Delegation is defined as the ability of the nurse to transfer the responsibility of a nursing task to an unlicensed person while the nurse continues to be accountable for the outcomes (American Nurses Association [ANA], 2007). Delegation of nursing tasks in school settings is a necessity given the multitude of school nursing responsibilities, the increase of health needs among students in the 21^st century, and the limited number of school nurses available to meet these needs. A variety of factors influence this growing need, yet barriers to the safe and effective practice of delegation continue to challenge school nurses and concern others.

One such concern is the lack of an adequate number of school nurses to provide quality care in schools. The nationally recommended nurse to student ratio is 1 nurse to 750 well students (National Association of School Nurses [NASN], 2010). However, it is well documented that school nurses often cover more than one school building and have nurse to student ratios as high as 1:4,000 (NASN).

According to the ANA and the National Council of State Boards of Nursing [NCSBN] (2006):

Delegation is a process that, used appropriately, can result in safe and effective nursing care. Delegation can free the registered nurse to attend to more complex patient care needs, develop the skills of nursing assistive personnel and promote cost containment for the healthcare organization (Conclusion, 1).

...the process of delegating nursing care often includes complex legal and clinical issues...However, the process of delegating nursing care often includes complex legal and clinical issues related to the necessary education and supervision of unlicensed personnel. This is especially true in school settings where the school nurse may be the only healthcare professional in the building (Selekman, 2006), and where there is no cookie-cutter recipe or "one-size fits all" solution to delegation issues that arise in these settings. Nonetheless, there are principles, standards of care, regulations, and laws to guide the school nurse in delegating some of the care needed.

This article will discuss the need for delegation; the factors necessary for safe delegation; the benefits and challenges associated with delegation; and the implications of delegation for practice in school settings, including policy development, the rights of delegation, education for delegation, and the building of relationships that support delegation. The Table below provides definitions related to delegation that will be used throughout this article.

Need for Delegation in the School Setting

The need for delegation of nursing tasks in the school setting is greater today than ever before due to the following factors identified by NASN (2006a), NASSNC (2000), and Spriggle (2009).

• unfunded mandates, such as health screenings and immunization reporting, that pull the school nurse away from direct care;
• shortage of qualified nursing staff in schools, i.e., lack of nurses that meet the state requirement to work as a school nurse;
• budgetary constraints that limit the schools’ ability to hire and retain qualified staff;
• staffing patterns that assign one nurse to multiple school buildings thereby leaving buildings without nurses at various times; and
• federal and state requirements, such as the Individuals with Disabilities Education Act (IDEA) of 1975, Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act of 1990, requiring that school health services for complex student health needs, such as providing care to ventilator-dependent children, be provided so that students can access their education.

As mentioned above, two major federal laws have greatly influenced the need for health services in the school setting. Section 504 of the Rehabilitation Act of 1973 was established as a civil rights provision that prohibits the discrimination, on the basis of handicap, by agencies and organizations (including most schools) if they receive federal funds. It requires these agencies to provide individuals with access to programs, buildings, and services; and it prohibits exclusion of a student based solely on a handicap. To be eligible for service under Section 504, a student needs to have a physical or mental health impairment that substantially limits a major life function, such as eating, seeing, hearing, and/or walking. Additionally, the Individuals with Disabilities Education Act was initially adopted in 1975 to provide federal funds to states that provide for “a free, appropriate education in the least restrictive environment to students who qualify as disabled under this law” (Schwab & Gelfman, 2001, p. 63). In return for these funds states are required to provide special education and related services, including complex school health services, so that all students have access to the education offered by the school (Schwab & Gelfman).

Due to...federal requirements many children who are now attending schools rely on assistive medical equipment, such as ventilators, pacemakers, and insulin pumps. Due to these federal requirements many children who are now attending schools rely on assistive medical equipment, such as ventilators, pacemakers, and insulin pumps. In addition, many children also require skilled nursing care, such as gastrostomy tube feedings, nebulized treatments, intermittent catheterizations, and administration of various medications (ANA, 2007). NASN (2006b) has concluded that the registered professional school nurse is the healthcare provider who has the knowledge, education, experience, and authority to manage and provide the full range of these health services in these educational settings. School nurses are in a position to use their expert assessment skills to address a myriad of health conditions and behaviors and who, when safe and determined by the school nurse as appropriate, have the ability to delegate some nursing functions to unlicensed assistive personnel (UAPs). This growing need to provide skilled nursing care increases the need to properly utilize trained UAPs, while continuing to provide safe and high quality healthcare in the school environment.

