Nurses’ group balks at proposal on delegating duties

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A proposed change to Rhode Island’s nursing regulations that would allow nurses to delegate tasks to unlicensed aides “when the client’s health status is stable and predictable” has caused alarm amid leaders in the profession.
But Pamela L. McCue, the state director of nurse registration and nursing education, says the proposal is still in its earliest stages, subject to revision, and its implications are much narrower than the Rhode Island State Nurses Association and others may believe.
Delegation of nursing duties has long been a contentious topic, with nurses generally balking at the notion of letting less-trained, less-skilled people do pieces of their jobs, and others arguing that not all nursing care requires high-level skills.
In hospitals, nursing homes and other tightly regulated facilities, nurses routinely delegate aspects of care, but in Rhode Island, they may only delegate to certified nursing assistants and licensed practical nurses, and only within their narrowly defined “scope of practice.”
Bathing a patient, for example, or changing a bedpan, would be delegated without concern, but starting an IV or medically evaluating a patient – say, checking the pupils – would be done by a nurse, said Donna M. Policastro, executive director of RISNA.
Yet with nurses in short supply and budget pressures weighing on them, providers across the nation and in Rhode Island have been pushing nurses to delegate more and more duties.
In addition, a growing number of nurses work in non-traditional settings such as group homes and home care agencies, where their practice is less tightly structured and much of the work is done by people with little or no medical training or certification.
In group homes for the developmentally disabled, delegation to unlicensed workers became such a concern a few years ago that nurses pleaded for new rules that acknowledged the practice and set some limits and standards, said Marie Ghazal, vice president for patient care and nursing services at Providence Community Health Centers and an active RISNA member.
“We had nurses practically crying … telling us that they were in situations where it was so unsafe,” she said.
After working for two years with RISNA – whose executive director at the time was McCue – the R.I. Department of Mental Health, Retardation and Hospitals issued a detailed set of standards for nursing delegation, and the R.I. Department of Health created an exception in its own rules to allow for delegation at MHRH-regulated facilities, under those standards.
The problem is the standards, approved in February 2004, were never fully implemented. And when Ellen Nelson took over as director of MHRH last April and started meeting with different constituencies, providers convinced her that the standards were too burdensome.
“Basically, I was told, ‘We cannot implement them,’ ” she said.
Nelson said she spoke with McCue and Dr. David R. Gifford, the state health director, and with leaders in the developmental disabilities nursing community, and they agreed to set the 2004 standards aside, go back to less-stringent standards set in 2001, and revisit the issue, aiming to reflect MHRH’s new approach of being “less regulatory and more standards-driven, more outcomes-driven.”
Discussions on a new set of standards ended in February, Nelson said, and she expects the working group to report back to her shortly, so the updated standards can be issued in April.
But in the meantime, prompted by the MHRH discussion, McCue and the Board of Nurse Registration and Nursing Education have come up with a much broader-based approach to delegation.
Policastro said RISNA only heard about the planned changes at the last minute, and she couldn’t understand why the group had not been invited to the table from the start.
The proposal is also much broader than Policastro and others at RISNA and the United Nurses & Allied Professionals – the state’s largest nurses’ union – are comfortable with. It says nurses “may delegate nursing activities that are consistent with the level of knowledge and skills of the unlicensed assistive personnel when the client’s health status is stable and predictable, as defined herein.”
The proposal goes on to offer criteria for determining what tasks may be delegated, including the “knowledge and skills of the delegatee,” the stability of the client/patient, accessible resources and established policies and procedures, and the accessibility of the nurse.
McCue said the language is based on national standards and takes ideas from regulations in other states. And she stressed that none of this would apply to hospitals, nursing homes or any other facilities where other regulations limit delegation to CNAs or LPNs.
Last Thursday, to begin the discussion, the Department of Health held an informal meeting to solicit input, and RISNA testified, asking that the existing language be kept and the MHRH issue be resolved separately. RISNA also has been scheduled to address the full nursing board on the issue at its April 9 meeting.
McCue said she hopes all the input will help create “the best possible” regulations, but this isn’t just about MHRH. “MHRH provided us with an opportunity,” she said, “but those delegation standards would have had to be addressed at some point.”

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