PERFORMANCE OF NURSING TASKS BY SUPPORT WORKERS IN COMMUNITY SETTINGS

2003 PERFORMANCE OF NURSING TASKS BY SUPPORT WORKERS IN COMMUNITY SETTINGS

This Interpretive Document was approved by ARNNL Council in 2003 and replaces Delegation of Nursing Tasks and Procedures to Support Workers in Community Settings (1995) and Performance of Tasks by Auxiliary Workers (1991).

Performance of Nursing Tasks by Support Workers in Community Settings Acknowledgements This document was developed following extensive consultation with registered nurses and other key stakeholders from around this province who are involved with support workers in community settings. Members of the ARNNL Provincial Working Group are: Judy Davis, Maxine Isaacs, Edwina Kirkland, Lisa Hoddinott, Terri Lynn Ricketts, Theresa Dyson, Rosarii Patey, Beverly Griffiths, Debbie Morris, Bernice Blake-Dibblee, Wally Pardy, and Lynn Power (ARNNL Staff Resource). i 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca ARNNL.CA

Association of Registered Nurses of Newfoundland and Labrador Preamble Over the past decade the range of health services provided in the community has rapidly expanded. As much as possible, individuals with acute, continuing, or rehabilitative health needs are supported to live independently in community settings. This philosophical shift has resulted in a growing number of support workers providing care in a continually increasing variety of settings. Today, community based support services are considered an essential part of the continuum of health care services. Community Support Services address three main functions: maintenance and prevention: support individuals with health problems or functional deficits to live independently, and prevent hospitalization and/or institutionalization. This includes the opportunity to attend educational and recreational programs. long term care substitution: meet the needs of individuals who otherwise would require placement in a nursing home or other residential setting. acute care substitution: meet the needs of individuals who otherwise would have to be admitted to or remain in hospital for an extended period. Registered Nurses have indicated that ARNNL s guidelines for the Delegation of Nursing Tasks and Procedures to Support Workers in Community Settings (1995) and Performance of Tasks by Auxiliary Workers (1991) required revision to adequately reflect current trends and practices. Specifically nurses asked ARNNL to: clarify roles and responsibilities of all stakeholders, provide greater flexibility for professional judgment, recommend a framework for preparing and monitoring support workers performance of nursing tasks, acknowledge clients, families, and designated other s role in determining and/or contributing more significantly to monitoring community health care services. These new guidelines continue to emphasize the importance of clients receiving quality, safe community support services. ii ARNNL.CA 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca

Performance of Nursing Tasks by Support Workers in Community Settings Table of Contents Introduction...1 Authorization...1 Authorization: Performance by Assistance...2 Authorization: Performance under Direction...2 Authorization: Performance through Delegation...3 Framework for Decision-Making...4 Step 1: Assessment...4 Step 2: Authorization...4 Step 3: Implementation...5 Shared Roles... 6 Documentation...6 Unexpected and Emergency Situations...8 Unsafe Care...8 Resources... 9 Appendices: Appendix A: Glossary... 10 Appendix B: Methods of Authorization Flow Sheet... 12 Appendix C: Sample Verification of Competency... 13 Appendix D: Sample Verification of Supervision / Ongoing Competency... 14 Appendix E: Example of the Three (3) Levels of Authorization for Support Worker Medication Administration... 15 Appendix F: Framework for Professional Decision-Making Flowsheet... 16 iii 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca ARNNL.CA

