RULES DEFINING COMPONENTS OF PRACTICE FOR THE REGISTERED NURSE

RULES DEFINING COMPONENTS OF PRACTICE FOR THE REGISTERED NURSE Rules which further define the Nursing Practice Act have been established by the Board of Nursing. These rules are considered law and provide the parameters for the legal scope of practice for the licensed nurse; therefore, every nurse should have working knowledge of these rules in order to provide the public with safe nursing care. 21 NCAC 36.0224 COMPONENTS OF NURSING PRACTICE FOR THE REGISTERED NURSE (a) The responsibilities which any registered nurse can safely accept are determined by the variables in each nursing practice setting. These variables include: (1) the nurse's own qualifications including: (A) basic educational preparation; and (B) knowledge and skills subsequently acquired through continuing education and practice; (2) the complexity and frequency of nursing care needed by a given client population; (3) the proximity of clients to personnel; (4) the qualifications and number of staff; (5) the accessible resources; and (6) established policies, procedures, practices, and channels of communication which lend support to the types of nursing services offered. (b) Assessment is an on-going process and consists of the determination of nursing care needs based upon collection and interpretation of data relevant to the health status of a client, group or community. (1) Collection of data includes: (A) obtaining data from relevant sources regarding the biophysical, psychological, social and cultural factors of the client's life and the influence these factors have on health status, including: (i) subjective reporting; (ii) observations of appearance and behavior; (iii) measurements of physical structure and physiological functions; (iv) information regarding available resources; and (B) verifying data collected. (2) Interpretation of data includes: (A) analyzing the nature and inter-relationships of collected data; and (B) determining the significance of data to client's health status, ability to care for self, and treatment regimen. (3) Formulation of a nursing diagnosis includes: (A) describing actual or potential responses to health conditions. Such responses are those for which nursing care is indicated, or for which referral to medical or community resources is appropriate; and (B) developing a statement of a client problem identified through interpretation of collected data. (c) Planning nursing care activities includes identifying the client's needs and selecting or modifying nursing interventions related to the findings of the nursing assessment. Components of planning include: (1) prioritizing nursing diagnoses and needs; (2) setting realistic, measurable goals and outcome criteria; (3) initiating or participating in multidisciplinary planning; (4) developing a plan of care which includes determining and prioritizing nursing interventions; and (5) identifying resources based on necessity and availability. (d) Implementation of nursing activities is the initiating and delivering of nursing care according to an established plan, which includes, but is not limited to: (1) procuring resources; (2) implementing nursing interventions and medical orders consistent with 21 NCAC 36.0221(c) and within an environment conducive to client safety; (3) prioritizing and performing nursing interventions; (4) analyzing responses to nursing interventions; (5) modifying nursing interventions; and (6) assigning, delegating and supervising nursing activities of other licensed and unlicensed personnel consistent with Paragraphs (a) and (i) of this Rule, G.S. 90-171.20(7)d and (7)i, and 21 NCAC 36.0401. (e) Evaluation consists of determining the extent to which desired outcomes of nursing care are met and planning for subsequent care. Components of evaluation include: rth Carolina Administrative Code Title 21, Chapter 36.0224(RN) blue Page 1 of 3

(1) collecting evaluative data from relevant sources; (2) analyzing the effectiveness of nursing interventions; and (3) modifying the plan of care based upon newly collected data, new problem identification, change in the client's status and expected outcomes. (f) Reporting and Recording by the registered nurse are those communications required in relation to all aspects of nursing care. (1) Reporting means the communication of information to other persons responsible for, or involved in, the care of the client. The registered nurse is accountable for: (A) directing the communication to the appropriate person(s) and consistent with established policies, procedures, practices and channels of communication which lend support to types of nursing services offered; (B) communicating within a time period which is consistent with the client's need for care; (C) evaluating the responses to information