |
|
|
A common question by nurses. “Is there a list of nursing tasks that may or may not be delegated?”
Minnesota does not have a defined list of nursing tasks and functions that may or may not be delegated. RNs cannot delegate the nursing process or nursing judgement. Delegation is for a specific task and determined on a case-by-case basis and is most appropriate when they are caring for students with routine, repetitive, ongoing nursing task needs. When the necessary task is not routine and the student's response to treatment is less predictable, nursing delegation should be carefully considered.
A common question by nurses. “Can I delegate to staff/coaches for extracurricular activities, or before/after school childcare programs?”
Minnesota does not provide a list or who can or cannot be a “delegatee”. Using the Five Right of Delegation, the professional nurse makes the decision to whom a nursing task is delegated. However, there are other considerations for these activities outside of the school day which include the nurse’s individual job description and capacity (time) to provide training, monitoring, and supervision which are required for delegation. While the school district has the responsibility to provide for the health needs of students, it may not be through delegation by the professional nurse who provides care during the regular school day.
When nursing delegation is not possible, the professional nurse can provide consultation which is a professional (RN) activity of collaborating and coordinating with others in the management of care across systems. This is not “student specific” like delegation, but population based, and can include general health information to others regarding a health condition, safe medication administration procedures, and emergency response such as for activities occurring outside of the regular school day or students going on an out-of-state or out-of-country field trips.
Assignment
Delegation should not be confused with assignment. As defined above, assignment is the routine care, activities, and procedures that are within the authorized scope of practice of the RN or LPN or part of the routine functions of the UAP. If it is assignment, the person completing the nursing task is both responsible and accountable for that activity.
LPN’s who are performing nursing activities such as medication administration by most routes, g-tube feedings, or catheterization are most likely performing these as part of an assignment outlined in their job description. These nursing activities are within their scope of practice and most likely a part of their initial educational program or a specialized training. The professional nurse (RN or LSN) and the LPN should have a mutual understanding about which nursing activities are assignment, and which are under delegation.
School health office UAPs who have had training, maintain competency, and whose job description includes the administration of oral medications and first aid for minor injury or illness are most likely performing those as an assignment. The training for these activities are population based versus student specific. UAPs who are administering medications in any other route (inhaled, injected, rectal, sublingual) are most likely being delegated that medication specific to a student versus a school population. A well-developed job description or list of responsibilities is helpful in distinguishing assignment.
In most instances, a RN is not delegating to another RN but could be assigning a particular nursing task to another RN.
The professional nurse (RN) is responsible for training the persons to whom a nursing task is being delegated to prior to the person performing the nursing task for the first or subsequent times. These are some of the considerations related to training:
- What is the content of the training to ensure competency in performing the task and meeting the health and safety needs of the student?
- How will competency be evaluated? Knowledge check, return demonstration, etc.?
- How much time is there for initial training and repeat training if needed?
- How and where to document training and understanding of the delegated task?
- What are the communication methods between the nurse and delegatee? Verbal, email, or text? Under what circumstance is communication urgent verses non-urgent?
- What is the plan for an emergency? Who will be contacted? What if the RN cannot be contacted? How will that communication occur?
- How will the student’s right to privacy and confidentiality be protected?
- How will the delegatee document the nursing task provided and the student response?
In Minnesota, at present there are no specific training requirements; however, many professional resources are available for school nurses through the National Association for School Nurses and on the Managing Chronic Health Conditions in Schools.
Documentation of initial and on-going training must be completed. Best practices for documentation include documenting who was trained, materials used or provided in the training, evidence that the person demonstrated competency such as through checklists or return demonstration, and evidence that the delagatee understands any possible risks and how to respond to adverse event.
Monitoring and supervision are specially defined in statute for nursing practice. While both the LPN and RN have a role in monitoring, only the RN can provide supervision of a nursing task or activity. (Minnesota Statute § 148.171 subd. 8 and 23)
| Delegation | Monitoring | Supervision |
|---|---|---|
| Means the transfer of authority from the RN to another nurse or competent, unlicensed assistive person to perform a specific nursing task or activity in a specific situation. | Periodic inspection by RN or LPN of delegated or assigned activity and includes:
| Guidance by RN in the accomplishment of a nursing task or activity. Supervision consists of the monitoring AND:
|
As outlined in the Process of Nursing Delegation in the Five Rights of Delegation the amount, frequency, and type of supervision or monitoring is determined by the professional nurse (RN) is based on nursing assessment, complexity of the task, the student’s health condition, and the delegatee’s competence. Nurses should document both monitoring and supervision with each occurrence. Documentation should note the student’s response to the delegated nursing task and the delegatee’s comfort, competence, and adherence to the proper steps to complete the nursing task.
Delegation is necessary in most healthcare settings including schools. Delegation can be a safe and effective method to provide students with the necessary health care services to attend and learn in the school setting. Delegation is a complementary practice in school health, but it cannot be used as a substitute for professional nursing practice. To do so, puts the health and safety of the individual student at risk, can put non-nurse employees at risk for practicing nursing without a license, and increase the organizational risk for schools. The professional nurse and school administrators should work together to establish policy or procedures for safe nursing delegation.