Association of Registered Nurses of Newfoundland and Labrador Introduction The Association of Registered Nurses of Newfoundland and Labrador (ARNNL) recognizes the valuable role that support workers play in facilitating independence and autonomy of individuals with health care needs or functional deficits in community settings. Through the provision of personal and behavioral support, household management, and respite care, support workers assist clients and their families to manage basic activities of daily living. At times it may also be necessary for support workers to perform selected nursing tasks for specific clients. The following guidelines advocate for safe, quality client care, while acknowledging the importance of professional judgment and client/family/ designated care monitor s involvement in the process where support workers are authorized to perform nursing tasks. The ARNNL recognizes that other health professionals may be involved in authorizing support workers to perform tasks that are not exclusive to the domain of nursing (e.g., medication administration). We further acknowledge that more than one health professional may be involved in the preparation, supervision and ongoing monitoring of the support worker s performance, client s health status, and care situation (i.e. shared roles). These guidelines specifically address responsibilities of the Registered Nurse* when he/she authorizes support workers to perform nursing tasks for clients, and/or collaborates with client, family members, designated care monitors, and other health care professionals to achieve this end. This document describes three different methods for authorizing support workers to perform nursing tasks, a decision-making framework to guide nurses professional judgment about when authorization is appropriate, roles and responsibilities of key stakeholders, actions to take in emergency or unsafe situations, and guidelines for documentation. Flow-charts and examples are included to illustrate the methods of authorization and the decision-making framework. A glossary defining the key terms (highlighted by italics) used in this document is provided as Appendix A. Boards and/or agencies employing nurses and/or support workers are responsible for setting agency specific policies. These policies should describe in more detail the educational, monitoring, and documentation practices expected within each board or agency. Authorization Authorization refers to the formal agreement whereby a support worker is permitted to perform, for an individual client (client specific, non-transferable), a select nursing task that is outside the support worker s scope of practice (see Appendix A for definitions). There are three methods whereby this can occur: performance by assistance, performance under direction, and performance through delegation. All three methods require assessment and verification of support worker s competence to perform the identified nursing task(s), and a process for monitoring overall performance. The method of authorization selected must ensure safe and competent client care and as such, might need to be altered if there is a change in the client s health status, client care situation, and/or the nurse s assessment of support worker s competence. A flowchart depicting the three methods for authorization is provided in Appendix B. * The term nurse here-after refers to a Registered Nurse 1 ARNNL.CA 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca

Performance of Nursing Tasks by Support Workers in Community Settings Authorization: Performance by Assistance Clients who are competent to independently direct their own care, or family assuming this responsibility, may request that a support worker perform a required nursing task associated with the client s activities of daily living by assistance. The client/family retains responsibility for the education, supervision, and monitoring of the ongoing performance of the support worker. The support worker is directly accountable to the client/family for the nursing task provided. The client/family may request assistance with the educational preparation of the support worker from a nurse. The content and type of education and/or supervision provided must reflect the nurse s professional judgment of the situation, his/her agency s policies, and the wishes of the client/family. If the nurse has any concerns about the support worker s ability to perform the identified task, or the client s/family s ability to monitor the situation without ongoing professional supervision, the performance under direction or performance through delegation method of authorization must be implemented. Example - A support worker assists a mentally competent client with arthritic hands to prepare and give insulin. Upon request, the nurse demonstrates to the support worker how to administer a subcutaneous injection. Authorization: Performance under Direction Clients residing in established residential arrangements (e.g. personal care home), or those attending formal educational programs whereby a person other then the client/family is designated responsibility for providing ongoing monitoring of the client s health status and/or care situation, may, through authorization under direction, have a support worker perform an identified nursing task associated with the client s activities of daily living. Designated Care Monitors include Alternate Family Care (AFC) providers, operators of licensed personal care homes and in select circumstances designated education professionals in school settings. Performance under direction involves a sharing of roles between the nurse and the designated care monitor. The designated care monitor retains responsibility for ongoing monitoring of the client s general health status, the care situation, and the overall monitoring of the performance of the support worker. The nurse involved in preparing a support worker to perform a nursing task in this situation is responsible for: providing or arranging by an appropriate health care professional for the education of the support worker(s); instructing the designated care monitor and support worker on what to observe, report and actions to take if an adverse response to care occurs or if there is a change in the client s health status and/or situation; identifying the parameters for the performance of the nursing task by the support worker, including any restrictions of performance. 2 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca ARNNL.CA

