Many people with disabilities need paid support to help with health maintenance activities (HMAs), such as ostomy care, bowel, and bladder care, insulin injections, and management of other medications. There is much variability across the country in nursing practice acts. In many states, laws prohibit paid workers without nursing or other medical licenses from performing HMAs. In others, nurses or other licensed healthcare workers are permitted to delegate HMAs to unlicensed staff or such staff can perform HMAs under the direction of the consumer, without nurse delegation or supervision.
Unfortunately, states are experiencing nurse shortages, and providing necessary, on-site nursing tasks may be hindered or delayed. According to the United States Registered Nurse Workforce Report Card and Shortage Forecast published in the September/October 2019 issue of the American Journal of Medical Quality, a national dearth of registered nurses is projected to spread through 2030. Delegating nursing tasks to direct care staff is one strategy to address this shortage. Nurse delegation services can enhance the accessibility of needed support for people in their own homes and community residential settings allowing them to live as independently as possible achieving the quality of life they desire.
The following is a collection of submitted states’ nurse delegation statutes. Generally, delegation should a) ensure that the person is stable and predictable, b) consider consent from the person, c) determine that the task can be properly and safely performed by a willing, non-licensed person other than a nurse, d) ensure proper training for those performing the task, e) document the rationale and individualized, non-transferable procedures, and f) ensure appropriate supervision and monitoring by the nurse. In most states, I/DD agencies work closely with nursing boards to determine the most appropriate approach considering the state’s workforce and systemic considerations.
Specific statute language and strategies to note:
- Illinois made a clear distinction between staff being “authorized” and not “certified” after being trained by Registered Nurses.
- New York established a registered nurse/consumer ratio that ensures adequate nursing supervision for delegated tasks. The established ratio should not exceed one full-time equivalent of a Registered Nurse to 35 consumers (1:35).
- Texas included and acknowledged the “Five Rights of Delegation” (National Council of State Boards of Nursing): the right task; the right person to whom the delegation is made; the right circumstances; the right direction and communication by the Registered Nurse; and the right supervision.
- Texas Board of Nursing developed a Delegation Resource Packet to provide Registered Nurses with a clearer direction for delegation in a variety of settings. This packet includes resources like decision flowcharts, FAQs, and infographics to aid in making delegation decisions.
- Some states, like Oregon, acknowledged the liability of the nurse: “A nurse who delegates the provision of nursing care to another person pursuant to ORS 678.150 shall not be subject to an action for civil damages for the performance of a person to whom nursing care is delegated unless the person is acting pursuant to specific instructions from the nurse, or the nurse fails to leave instructions when the nurse should have done so.”
- Some states, like Texas and Oregon, detailed situations in which the person or their designated caregiver can train an unlicensed staff to perform an HMA under certain conditions (e.g., when the designated caregiver is present and supervising, the person or designated caregiver can direct the staff to perform the task, the designated caregiver has witnessed the staff performing the task and is available by telecommunications, etc.)