Factors Necessary for Safe and Effective Delegation

...delegation is not appropriate for all students, all nursing tasks, and/or all school settings. In order to provide safe healthcare in the school setting, school nurses need to understand the legal parameters, e.g. their state Nurse Practice Acts, rules, and regulations; along with clinical parameters, such as the standards of practice and professional health-related position statements developed by professional organizations, including, among others, the American Nurses Association, the National Association of School Nurses, and the American Academy of Pediatrics, for delegating nursing tasks and responsibilities to UAPs. In addition, the individual nurse’s critical thinking skills are of utmost importance in providing safe care. The NASSNC (2000) has stated that the RN (registered nurse) “must determine which student care activities may be delegated, under what circumstances it is appropriate to delegate aspects of student care, and by whom the...care can safely be provided.” Based on the guiding principles set forth by ANA (2005), NASSNC, and NCSBN (1995), it is clear that delegation is not appropriate for all students, all nursing tasks, and/or all school settings.

For delegation to be safe and effective, it is essential for school nurses to have appropriate education related to delegation, including an understanding of state nurse practice acts and regulations and formal opinions on what nursing responsibilities and tasks can and cannot be delegated to UAPs (AAP, 2009; ANA, 2007; Gordon & Barry, 2009; Spriggle, 2009). It is also important to recognize that the regulation of nursing practice varies greatly from state to state. Some states have clear statements and regulations; others have vague or no statements at all; and still other states do not allow any delegation of nursing responsibilities to UAPs. For example, the Connecticut General Statute (C.G.S.), Section 20-87a defines the practice of nursing by an RN as:

The process of diagnosing human responses to actual or potential health problems, providing supportive and restorative care, health counseling and teaching, case finding and referral, collaborating in the implementation of the total healthcare regimen, and executing the medical regimen under the direction of a licensed physician, dentist or advanced practice registered nurse (C.G.S., Chapter 378, Section 20-87a).

No reference to delegation is included in this statutory language; however, the Connecticut Board of Examiners for Nurses has issued two declaratory rulings that delineate delegation. These declaratory rulings, Licensed Practice Nurses (1989) and Delegation by Licensed Nurses to Unlicensed Assistive If school nurses examine only their Nurse Practice Acts and not their state’s declaratory rulings, they may miss important rulings they need to be aware of before delegating...Personnel (1995) set clear guidance on what can and cannot be delegated to UAPs in Connecticut. If school nurses examine only their Nurse Practice Acts and not their state’s declaratory rulings, they may miss important rulings they need to be aware of before delegating school nursing tasks to others.

Even with formal education regarding delegation, school nurses may lack experience in delegation and hence may not be comfortable delegating responsibilities or tasks to UAPs. According to ANA and NCSBN (2006) the development of delegation skills occurs over time and with experience. New registered nurses, whether in a school or an inpatient setting, are still developing their basic skills and may lack the knowledge or expertise needed for skillful delegation of nursing activities. Even more mature or seasoned school nurses may lack the confidence needed to delegate competently to UAPs.

Benefits of Delegation in the School Setting

The literature provides support for the contribution UAPs make in schools when there is adequate training and supervision for the UAP (Hanson, Randolfi, & Olson-Johnson, 2002; Selekman, 2006). Many school nurses, too, believe that UAPs can meet important student healthcare needs provided their role is clearly defined and within the scope of the individual UAP’s competence and proficiency. School nurses have the responsibility for a wide range of nursing activities, including direct care, case management, coordination of care, health screenings, health teaching, promoting a healthy and safe environment, as well as recording and documenting immunizations, physical examination data, and health insurance status (AAP, 2008; NASN, 2006b; NASSNC, 2000). Within these various roles and responsibilities, there are many opportunities for a school nurse to safely and effectively utilize UAPs. Depending on state laws and individual UAP competency, nursing tasks in school settings, including medication administration; health screenings for vision and hearing; gastrostomy tube feedings; intermittent catheterizations; and clerical tasks, such as documenting immunizations and health assessments, may safely be delegated to UAPs.

...school nurses... viewed delegation as an opportunity for the school nurse to engage in other nursing responsibilities, such as health education or caring for students with more complex healthcare needs. The complexity of care needed by some children can pose challenges to school nurses. Some of these medically fragile children need to have a one-to-one staff person with them at all times to monitor their health status. In these situations, a UAP might be the appropriate person to monitor such students. With the proper protocol and an individualized plan of care delineated by the school nurse, the UAP could be responsible for observing the student throughout the day; providing routine care; identifying potentially life-threatening situations; and seeking the school nurse to conduct any necessary assessments or adjustments to the plan of care based on the student’s condition. In these situations, too, UAPs can become an essential component of the nursing care plan.

