FAQ: RN/APRN Delegation to MAs, Unlicensed Personnel
Thursday, September 19, 2019
Posted by: Erin Cusack
The Medical Practice Act provides broad delegation authority for physicians to delegate to APRNs, PAs, other licensed health care providers, and unlicensed health care personnel. However, it is important to note that the Nursing Practice Act does not provide similar broad delegation authority for nurses at any level of licensure. While many APRNs work with unlicensed personnel in a variety of practice settings, their ability to delegate is limited to certain nursing tasks in accordance with the Board of Nursing’s Registered Nurse Delegation Rule Chapters 224 and 225. Please see the BON FAQ on this issue here.
According to Rule 224.8, an RN/APRN can delegate the following nursing tasks to unlicensed personnel:
- non-invasive and non-sterile treatments;
- the collecting, reporting, and documentation of data including, but not limited to: vital signs, height, weight, intake and output, capillary blood and urine test; environmental situations; client or family comments relating to the client's care; and behaviors related to the plan of care;
- ambulation, positioning, and turning;
- transportation of the client within a facility;
- personal hygiene and elimination, including vaginal irrigations and cleansing enemas;
- feeding, cutting up of food, or placing of meal trays;
- socialization activities;
- activities of daily living; and
- reinforcement of health teaching planned and/or provided by the registered nurse.
The following are nursing tasks that are not within the scope of sound professional nursing judgment for an RN/APRN to delegate to unlicensed personnel in acute care environments or for patients with acute conditions:
- physical, psychological, and social assessment which requires professional nursing judgment, intervention, referral, or follow-up;
- formulation of the nursing care plan and evaluation of the client's response to the care rendered;
- specific tasks involved in the implementation of the care plan which require professional nursing judgment or intervention;
- the responsibility and accountability for client health teaching and health counseling which promotes client education and involves the client's significant others in accomplishing health goals; and
- administration of medications, including intravenous fluids, except by medication aides as permitted under §224.9 (relating to The Medication Aide Permit Holder).
On the issue of medication administration specifically, Rule 224.8 lists this as one of the tasks that an RN/APRN cannot delegate to unlicensed personnel, including Medical Assistants (MAs). This rule applies to any RN/APRN providing care for: 1) patients with an acute health condition that is unstable or unpredictable; or 2) patients in an acute care environment where nursing services are continuously provided. Settings include, but are not limited to, hospitals, rehabilitation centers, skilled nursing facilities, clinics, correctional health, private practice physician offices, and settings that do not otherwise meet the definition of independent living environment. The inclusion of physician offices and outpatient settings makes this rule broadly applicable.
While APRNs cannot delegate medication administration to unlicensed personnel in these settings, their delegating physicians can delegate these tasks. We sent this question to the Board of Nursing and they recommended the following:
“If the physician delegates medication administration to unlicensed personnel and that delegation includes medication administration for drugs ordered by the APRN, the Board of Nursing recommends that this occur in the form of a written policy clarifying that it is the physician who delegates medication administration to the unlicensed person. The APRN may then order the drug and assign the unlicensed person to administer it. The APRN has a duty to make sure the unlicensed person is trained and to supervise the medication administration. If the APRN observes unsafe and/or improper practices, the APRN has a duty to intervene and report his/her observations back to the physician who delegated medication administration as set forth in Board Rule 224.10. The physician is not required to be physically present at the site when the APRN makes the assignment to the unlicensed person.”
The Board of Nursing does not specify what kind of written policy would be required to allow for this type of delegation to unlicensed personnel. The written policy could be a Prescriptive Authority Agreement, facility-based protocol, facility or clinic policy, or some other written policy. The important thing is that the written policy exists and can be used to verify that the delegation is from the physician and the APRN can then assign and supervise the performance of the task.
For the rule language on the topic of RN/APRN delegation, please see the relevant rules here.