Association of Registered Nurses of Newfoundland and Labrador The support worker is accountable to the client, designated care monitor, and as appropriate to the nurse. If the nurse has any concerns about the support worker s ability to perform the identified nursing task or the designated care monitor s ability to monitor the situation without ongoing professional supervision, the performance through delegation method of authorization must be implemented. Example A support worker, following education and supervision by an appropriate health professional, performs the tube feeding while the designated care monitor (e.g., AFC provider, home operator, teacher) assumes the care monitoring role. Authorization: Performance through Delegation Performance through delegation is initiated when the client is unable to manage his/her care and there is no family member available or designated care monitor assigned responsibility for the ongoing monitoring of the support worker. Therefore, the nurse is required to authorize the support worker to perform the identified nursing task through delegation. The nurse determining the need for a support worker to perform a nursing task in this situation is responsible for: providing or arranging for the education of the support worker; monitoring the client s health status, care situation and support workers performance on an ongoing basis; instructing the support worker on what to observe, report and actions to take if an adverse response to care occurs or if there is a change in the client s health status and/or situation; identifying the parameters for the performance of the nursing task, including any restrictions of performance. The support worker is accountable to the nurse or identified health professional deemed responsible for the ongoing monitoring. If the nurse is not able to provide the appropriate level of monitoring, delegation should not occur. Appendix C and D provide examples of forms that could be used to document education, supervision, and verification of initial and ongoing competency. Example A support worker, following appropriate education and supervision, provides daily wound care to a blind individual, with a diabetes related foot ulcer, who resides alone in his/her own home with no immediate family involvement. An illustration of the role that support workers can assume with medication administration, under the three methods of authorization, is provided as Appendix E. 3 ARNNL.CA 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca

Performance of Nursing Tasks by Support Workers in Community Settings Framework for Decision-Making There is no established list of nursing tasks that support workers can perform. A three step framework to assist nurses decision-making about the appropriateness of authorizing a support worker to perform a client specific, non-transferable nursing task is presented. A flowsheet of the decision-making framework is provided as Appendix F. Client health assessment, care planning, and evaluation of support worker s competency must always be performed by a health care professional. These responsibilities cannot be transferred to support workers. Step 1. Assessment Nurses must be satisfied that it is appropriate and safe for the support worker to perform the identified nursing task for the specific client. Nurses must reflect upon: The Client Status and Care Situation What are the client specific care needs? Is the client s health perceived to be stable? Are the care needs and outcomes of care predictable? Is the identified nursing task considered to be a part of the client s activities of daily living? Is there a process to follow when there are changes in the client s health status, the situation, or if there is an unexpected emergency? Employer Policy Are there policies and procedures within the nurse s employing agency, and if applicable the home support agency, to support authorization of nursing tasks to support workers? Are these policies clear, concise, and comprehensive? Are roles and responsibilities of all stakeholders understood and communicated? Support Worker Competency Does the support worker have the competence to successfully learn the required knowledge and skill to safely perform the nursing task? Will the nursing task be performed routinely enough to maintain the support worker s competency? Can the support worker perform the task independently without risk of harm to the client? Are the necessary supports available to monitor the support worker s performance and provide assistance if required? Step 2. Authorization Once it has been identified that it is appropriate for a support worker to perform a nursing task, the nurse must determine the most appropriate category of authorization: performance by assistance, performance under direction, or performance through delegation. The level of authorization is not static, it can change depending on the client s care needs and situation, as well as the learning needs of the support worker. 4 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca ARNNL.CA

Association of Registered Nurses of Newfoundland and Labrador Step 3. Implementation The nurse must determine the most appropriate method(s) for educating/ preparing the support worker to obtain competency, and as necessary establish a process for supervising maintenance of competency and monitoring overall performance of the nursing task by the support worker. Support Worker Education The nurse or health professional designated to educate/prepare the support worker must be competent in the particular nursing task to be taught. The professional has the responsibility of determining the most appropriate method of teaching and verifying theoretical and practical competency as well as determining the level of supervision required. Education/preparation includes both theoretical and practical components. The options presented are applicable for all three levels of authorization. Theoretical education can be provided through group, one-on-one, self-learning methods and/or a combination of either approach. Theory must include relevant client specific data. When selecting the method(s) for teaching, consideration is given to the support worker s past experience with the task and the complexity of implementing the task for the specific client. Theoretical learning can be assessed through verbal and/or written testing. Practical education is required to ensure that the support worker obtains competency in the assigned nursing task (s). When support workers are required to learn a new task for a new client, practical education/preparation should involve one-on-one direct supervision. When a support worker is required to perform a task which he/she is currently competent to perform but for a different client, the need and/or level of practical supervision is to be determined by the nurse s professional judgment of the situation and client-specific assessment. Example - A support worker currently competent to perform insulin administration for a client is only permitted to perform that task for that specific client. Should another client require insulin administration, it is the responsibility of the nurse/client and/or care monitor to ensure that the support worker receives client specific education, required practical education, and is deemed competent before the support worker is authorized to perform the task for the second client. Supervision The type and frequency of supervision is based upon the nurses professional judgment of the specific situation. Definitions of direct and in-direct supervision are contained in Appendix A. Factors to consider include: the complexity of the assigned nursing task, the condition of the client, the knowledge and the competency of the support worker, and stipulations in relevant agency policies. If monitoring data identifies a concern with the support worker s performance of the task, the nurse must provide or arrange for another health professional to provide the necessary education (theory and/or practice) and supervision. Ongoing liaison with the health professional responsible for the initial education may be necessary. Monitoring Monitoring includes ongoing assessment of the client s overall health status and the client care situation as well as verification that the support worker completes the authorized nursing tasks. Ongoing monitoring is required to ensure that the performance of nursing tasks by support workers is safe and appropriate. The health professional, who identified the need for the required nursing task, is expected to determine who is responsible for monitoring and for providing the identified care monitor with the necessary information on what to monitor and with whom to follow-up, if there is a concern or change in the client s health status or the care situation. 5 ARNNL.CA 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca

Performance of Nursing Tasks by Support Workers in Community Settings Shared Roles and Responsibilities The responsibility for authorizing and preparing support workers to perform nursing tasks can be shared among health care professionals/stakeholders. For example, a family physician may determine the need for a client to receive an identified nursing task, the community health nurse may assess the situation and determine the method of authorization, the agency employing the support worker may arrange for a health professional in another agency to implement the education program, and the Department of Health and Community Services may assist with funding. In such situations, communication of responsibilities between the professionals/stakeholders is critical. This includes identification of which health care professional will determine the method of authorization, who will do the education, who will instruct the designated care monitor, and who is responsible for ongoing monitoring. Accountabilities will therefore vary accordingly. Table 1 provides an overview of the various roles of each stakeholder. Documentation Documentation of health services is a professional and legal obligation of all health care professionals. As there may be more than one health care professional involved in educating and supervising support workers to perform the nursing task, and in some cases nonprofessionals involved in monitoring, it is essential that accurate and timely documentation be done by all health professionals involved. Documentation should be done by the health professional who is responsible for implementing the various activities. The following information should be recorded: Assessment data that supported the selection of the method of authorization for support workers to perform the nursing task; The identification of the persons responsible for i) education ii) ongoing supervision of the support worker s competency, and iii) monitoring of the client care situation; The methods utilized for, and outcomes of, support worker education and supervision; The parameters for the performance of the nursing task by the support worker and any restrictions of performance; All instructions given to the person designated responsibility for ongoing monitoring; Information shared with the client/family member regarding the performance of the nursing task by a support worker; Ongoing assessment of the client s health status, plan of care, and evaluation of outcomes. Boards and/or agencies employing nurses and/or support workers are responsible for setting agency specific policies on documentation. 6 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca ARNNL.CA

Association of Registered Nurses of Newfoundland and Labrador Table 1. Key Stakeholder Roles in Authorization Process for Support Workers Performing Nursing Tasks in Community Settings Support Worker STAKEHOLDER Registered Nurse (Independently or in collaboration with other Health Care professionals) ROLES Identify and address own learning needs Provide safe, competent care Report relevant observations (i.e. change in client status/ situation) Adhere to relevant policies and pertinent instructions Assess client situation, validate need for support worker to perform the task Determine method of authorization Inform client/family on who will be providing the required nursing task Provide or arrange for relevant education Provide or arrange for initial verification of competence and as required, ongoing competence Respond as required to requests for additional education and/or supervision In all cases nurses are responsible to intercede if and when they become aware of unsafe situations (ARNNL Standards for Nursing Practice in Newfoundland and Labrador, 1995). Employers of Support Workers Verify that support workers have the necessary education and information to perform task Develop policies/processes on reporting and responding to changes in client status, and documentation. Regional/Integrated Health and Community Services Boards Department of Health and Community Services As appropriate, develop service plan and monitor delivery of publicly funded services to clients in the community Develop relevant nursing policies Approval of home support agencies, licensing of personal care homes Set policy directives for governing home support services and personal care homes 7 ARNNL.CA 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca

Performance of Nursing Tasks by Support Workers in Community Settings Unexpected and Emergency Situations In the event that a client s health status suddenly changes, such that the support worker performance of a nursing task may need to be reassessed, it is the responsibility of the person designated to monitor the client s health status and care situation to contact the identified health professional to have the situation reassessed. The health professional is then responsible to determine if it safe for the support worker to continue to perform the nursing task. If necessary the health professional must also provide (or arrange for another health professional to provide) any required additional education or supervision. Instructions for support workers on how and when to contact the nurse or health professional responsible for supervising the competency of the support worker and responding to changes in the client s status, should be clearly articulated. Authorization for support workers to perform nursing tasks in an emergency situation is not appropriate as the client situation is no longer stable and the task may not be performed on a regular basis to obtain and maintain proficiency. However, it may be necessary for the nurse to instruct support workers to act appropriately in emergency situations to maximize client safety. This may involve instruction on the performance of a nursing task that has not been authorized, for example, the administration of medications, such as an epipen or glucagen tablets. The frequency of occurrence of emergency situations and client outcomes should be evaluated to maximize client safety. If necessary, nursing tasks identified to occur on a frequent basis may need to be authorized to specific support workers. Unsafe Care All nurses have a professional obligation to promptly address situations of unsafe care as outlined in the ARNNL Protocol Regarding Concerns About Client Care (1995) and Duty to Report Inappropriate Behavior (1995). In all cases the safety of the client must be the nurse s utmost concern. This may mean refusing to permit the support worker to perform or continue to perform nursing tasks until action can be taken to resolve the issue of unsafe care. In situations where unsafe care is observed and the nurse is not directly involved in supervising or monitoring the client s care, the nurse must report the unsafe care to the appropriate health professional and person designated to monitor care (e.g., the family physician, the client who hired the support worker, the owner of a private agency). Once the concern regarding unsafe care has been reported, it is the responsibility of the nurse to assure that the appropriate person takes all necessary actions to seek a safe resolution. The nurse should document his/her assessment, actions, and plans for follow-up. 8 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca ARNNL.CA

Association of Registered Nurses of Newfoundland and Labrador Resources Association of Registered Nurses of Newfoundland. (1995). Guidelines: Duty to Report Inappropriate Behavior. St. John s: Author. Association of Registered Nurses of Newfoundland. (1995). Protocol Regarding Concerns About Client Care. St. John s: Author. Association of Registered Nurses of Newfoundland & Labrador. (1998). Competencies Required by Registered Nurses for Entry to Nursing Practice, 2000-2001. St. John s: Author. Association of Registered Nurses of Newfoundland & Labrador. (2000). Guidelines Regarding Shared Scope of Practice with Licensed Practical Nurses. St. John s: Author. Canadian Nurses Association. (1995). Unregulated Health Care Workers Supporting Nursing Care Delivery: Policy Statement. Ottawa: Author. Canadian Nurses Protective Society. (2000). Delegation to Other Health Care Workers. InfoLAW, 9(2). Ottawa: Author. Department of Health and Community Services. (1995). Policy Directive Manual Governing Home Support Workers. St. John s: Author. Department of Health and Community Services. (2001). Policy Directive Manual Governing Personal Care Homes. St. John s: Author. ARNNL.CA 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca 9

Performance of Nursing Tasks by Support Workers in Community Settings Appendix A Glossary Client Specific and Non-Transferable: Authorization for a support worker to perform a nursing task(s) is permitted for that particular client and is not permitted to be transferred to another client without the appropriate assessment and preparation. Competence is defined as having the necessary skill, knowledge, judgment, and attitude to safely provide a client service (ARNNL, 1998). Delegation is the formal process where a nurse transfers authority to a support worker to perform a task that is traditionally performed by a nurse (CNPS, 2000). Designated Care Monitor: persons (i.e., alternate family care provider, operators of a personal care home and in select circumstances designated education professionals in school settings) who have been designated the responsibility for monitoring the client s care and health status and the overall performance of the support worker(s). For example, the care monitor ensures the support worker completes authorized nursing task(s). Education: refers to the process whereby the appropriate health professional prepares the support worker to perform the specific nursing task for a specific client. It includes both a theoretical and practical component. Health Professional: all of the regulated health care providers who could be involved in the decision and/or the process of preparing support workers to perform nursing tasks. Examples include: registered nurses, physicians, dieticians, licensed practical nurses, respiratory therapists, physiotherapists, etc. Monitoring: refers to the overall assessment of the support worker s performance, the client s general care, health status, and home/school situation. Monitoring may be done by the client/family, assigned care monitor, or by a health professional. Changes or concerns are reported to the appropriate health care professional. Ongoing: periodic, but never ending. Routine Activity of Daily Living: Tasks are considered routine activities of daily living when the need, response and outcome of performing the procedure have been established over time and are predictable. These procedures are done frequently enough to enable the support worker to maintain the knowledge and skill necessary to safely perform the task. For example a client has a colostomy and requires assistance to change the appliance or the client has a permanent stable tracheostomy and requires suctioning to maintain a clear airway provided, the client s care needs and response to suctioning is predictable. Stable and Predictable Client Health Status: The client s health status is considered stable and predictable if it can be anticipated, the plan of care is readily established and is managed with interventions that have predictable outcomes (ARNNL 2000, Guidelines regarding the shared scope of practice with Licensed Practical Nurses). Supervision: refers to the ongoing methods whereby the appropriate health professional assesses and validates initial and continuing competence of the support worker to ensure safe and appropriate performance of the nursing task. 10 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca ARNNL.CA

