Introduction

To benefit from educational programs and to maximize energy for learning, students with chronic health conditions need to maintain an optimal level of functioning in school. This requires access to safe environments and to health care services provided by school nurses licensed by the Public Education Department (PED) and, when appropriate, by qualified unlicensed assistive personnel (UAPs) to whom PED-licensed nurses can safely delegate certain aspects of student health care. The PED-licensed School Nurse uses professional judgment to decide which student health care tasks may be delegated, to whom, with what instructions, under whose supervision, and under what circumstances.

Definitions

Assignment of Nursing Activity — Assignment of nursing activity involves appointing or designating another licensed nurse or assistive personnel that is consistent with their scope of practice, if licensed, or role description, if unlicensed. (NMAC § 16.12.2.7)

Data Collection — The process of obtaining information, material, facts, or clinical observations which will be used in the assessment process; data collection is not limited to licensed individuals. (NMAC § 16.12.2.7)

Delegation — The transferring to a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains accountability for the delegation. (NMAC § 16.12.2.7)

Supervision/Direction — Initial verification of a person’s knowledge and skills in the performance of a specific function and/or activity followed by periodic observation, direction, and evaluation of that person’s knowledge and skills as related to the specific functions and/or activity. (NMAC § 16.12.2.7)

Unlicensed Assistive Personnel (UAP) — Any unlicensed personnel, regardless of title, to whom nursing tasks are delegated, including but not limited to Board of Nursing (BON) certified medication aides, Public Education Department (PED) licensed health assistants, clerks, and administrative assistants.

Standards of Delegation Practice

All licensed nurses are responsible for knowing rules, regulations, and policies for delegation of health services for the state in which they practice. The authority to delegate nursing care and standards for delegation practice in New Mexico are written into the New Mexico Administrative Code (NMAC § 16.12.2.12(B)) regulating nursing practice (NMAC § 16.12.2).

B. The nurse shall assign/delegate to licensed and unlicensed persons only those nursing actions which that person is prepared, qualified, licensed, or certified to perform.

   (1) The nurse is accountable for assessing the situation and is responsible for the decision to delegate or make the       assignment.

   (2) The delegating nurse is accountable for each activity delegated, for supervising the delegated function and/or activity, and for assessing the outcome of the delegated function and/or activity.

   (3) The nurse may not delegate the specific functions of nursing assessment, evaluation, and nursing judgment to non-licensed persons.

NMAC § 16.12.2.12(B)

National standards for delegating nursing care and for the use of unlicensed assistive personnel are articulated by the National Council of State Boards of Nursing (NCSBN), the American Nurses Association (ANA), the National Association of State School Nurse Consultants (NASSNC), and the National Association of School Nurses (NASN).

For more information, see links in Resources and References.

School Nurse's Responsibility for Quality Care

The PED-licensed School Nurse is uniquely qualified and ultimately responsible for:

• The management and provision of nursing care provided to students;
• All managerial decisions, policy-making, and practices related to delegation of nursing care;
• Assuring that the delegated task is performed in accordance with established standards of practice.

The School Nurse who assesses the student’s health needs and plans for nursing care is responsible for determining the task(s) to be delegated. It is inappropriate for employers or others to require nurses to delegate when, in the nurse’s professional judgment, delegation is unsafe and not in a student’s best interest. While school administrators have certain responsibilities regarding the educational placement of students, they cannot legally assume responsibility for deciding the level of care required for any individual student with specialized health care needs.

The registered professional School Nurse is responsible for determining whether delegation of nursing care is appropriate in each individual situation—even if a physician or other health professional states or “orders” that specific care should be provided by a UAP, unless that physician or other professional takes full responsibility for training and supervising the UAP.

While the New Mexico Nursing Practice Act makes exceptions for parents or family members to provide nursing care in their homes, this exception to the licensure provisions does not empower these individuals to extend that right to others in other settings. Parents do not have the authority in the school setting to make administrative decisions or to supervise school staff. The family, licensed School Nurse, school health team, and health care provider(s) must collaborate in planning to provide high quality care in an environment that is least restrictive and safe for all students and school staff.

