Current through Register 1518, March 29, 2024
The licensed nurse is responsible for engaging in the practice
of nursing in accordance with the nurse's scope of practice as defined at
M.G.L. c. 112 § 80B, and 244 CMR: Board of Registration in
Nursing within the limits of the nurse's educational preparation,
subsequent acquired education, experience and demonstrated competence. Nursing
assessment and analysis of the nursing needs of a patient, development of the
nursing plan of care, implementation of the plan, and evaluation of the plan
are essential components of nursing practice and are the functions of the
licensed nurse. The full utilization of the services of a licensed nurse may
permit him or her to delegate selected nursing activities to unlicensed
persons. Although unlicensed persons may be used to complement the licensed
nurse in the performance of nursing functions, such persons cannot be used as a
substitute for the licensed nurse. The following sections govern the licensed
nurse in delegating and supervising nursing activities to unlicensed
persons.
(1)
Definitions. Definitions for terms used in 244 CMR
3.05 and throughout 244 CMR are set forth in 244 CMR 10.00: Definitions
and Severability.
Delegation - The authorization by a
qualified licensed nurse to an unlicensed person as defined in 244 CMR 3.05(1)
to provide selected nursing services.
Supervision - Provision of guidance by
a qualified licensed nurse for the accomplishment of a nursing task or activity
with initial direction of the task or activity and periodic inspection of the
actual act of accomplishing the task or activity.
Unlicensed Person - A trained,
responsible individual other than the qualified licensed nurse who functions in
a complementary or assistive role to the qualified licensed nurse in providing
direct patient/client care or carrying out common nursing functions. The term
includes, but is not limited to, nurses' aides, orderlies, assistants,
attendants, technicians, home health aides, and other health
aides.
(2)
General Criteria for Delegation. Regardless of
setting, the licensed nurse who delegates nursing activities to unlicensed
persons must comply with the following requirements:
(a) The delegating nurse is directly
responsible for the nature and quality of nursing care rendered under his or
her direction. However, in the event the qualified unlicensed person deviates
from the instruction, nursing plan of care or other delegating nurse directive,
the delegating nurse does not bear responsibility and accountability for the
outcome of the delegated activity performed by the unlicensed person.
(b) The final decision as to what can be
safely delegated in any specific situation is within the scope of the
delegating nurse's judgment.
(c)
Prior to delegating the nursing activity, the delegating nurse must make an
assessment of the patient's nursing care needs and care delivery setting to
ensure it can be safely delegated to the unlicensed person.
(d) The nursing activity to be delegated must
be one that a reasonable and prudent nurse would determine to be delegable
within the scope of nursing judgment; would not require the unlicensed person
to systematically assess, analyze, interpret, plan and/or evaluate patient
data. The delegated activity must be one that can be properly performed by the
unlicensed person without jeopardizing the patient's safety and
welfare.
(e) Said delegation must
occur within the job description of the unlicensed person, and the employing
agency's policies and procedures in compliance with 244 CMR 3.05(4) and (5).
Such employer policies and procedures must include acknowledgement that the
final decision to delegate is made by the delegating nurse only. Employer
policy or contractual language can not mandate the licensed nurse to delegate,
nor mandate any components of the delegation process.
(f) The unlicensed person must have on file
within the employing agency current documentation of the unlicensed person's
competencies for the proper performance of each of the nursing activities
identified within the unlicensed person's job description. Such documentation
must demonstrate that the unlicensed person's competence for each nursing
activity has been periodically validated; and that an administratively
designated nurse has communicated the unlicensed person's job functions and
competencies to the licensed nurse(s) who will be delegating activities to the
unlicensed person. Uniform training and certification may be used as a basis to
presume the baseline competencies of an unlicensed person.
(g) In addition to the unlicensed person's
competence to perform selected nursing activities, other competencies to be
considered include, but are not limited to, the unlicensed person's ability to
effectively collaborate, communicate and cooperate, as appropriate, with other
health care providers and with the patient.
(h) The delegating nurse must provide the
unlicensed person with a nursing plan of care that includes, but is not limited
to, the desired effect of the activity, the sequence of steps to perform the
activity, adverse side effects to be reported to the appropriate licensed
nurse, and the need to report to the licensed nurse those activities that do
not produce the desired effect.
(i) The delegating nurse must adequately
supervise the performance of the delegated nursing activity in accordance with
the requirements of supervision as found in 244 CMR 3.05(3).
(j) The delegating nurse can determine at any
time that the nursing activity can no longer be delegated based on a change in
the health status of the patient, in the unlicensed person's performance of the
activity, or other reason the delegating nurse determines may jeopardize
patient health or safety.