According to Spriggle (2009), school nurses that received education in delegation view the use of delegation in a positive manner because it affords them time in the classroom for health teaching and direct student contact. Tetuan and Akagi (2004) noted that school nurses who had not had any education in delegation did not view it as an opportunity for them to provide health education to students but rather as a potential threat that might lead to the elimination of school nurse positions. Both studies indicated that school nurses who were educated and experienced in delegation viewed delegation as an opportunity for the school nurse to engage in other nursing responsibilities, such as health education or caring for students with more complex healthcare needs. Health education in the school setting often includes individual teaching to students and their families; group education to students on a broad array of topics, such as tobacco and alcohol prevention; and health education for teachers and administrators regarding the educational implications of the common student health needs and accompanying interventions.

Challenges in Delegation

As noted above, delegation may be a solution in situations when there are less than the optimal number of school nurses available and/or growing numbers of students with healthcare needs as long as adequate training is provided for UAPs. One of the delegation challenges is to provide this needed training. This training should include an understanding of student health needs, the task to be performed, the expected outcomes, and any potential side effects. All training for UAPs must include practice in performing each task and a demonstration of competence prior to giving the UAP responsibility for the task. The school nurse is the person responsible for ongoing training of the UAPs, for monitoring the student’s responses to the care provided by the UAP, and for evaluating the UAPs performance. This supervision and monitoring of UAPs is generally taken to include periodic “on-site” visits for which the nurse is physically present or immediately available to assess the student’s response to the care and provide feedback to the UAP providing the care. The school nurse might provide supervision by making a monthly visit to observe a particular UAP obtain a blood glucose level on a young student, record the results, and decide whether any additional action is necessary based on the blood glucose results.

RNs err when they allow UAPs to perform tasks for which they have not been prepared... Delegation can be a solution only when the UAPs have been well prepared to carry out a specific task and thoroughly understand their responsibilities in doing so. Situations in which an RN is asked to delegate to a UAP without evidence that the UAP is proficient in performing the task and understands the responsibilities inherent in performing this task poses a risk to the student and to the RN’s professional standing. For example, if a student routinely requires daily treatments for asthma and the UAP is not competent in monitoring the student’s response to the treatment, early indicators of respiratory distress might be missed by the UAP, resulting in acute respiratory distress for the student and the RN being held liable for the outcome of this inappropriate delegation.

The high ratio of school nurse to students in some school districts, as well as hiring nurses part time in a school system or asking a nurse to cover multiple school buildings, may limit the use of delegation as an option for some school nurses as the nurse would not be able to provide the close supervision required when delegating nursing tasks and responsibilities to UAPs.

Another challenge to delegation is that school administrators often do not understand the legal and regulatory parameters which guide delegation in the nursing arena, and especially in school settings. Nor do they understand the complexity of delegating care in school settings which, as NASN (2006a) has noted, is more complex in the non-traditional healthcare settings, such as in a school, than in the more traditional healthcare settings.

Some schools lack policies regarding who can care for students with health needs when the nurse is not available. This leads to inappropriate delegation by administrators to principals, teachers, office or cafeteria staff, social workers, psychologist, and/or coaches whose primary function and scope of practice does not include providing nursing care (Schwab & Gelfman, 2001; Tetuan & Akagi, 2004). The school nurse needs to remind administrators and other personnel that only an RN can delegate health-related tasks to others. The school nurse needs to have input into all delegation of nursing responsibilities (NASN, 2005; Spriggle, 2009).

Inappropriate delegation occurs because non-nurse personnel do not realize that nursing tasks commonly performed in the home setting by a student or caregiver take on a more complex dimension in the school setting. Parents and school administrators may be confused as to why what appears to be a simple task is held to a much different and higher standard at school (NASN, 2006a). Additionally, parents and school administrators often do not understand that there is a requirement for medical orders for any health-related procedures in the school setting; that nurses are held to higher protocol standards than a parent would be (e.g., the use of gloves in the school setting versus simply washing hands before a procedure in the home), and that a student’s response to a given intervention at school may differ from the student’s response in the home setting. Tetuan and Akagi (2004) have stated that “administrators visualize the nurses’ role as performing tasks and not making judgments, thereby assuming anyone can be trained to perform the duties of the school nurse” (p. 356). Administrators, teachers, and parents need help in understanding that the role of the school nurse is not simply to perform a “task” but also to assess both the situation and the student and to develop the right plan of care for each particular student.