The Five Rights of Delegation

All decisions related to delegation of nursing activities should be based on the fundamental principles of public protection. The five rights of delegation are identified in the Joint Statement on Delegation (2019) from the American Nurses Association (ANA) and National Council of State Boards of Nursing (NCSBN):

• Right Task: An appropriate task to delegate is one that can be delegated to a specific person for a specific client. Organizational policies, procedures, and standards must allow for delegation for it to be considered appropriate. Typically, tasks which might be considered for delegation include those that reoccur in the daily care of a specific student, utilize a standard and unchanging procedure, do not require the UAP to exercise nursing judgment, and for which the results are predictable and the potential risk is minimal.
• Right Circumstances: Appropriate setting, available resources, and other relevant factors should be considered when evaluating the right circumstances. Clear lines of authority must be established, and sufficient nursing staff should be available for UAPs to receive adequate supervision. The complexity of the delegated task should be consistent with the competency of the UAP and with the level of supervision available. The supervising nurse must be available for telephone consultation at all times.
• Right Person: This right refers to the right person, the nurse, delegating the right task to the right person, the UAP, to be performed on the right person, the student. Organization standards should specify the training and competency requirements for school nurses and UAPs involved in delegation. Verification of the UAP’s competency to perform a task should be documented on an individual and client-specific basis.
• Right Direction/Communication: Clear and concise description of the task, including objectives, limits, and expectations should be provided by the delegating nurse. The UAP should ask any clarifying questions and accept the delegated activity. Individualized student health care plans should include tasks to be performed, data to be collected, required documentation, expected results, potential complications, and criteria for when to report to the school nurse.
• Right Supervision/Evaluation: The licensed nurse must ensure appropriate monitoring, evaluation, intervention, and feedback of the delegated task. Supervision, feedback, and evaluation of the performance of the delegated task may be provided by the delegating nurse or by another licensed nurse to whom that responsibility has been assigned. While data may be collected by the UAP, evaluation of the student’s response to care remains the responsibility of the school nurse.

ANA and NCSBN. (2019). National Guidelines for Nursing Delegation.
View resource

Tools for Delegation Decision Making

The National Council of State Boards of Nursing (NCSBN) and the National Association of School Nurses (NASN) have developed tools to assist nurses in making appropriate delegation decisions. Links to the NCSBN Delegation Decision Tree, as well as NASN Tools and Resources, can be found in Resources and References.

Safe Care Provision at School

After consultation with the family, health care provider(s), members of the school health team, and appropriate consultants, the PED-licensed School Nurse might determine that the level of care required for the student cannot be safely provided under existing circumstances at the school. In this situation, the School Nurse should refer the student back to the initial assessment team to reassess the student’s needs and explore alternative options for a safer and more appropriate program.

When the PED-licensed School Nurse identifies an unsafe situation, they should consider the following guidelines when planning follow-up procedures:

• Provide written documentation of the unsafe situation to his/her immediate supervisor, with recommendations for correcting the unsafe situation and/or rationale for why care should not be performed in the school setting.
• Until the unsafe situation is resolved, regularly document and notify supervisor that an unsafe condition exists.
• Maintain a copy of all written correspondence concerning the unsafe situation.
• Allow for a reasonable time frame to initiate action to safeguard the student involved.
• If corrective action does not occur, forward documentation and recommendations to appropriate agencies/individuals, including the School District Superintendent, State Board of Nursing, PED/DOH School Nurse Consultant, DOH Regional School Health Advocate, and DOH Regional Health Officer.

Primary Editor: Kate LaRose, BS, RN, School Health Advocate, NE Region, New Mexico Department of Health

Secondary Editor: Susan Acosta, BS, RN, NCSN, State School Health Consultant, New Mexico Department of Health