reported; and (D) determining whether further communication is indicated. (2) Recording means the documentation of information on the appropriate client record, nursing care plan or other documents. This documentation must: (A) be pertinent to the client's health care; (B) accurately describe all aspects of nursing care including assessment, planning, implementation and evaluation; (C) be completed within a time period consistent with the client's need for care; (D) reflect the communication of information to other persons; and (E) verify the proper administration and disposal of controlled substances. (g) Collaborating involves communicating and working cooperatively with individuals whose services may have a direct or indirect effect upon the client's health care and includes: (1) initiating, coordinating, planning and implementing nursing or multidisciplinary approaches for the client's care; (2) participating in decision-making and in cooperative goal-directed efforts; (3) seeking and utilizing appropriate resources in the referral process; and (4) safeguarding confidentiality. (h) Teaching and Counseling clients is the responsibility of the registered nurse, consistent with G.S. 90-171.20(7)g. (1) Teaching and counseling consist of providing accurate and consistent information, demonstrations and guidance to clients, their families or significant others regarding the client's health status and health care for the purpose of: (A) increasing knowledge; (B) assisting the client to reach an optimum level of health functioning and participation in self care; and (C) promoting the client's ability to make informed decisions. (2) Teaching and counseling include, but are not limited to: (A) assessing the client's needs, abilities and knowledge level; (B) adapting teaching content and methods to the identified needs, abilities of the client(s) and knowledge level; (C) evaluating effectiveness of teaching and counseling; and (D) making referrals to appropriate resources. (i) Managing the delivery of nursing care through the on-going supervision, teaching and evaluation of nursing personnel is the responsibility of the registered nurse as specified in the legal definition of the practice of nursing and includes, but is not limited to: (1) continuous availability for direct participation in nursing care, onsite when necessary, as indicated by client's status and by the variables cited in Paragraph (a) of this Rule; (2) assessing capabilities of personnel in relation to client status and plan of nursing care; (3) delegating responsibility or assigning nursing care functions to personnel qualified to assume such responsibility and to perform such functions; (4) accountability for nursing care given by all personnel to whom that care is assigned and delegated; and (5) direct observation of clients and evaluation of nursing care given. (j) Administering nursing services is the responsibility of the registered nurse as specified in the legal definition of the practice of nursing in G.S. 90-171.20 (7)i, and includes, but is not limited to: rth Carolina Administrative Code Title 21, Chapter 36.0224(RN) blue Page 2 of 3

(1) identification, development and updating of standards, policies and procedures related to the delivery of nursing care; (2) implementation of the identified standards, policies and procedures to promote safe and effective nursing care for clients; (3) planning for and evaluation of the nursing care delivery system; and (4) management of licensed and unlicensed personnel who provide nursing care consistent with Paragraphs (a) and (i) of this Rule and which includes: (A) appropriate allocation of human resources to promote safe and effective nursing care; (B) defined levels of accountability and responsibility within the nursing organization; (C) a mechanism to validate qualifications, knowledge and skills of nursing personnel; (D) provision of educational opportunities related to expected nursing performance; and (E) validation of the implementation of a system for periodic performance evaluation. (k) Accepting responsibility for self for individual nursing actions, competence and behavior is the responsibility of the registered nurse, which includes: (1) having knowledge and understanding of the statutes and rules governing nursing; (2) functioning within the legal boundaries of registered nurse practice; and (3) respecting client rights and property, and the rights and property of others. History te: Authority G.S. 90-171.20(7); 90-171.23(b); 90-171.43(4); Eff. January 1, 1991; Temporary Amendment Eff. October 24, 2001; Amended Eff. August 1, 2002. rth Carolina Administrative Code Title 21, Chapter 36.0224(RN) blue Page 3 of 3