The need to address the public’s lack of understanding regarding delegation in school settings is essential for providing safe nursing care in schools.Delegation of nursing tasks by non-nurses, such as school administrators, can create litigious situations for both schools and school nurses. In Mitts v. Hillsboro Union High School District, 1987, the courts asked the Oregon Board of Nursing for a formal opinion on the delegation of intermittent catheterization of a student with spina bifida by a school principal to a school health assistant, despite the presence of a school nurse on staff. The Board found that (a) the school principal was practicing nursing without a license when he assumed responsibility for assessing, planning, and delegating healthcare for this student, and (b) that the health assistant was unlawfully practicing nursing by following the principal’s assignment. The school nurse in this situation was disciplined for failing both to follow a standard of care and to conduct a nursing assessment on the appropriateness of delegation (Schwab & Gelfman, 2001). The need to address the public’s lack of understanding regarding delegation in school settings is essential for providing safe nursing care in schools.

A third challenge to delegation in the school setting is that the primary mission and purpose of schools is not the provision of healthcare but rather of education (Davis-Alldritt, 2009). Although healthcare is essential for student achievement, it is not the school’s primary mission. With school budget cuts, a lack of understanding of the school nurse’s roles and responsibilities, and an unintentional lack of focus on healthcare; school nurses may be faced with choosing between following nursing standards/regulations/directives and the demands of school administrators to delegate nursing tasks. This may occur when administrators do not clearly understand the regulations and standards under which nurses must practice and/or when financial realities blind these administrators to the need for nurses to follow these regulations and standards. Whatever the reasons for these inappropriate demands on the part of school administrators, these demands result in considerable agony and stress for school nurses. Refusing to meet the demands of school administrators may place the nurse’s job in jeopardy. Yet at such times nurses must remember that “employer policies or directives do not relieve the school nurse of responsibility for determining the delegation of nursing tasks” (Davis-Aldritt, 2009, p. 182). RNs err when they allow UAPs to perform tasks for which they have not been prepared and/or for which they are not competent to perform; to administer medications when not permitted by state law; or to determine when “as needed” treatments should be administered. “As needed” treatment determinations necessitate a nursing assessment; they cannot be delegated to someone other than an RN.

Implications of Delegation for School Nursing Practice

The implications of appropriate delegation of nursing tasks for school nurses center around four major themes: development of school policies, competence in the five rights of delegation, education, and building relationships. Each of these themes will be discussed below.

Development of Policies

School nurses need to work with their administrators, whether in a school or any healthcare setting, to establish policies and procedures regarding delegation in an effort to offer safe, quality care to all. School nurses play a critical role in the development of such policies due to their knowledge and expertise regarding health-related needs and the delivery of healthcare. Policy development provides an opportunity for the school nurse to educate administrators, board members, and parents about the legal, regulatory, and educational requirements of delegation. The steps of policy development and implementation include: defining the issue or problem, gathering the necessary information to inform the problem/issue at hand, proposing recommendations, debating and discussing the recommendations with a broad group of stakeholders, finalizing and adopting the recommendations, providing oversight to ensure implementation, and assuring ongoing evaluation of the policy (Spriggle, 2009).

The Five Rights of Delegation

Understanding the Five Rights of Delegation outlined by NCSBN (1995) is essential for the school nurse to gain confidence and expertise in making sound decisions regarding delegation of nursing tasks to UAPs. These five rights consist of the right task, right circumstance, right person, right direction/communication, and right supervision/evaluation.

Similar to the five rights of medication administration, the Five Rights of Delegation provide the framework for safe delegation of nursing tasks. Formal checklists based on these five rights can serve to communicate and document the school nurse’s decision-making process in determining safe delegation. Each school nurse must consider safety, the needs of the student, the stability of the student, the complexity of the task, the competence of the UAP, the expected outcomes, and the needs of other students in determining the appropriateness of delegating a specific task to a UAP. Ultimately, school nurses are held accountable for delegating tasks appropriately, implementing them safely, and achieving positive outcomes.

Blood glucose monitoring provides a good example of how school nurses must utilize the Five Rights of Delegation to determine whether it would be appropriate to delegate this task. In school settings, blood glucose monitoring is often delegated to UAPs. However, it would not be appropriate to universally delegate blood glucose monitoring to unlicensed school staff because there are particular situations in which it would be unsafe to do so. Before delegating this monitoring the nurse should assess the student’s health history, fluctuations in blood glucose levels, responses to previous interventions, and the frequency of blood glucose emergencies in the past. Ultimately, the appropriateness of delegation can only be determined by a registered professional school nurse who engages in a thoughtful, decision-making process to determine whether delegation would be appropriate in the given situation (NASN, 2006a).

