As a member of Ohio Nurses Association Government Affairs Committee, I have been deluged with requests to review proposed legislation and rules related to nursing. Pharmacists are attempting to enact legislation that will allow them to administer medications (30 states have passed similar legislation), the role of unlicensed assistive personnel is expanding as the nursing shortage continues, and the distinction between registered nurses and licensed practical nurses has almost faded away. The boundaries between different groups of professionals, as well as between professionals and nonprofessionals, have blurred so much that an activity such as medication administration is now considered by legislators appropriate to be performed by registered nurses, licensed practical nurses, unlicensed assistive personnel, pharmacists, dialysis technicians, and the list goes on.

Perhaps medication administration, although historically performed predominantly by registered nurses, rightfully belongs to other groups as well. Physicians who traditionally performed otoscopic exams to diagnose otitis media see this activity routinely performed by nurse practitioners, certified nurse midwives, and physician assistants. We are at a point now where arguments that specific activities can only be performed by one group of practitioners based on history will not work (and shouldn't). The profession of nursing needs to develop consensus around what makes a nursing task or activity one that can only be performed by a registered nurse versus what nursing tasks and activities can be shared and delegated. These registered nurse activities and tasks should be the same throughout the United States and reflected in state legislation. However, this is not the case.

Let me give a few examples of the confusion surrounding legislation or rules dealing with nursing activities or tasks. Ohio, as numerous other states, is currently drafting staffing principles legislation. One proposed principle is the following:

No facility may assign an unlicensed person to perform nursing functions in lieu of a registered nurse. Additionally, no facility may allow unlicensed personnel to act under the direct supervision of a registered nurse to perform certain functions, including but not limited to, medication administration, intravenous therapy, venipuncture, parenteral or tube feedings, invasive procedures including the insertions of nasagastic tubes, catheters or tracheal suctioning, assessment of patient condition, and education of patients and their families concerning the patient's health care problems, including post discharge care.

Several questions need to be asked. What is a nursing function? What criteria or logic dictates the functions that are specifically prohibited for unlicensed assistive personnel? Delegation rules that are being drafted, on the other hand, would allow unlicensed personnel to give oral or apply topical medication. The draft rules also contain language related to nursing tasks without any criteria for defining what makes something a nursing task. The legislation attempts to set parameters by including "a licensed nurse shall not delegate to any unlicensed person any nursing task which requires judgement based on nursing knowledge or expertise" (Chapter 4723-13-04 Ohio Revised Code, Standards of Nursing Delegation).

Are there any nursing tasks that don't require judgement based on nursing knowledge or expertise? Conant (1967) provides an example of an elementary sounding activity, routine back care, that when critically analyzed, becomes more complex and requires judgment based on nursing knowledge and expertise. Routine back care involves judgements based on maintenance of skin and underlying tissue, attention to vulnerable areas, nutritional and fluid balance, manipulation of body parts, types of cleansing agents, use of lubricants or astringents, whether or not to use massage, teaching related to encouragement of the client to move and turn, and therapeutic communication. Conant (1967) describes nursing practice where nurses use a great deal of judgment to make decisions and systematically adapt nursing activities to the client and the situation. Inherent in this conceptualization of nursing activity is that each activity must be individualized for clients who present with different needs, desires, circumstances and abilities.

A non-nursing activity then would be an activity that does not require a great deal of judgment or decision making based on nursing knowledge or expertise and does not change based on the individual client or situation. Some non-nursing activities could fit within this definition such as bandaging a cut, making a bed, taking a temperature, feeding a client, measuring intakes and outputs, and obtaining a weight or height. Other activities are not so clear cut and need to be subject to discussion, debate and agreement within the nursing profession. The lack of consensus about what constitutes nursing and non nursing activities within nursing is a major problem that has resulted in ambiguous legislation and rules that contain different and often conflicting language.

In order to move forward with patient safety legislation, delegation and patient staffing principles legislation, as well as to respond to other professionals and non professionals who desire to practice nursing, we need to tackle this elusive question of what makes something a nursing activity or task that can only be done by a registered nurse. The nursing theorists have provided many theoretical definitions for us which is an excellent beginning. However, our work needs to continue to develop the operational definitions of nursing activities and tasks. If we fail to do so, others will do it for us.

Author

Greer Glazer, PhD, RN, FAAN
Director, Parent Child Nursing
College of Nursing
Kent State University
Kent, OH 44202
Email Address: GGlazer@kent.edu 

Dr. Glazer is Professor and Director of Parent Child Nursing at Kent State University College of Nursing. Besides her many research activities in the field of women's health and stress, Dr. Glazer is chairman of the Ohio Nurses Association Government Affairs Committee, a combination legislation committee and PAC. She is currently the legislative liaison to congressman Steve LaTourette and has previously been on health care committees at the state and national level. Locally she serves on the Board of the Cuyahoga County (Ohio) Children's Trust Fund and recently completed four years on the Health Care Committee allocation panel for United Way in Cuyahoga County.