P.O. BOX 2129 Raleigh, NC 27602 DECISION TREE FOR DELEGATION TO UAP (919) 782-3211 FAX (919) 781-9461 Nurse Aide II Registry (919) 782-7499 www.ncbon.com Step 1 of 4: Assessment and Implementation Is the task within the scope of practice for a licensed nurse (RN/LPN)? Stop! Do not delegate to UAP. Is the activity allowed by the Nursing Practice Act, Board Rules, Statements, or by any other law, rule or policy? Stop! Do not delegate to UAP. Is RN assessment of client s nursing care needs complete? Stop! RN to complete assessment, then proceed with consideration of delegation. Is the RN/LPN competent to make delegation decisions? Nurse is accountable for the decision to delegate, to implement the steps of the delegation process, and to assure that the delegated task is appropriate based on individualized needs of each client which includes stability, absence of risk of complications, and predictability of change in condition. The delegating nurse must be competent to perform the activity. See (A) and (B) pg. 2 Stop! Do not delegate to UAP. Is the task consistent with the rules for delegation to UAP? Must meet all the following criteria: Frequently recurs in the daily care of a client or group of clients Is performed according to an established sequence of steps Involves little to no modification from one client care situation to another May be performed with a predictable outcome Does not inherently involve ongoing assessment, interpretation, or decision making which cannot be logically separated from the procedure(s) itself; and Does not endanger the client s life or well being. Stop! Do not delegate to UAP. Is the UAP properly trained and validated as competent by an RN to accept the delegation? Does the capability of UAP match the care needs of the client? See (A) and (B) pg. 2 Stop! Do not delegate until evidence of education and validation of competency available, and then reconsider delegation; otherwise do not delegate. Stop! Do not delegate until the nurse has evaluated capability of UAP matches the care needs of the client. Are there written agency policies, procedures, and/or protocols in place for this task? Stop! Do not proceed without evaluation of need for policy, procedures and/or protocol or determination that it is in the best interest of the client to proceed with delegation in urgent or emergency situations. Is appropriate supervision available? See (C) (D) (E) pg. 3 Stop! Do not delegate to UAP. Page 1 of 3 Proceed with delegation. The UAP is responsible for accepting the delegation, seeking clarification of and affirming expectations, performing the task correctly and timely communicating results to the nurse. Only the implementation of a task/activity may be delegated. Assessment, planning, evaluation and nursing judgment cannot be delegated. Delegation is a client and situation specific activity in which the nurse must consider all components of the delegation process for each delegation decision. Specific direction by the nurse (RN, LPN) to UAP when assisting the nurse with a task or nursing activity and under the direct visual supervision of the nurse is not considered delegation.

IMPORTANT COMPONENTS FOR DELEGATION TO UAP Prior to proceeding to Step 2, consider the following: Delegation is a process of decision-making, critical thinking and nursing judgment. Decisions to delegate nursing tasks/activities to UAP are based on the RN s assessment of the client s nursing care needs. The LPN may delegate nursing tasks/activities to UAP under the supervision of the RN. Additional criteria that must be considered when determining appropriate delegation of tasks include, but are not limited to: (A) Variables: Knowledge and skill of UAP Verification of clinical competence of UAP Stability of the client s condition which involves predictability, absence of risk of complication, and rate of change Variables specific for each practice setting: o The complexity and frequency of nursing care needed by a given client population o The proximity of clients to staff o The number and qualifications of staff o The accessible resources Established policies, procedures, practices, and channels of communication which lend support to the types of nursing activities being delegated, or not delegated, to UAP (B) Use of critical thinking and professional judgment for The Five Rights of Delegation: 1. Right Task the task must meet all of the delegation criteria 2. Right Circumstance delegation must be appropriate to the client population and practice setting 3. Right Person the nurse must be competent to perform the activity and to make delegation decisions, the nurse must ensure the right task is being delegated to the right person (UAP) and competence has been validated by an RN, and the delegation is for the individualized needs of the client 4. Right Communication the nurse must provide clear, concise instructions for performing the task 5. Right Supervision the