(3)
Supervision. The
delegating nurse must provide adequate supervision of all nursing activities
delegated to unlicensed persons. The degree of supervision required is
determined by the delegating nurse after an evaluation of appropriate factors
involved including, but not limited to:
(a)
the stable and predictable nature of the patient's condition;
(b) the training, capability and initial and
continued demonstrated competency of the unlicensed person to perform the
activity;
(c) the complexity of the
nursing activity being delegated;
(d) the proximity and availability of a
licensed nurse to the unlicensed person when performing the nursing activity,
which may include the use of telephonic or other telecommunication device(s);
and
(e) the availability and
accessibility of other employed health care personnel, resources and written
employer policies and procedures. Such policies and procedures must, at a
minimum, describe established channels of communication and include a system
for reporting and responding to a deviation from the nursing plan of care by
the qualified unlicensed person.
(4)
Delegation of Nursing
Activities. By way of example, and not in limitation, the
following nursing activities are usually considered within the scope of nursing
practice to be delegable, and may be delegated provided the delegation is in
compliance with 244 CMR 3.05(2):
(a)
Activities that meet one or more of the following criteria:
1. can be performed according to an
established sequence of steps leading to a predictable outcome;
2. do not require nursing assessment and
judgment during implementation; or
3. do not involve modification;
(b) The collecting, reporting, and
documentation of simple data;
(c)
Activities which meet or assist the patient in meeting basic human needs
including, but not limited to: nutrition, hydration, mobility, comfort,
elimination, socialization, rest and hygiene;
1. The unlicensed person must have initial
and periodically validated competencies specific to the administration of
medication on file within the employing agency, and an administratively
designated nurse must communicate this information to the delegating nurse who
will be delegating and supervising the unlicensed person;
2. The patient must have a current and valid
medication order issued by a duly authorized prescriber for each medication to
be administered by the unlicensed person;
3. The patient must have properly labeled
prescribed medication consistent with the prescriber's valid medication
order
4. The delegating nurse will,
at regular intervals, assess the patient to monitor the patient's progress and
the effect of the medication on the patient;
5. The delegating nurse will review the
patient's medication records at regular intervals including, but not limited
to, the unlicensed person's medication administration documentation practices
pursuant to the employer agency's policies and procedures;
6. The nursing plan of care must include, but
is not limited to, the desired effect of the medication; the medication's
correct dose, route and frequency of administration; adverse side effects to be
reported to a licensed nurse; and the need to report to the licensed nurse
those medications that produce no results or missed doses as reported by the
patient; and
7. Prior to delegating
the administration of medication to an unlicensed person, the delegating nurse
must:
a. verify that nursing personnel,
resources and channels of communication are readily accessible to the
unlicensed person in the event the delegating nurse is unavailable to provide
consultation on request from the unlicensed person;
b. verify there are instructions for
unlicensed persons to follow when there is a medical emergency related to
medication administration; and
c.
provide instructions for the safe storage of medications.
(5)
Nursing
Activities That May Not Be Delegated. By way of example, and not
in limitation, the following are nursing activities that are not within the
scope of sound nursing judgment to delegate:
(a) Activities that meet one or more of the
following criteria:
1. require nursing
assessment, analysis, planning and evaluation of patient data leading to a
clinical conclusion during implementation;
2. may lead to an unpredictable outcome;
or
3. involve anticipated
modification.
(b)
Physical, psychological, and social assessment which requires nursing
assessment, analysis, planning and evaluation of patient data leading to a
clinical conclusion, intervention, referral and/or follow-up;
(c) Formulation of the nursing plan of care
or evaluation of the patient's response to the care provided, or both;
and
(d) Administration of
medications except as permitted in M.G.L. 94C, and
105 CMR 700.000:
Implementation of M.G.L. c. 94C. In addition to complying with
244 CMR 3.05(2)(a) through (j) and (3)(a) through (e), and, when the licensed
nurse is employed as a School Nurse,
105 CMR 210.000:
The Administration of Prescription Medications in Public and Private
School, the delegation of medication to an unlicensed person must also
comply with the following requirements.
(6)
Patient/Client Health
Teaching and Health Counseling. It is the responsibility of the
licensed nurse to promote patient education and to involve the patient and,
when appropriate, other individuals in the establishment and implementation of
health goals. While an unlicensed person may provide information to the
patient, the ultimate responsibility for health teaching and health counseling
must reside with the licensed nurse as it relates to nursing and nursing
services.
