Unlicensed Assistive Personnel and the Registered Nurse

Unlicensed Assistive Personnel and the Registered Nurse.

Chapter 8 Unlicensed Assistive Personnel and the Registered Nurse

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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

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

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.

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

Question #1

Is the following statement true or false?

Currently, strict standards related to the educational requirements are in place for UAP.

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.

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)

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

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

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

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

Answer to Question #2

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.

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

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

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)

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

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

Question #3

Is the following statement true or false?

The RN is responsible for instructing UAP in how to properly perform the assigned care.

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.

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

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

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

End of Presentation

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Unlicensed Assistive Personnel and the Registered Nurse

Unlicensed Assistive Personnel and the Registered Nurse

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