nurse must provide appropriate supervision/monitoring, evaluation, and feedback of UAP performance of the task Step 2 of 4: Communication - Communication must be a two-way process The nurse: The UAP: Assesses the UAP s understanding of: Asks questions and seeks clarification o Task to be performed and expectations of performance of tasks Informs the nurse if UAP has not performed the o Information to report including client specific observations, expected task or has performed it infrequently and concerns Requests additional training or guidance as o When and how to report/record information needed Communicates individualized needs of client population, practice Affirms understanding and acceptance of setting, and unique client requirements delegation Communicates and provides guidance, coaching, and support for UAP Complies with communication method between Allows UAP opportunity for questions and clarification nurse and UAP Assures accountability by verifying UAP accepts delegation Reports care results to nurse in a timely manner Develops and communicates plan of action in emergency situations Complies with emergency action plans Determines communication method between nurse and UAP Documentation by nurse and UAP (as determined by facility/agency policy) is: Timely, complete and accurate documentation of provided care: Facilitates communication with other members of the health care team Records the nursing care provided. Page 2 of 3

Step 3 of 4: Supervision and Monitoring The RN supervises the delegation by monitoring the performance of the task and assures compliance with standards of practice, policies and procedures. The LPN supervision is limited to on-the-job assurance that tasks have been performed as delegated and according to standards of practice established in agency policies and procedures. Frequency, level, and nature of monitoring vary with the needs of the client and experience of the UAP. (C) The nurse takes into consideration the: Client s health stability, status, and acuity Predictability of client response to interventions and risks posed Practice setting and client population Available resources Complexity & frequency of nursing care needed Proximity of clients to staff Number and qualification of staff Policies, procedures, & channels of communication established (D) The nurse determines: The amount/degree of supervision required Type of supervision: direct or indirect The Five Rights of Delegation have been implemented: 1. Right Task 2. Right Circumstances 3. Right Person 4. Right Directions and Communications 5. Right Supervision and Evaluation (E) The nurse: Maintains accountability for nursing tasks/activities delegated and performed by UAP Monitors outcomes of delegated nursing care tasks Intervenes and follows-up on problems, incidents, and concerns within an appropriate timeframe Nursing management and administration responsibilities are beyond LPN scope of practice. To assure client safety, the LPN may need authority to alter delegation or temporarily suspend UAP per agency policy until appropriate personnel action can be determined by the supervising RN. Observes client response to nursing care and UAP s performance of care Recognizes subtle signs and symptoms with appropriate intervention when client s condition changes Recognizes UAP s difficulties in completing delegation activities Step 4 of 4: Evaluation and Feedback Evaluate effectiveness of delegation and provide appropriate feedback Evaluate the nursing care outcomes: o (RN) Evaluate the effectiveness of the nursing plan of care and modify as needed o (LPN) Recognize the effectiveness of nursing interventions and propose modifications to plan of care for review by the RN Evaluate the effectiveness of delegation: o Task performed correctly? o Expected outcomes achieved? o Communication was timely and effective? o Identify challenges and what went well o Identify problems and concerns that occurred and how they were addressed Provide feedback to UAP regarding performance of tasks/activities and acknowledge the UAP for accomplishing the task References: G.S. 90-171.20 (7)(d) & (i) and (8) (d) Nursing Practice Act American Nurses Association Decision Tree for Delegation by Registered Nurses, 2012 21 NCAC 36.0221 (b)licensed Required Joint Statement on Delegation ANA and NCSBN Decision Tree for Delegation to Nursing 21 NCAC 36.0224 (a) (b) (c) (d) (e) (f) (i) & (j) Components of Practice for the Registered nurse Assistive Personnel, 2005 21 NCAC 36.0225 (b) (c) (d) (e) (f) Components of Practice for the Licensed Practical Nurse National Council of State Boards of Nursing Decision Tree Delegation to Nursing Assistive 21 NCAC 36.0401 (c) Roles of Unlicensed Personnel Assistive Personnel, 2005 Page 3 of 3 Origin: 5/2000; Revised 4/2007; Reviewed 2/2013; Revised 9/2013