Education

Educational preparation for school nurses should include, but not be limited to, learning about their individual state Nurse Practice Act; the scope and standards for the professional school nurse; and the principles set forth by the National Association of School Nurses, the National Association of State School Nurse Consultants, and the American Nurses Association, as well as other professional organizations. School nurses need to become knowledgeable regarding their individual state nurse practice acts and any pertinent state rulings and regulations. These formal acts, rulings, and regulations determine the legality of delegation decisions provided in the school. In addition school nurses also need to understand the scope and standards of practice for school nurses as set forth by relevant professional associations. These standards articulate the competencies and measures for safe nursing practice in a given specialty area, such as school nursing. Together, these regulations and standards form the legal underpinnings for the transfer of responsibility for nursing tasks from the RN to a given UAP.

This education can be provided formally through academic nursing courses and school nurse orientation programs. It can also be provided informally as individual nurses explore the school nursing literature and confer with other nurses and nursing leaders at their state nursing board to learn about the legalities of school nursing in their state.

School nurses also need to obtain the skills necessary to train, supervise, and determine the competency of others performing nursing tasks. Ultimately, the school nurse is accountable for all actions performed by the UAPs. School nurses delegate responsibly when they determine that the UAP has the appropriate training and competency to perform a task safely before delegating a task to this UAP. For liability purposes, the school nurse must possess the skills to make these determinations and to educate and supervise others. However, as Schwab and Gelfman (2001) have noted:

If the nurse fulfills [his/]her responsibilities as a supervisor (e.g., makes an appropriate assignment or delegation, trains and supervises the UAP, and evaluates student outcomes and UAP performance on a periodic basis), the supervising nurse should not be liable for the unpredictable errors of the UAP (p.149).

While ultimately the interpretation of the school nurse’s accountability for delegation will be determined based on legal precedent, school nurses may be liable for adverse outcomes when it is not evident that the person to whom they delegated a task had the training and competency to perform the given task. It is not anticipated that they would be liable for unexpected errors made by a well-trained and competent UAP.

Building Relationships

Finally, the school nurse needs to build trusting relationships for safe and effective delegation. This requires taking the time to establish trust between all parties, including the school nurse, the school administrators, the UAPs, and students and their families before delegation occurs. Building trusting relationships fosters an environment in which all involved in the delegation can gain an appreciation of the complexity of delegation and the various responsibilities of each of the team members involved in the process of delegation. These trusting relationships ultimately enhance the safety and appropriateness of care provided to the students. To build this trust school nurses need to gain the respect of all parties for their expertise in meeting student healthcare needs and in turn to have confidence in the abilities of the entire school health team (Broussard, 2007).

Conclusion

Safe delegation is critical for the provision of safe, effective, and efficient health services in school settings. To ensure safe delegation practices, it is essential that RNs, other healthcare professionals, administrators, parents, and the public understand the various roles that the school nurses and UAPs play. Delegation can be a valuable tool in meeting the growing health needs of students, as long as the nurse and UAP adhere to established legal parameters, sound delegation policies are in place, the five rights of delegation are considered, education for both the nurse and the UAP is provided, and trust exists among all members of the healthcare team.

Author

Cheryl Resha, EdD, MSN, RN
E-mail: reshac1@southernct.edu

Dr. Cheryl Resha is currently Director for the Child Nutrition and School Health Programs at the Connecticut State Department of Education. She is also an adjunct faculty member at the University of Hartford, Division of Nursing. Dr. Resha began her career as a pediatric nurse at the Children's Hospital of Philadelphia where she worked in the ICU, ER, and ambulatory care settings, developing a special interest in children with special healthcare needs. Continuing to pursue her passion for promoting healthy outcomes for children, Dr. Resha moved into the field of school nursing. In this capacity, Dr. Resha developed several publications to guide school nursing practice in Connecticut. Dr. Resha has received the Outstanding State School Nurse Consultant Award and also the American Academy of Pediatrics Martin Sklaire Award for excellence and leadership in school health. Dr. Resha continues to advocate for children, school nurses, and school health programs. In addition to her work at the Connecticut State Department of Education, Dr. Resha serves on the American Nurses Association Congress of Nursing Practice and Economics and on the editorial board of the Journal of School Nurses. Dr. Resha received a Bachelor of Science in Nursing degree from Salve Regina University in Newport, RI, a Master of Science in Nursing degree from the University of Hartford (CT), and a doctoral degree (EdD) in Educational Leadership from the University of Hartford.

Individuals with disabilities education act (IDEA). (1975), 20 U.S.C. §§1400 et seq.

Rehabilitation act of 1973. (1973). (Section 504), 29 U.S.C.§794.

© 2010 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2010