Association of Registered Nurses of Newfoundland and Labrador Direct Supervision: the competent individual is immediately present to direct and guide performance of the task and to evaluate or follow-up on performance. Indirect Supervision: the competent individual is not immediately present during the performance of the task but is available if required to evaluate or follow-up on performance. Support Worker: non-regulated, non-licensed care providers employed by clients residing in the community, home support agencies, and/or community or educational facilities that provide personal care and assist clients to meet their needs for everyday living. These workers may be employed in a client s own residence, school, group home, or personal care home. Examples of titles currently used to refer to this role include: home support worker, home-health aide, personal care attendant, and student assistant. 11 ARNNL.CA 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca

Performance of Nursing Tasks by Support Workers in Community Settings Appendix B Methods of Authorization Flow Chart CLIENT Capable of self/family-directed care Incapable of self/family-directed care Care monitor available No care monitor available Support Worker performs task by assistance Support Worker performs task under direction Support Worker performs task through delegation Physical Assistance (e.g. give medications, apply dressings) Verbal Assistance (cue/remind) Care and competency monitored by client/family Care monitor and support worker receive education from appropriate health professional Care monitored by designated person Competency monitored by Registered Nurse PRN Additional Education PRN Support Worker receives education from Registered Nurse Care and competency monitored by Registered Nurse 12 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca ARNNL.CA

Association of Registered Nurses of Newfoundland and Labrador Appendix C Verification of Competency Sample Record This is to certify that has completed the Name of Support Worker Instruction for the task to be Name of Nursing Task Performed for. Name of Client Instructions: I hereby verify to be competent to perform Name of Support Worker The task as instructed for the client named above. Signature of Registered Nurse/Health Care Professional Date 13 ARNNL.CA 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca

Performance of Nursing Tasks by Support Workers in Community Settings Appendix D Supervision/Recertification Sample Record Client s Name: Support Worker: Nursing Task : Date Instruction Completed: Registered Nurse: DATE TYPE OF VISIT Supervision Ongoing Monitoring COMMENTS (Record performance level and/or need for additional in-service etc.) REGISTERED NURSE S SIGNATURE 14 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca ARNNL.CA

Association of Registered Nurses of Newfoundland and Labrador Appendix E Example of the Three Levels of Authorization For Support Workers to Administer Medications Medication administration is outside the approved scope of practice of the support worker role. However, there may be occasions when an RN s assessment of the client s health status, the support workers competency, and the care situation (according to the framework for decision-making) justifies authorization of the nursing task of medication administration to a support worker on a client-specific and non-transferable basis. Authorization must occur in accordance with all of the guidelines identified in this document. All three levels of authorization require that the support worker receives the necessary educational preparation, supervision, and monitoring. Medication Administration by Assistance It is appropriate for a support worker to assist and/or remind the client to take prescribed medications, and to observe and report to the appropriate professional the client s compliance or non-compliance with the established regime. For example a client is unable to physically access or self-administer a medication (e.g., a client with arthritic hands who needs another individual to either open blister pack or draw up and administer insulin). In this situation, the client/ family member retains the responsibility for knowing why the medication has been prescribed, the desired therapeutic effect, and when to contact the physician for monitoring therapeutic effect or when side effects occur. Consequently the client/family member is responsible to educate (or arrange for the education), supervise and monitor the performance of the support worker. Medication Administration Under Direction It is also appropriate for a nurse to authorize a support worker to administer medications under direction. This could occur in situations where clients are unable to independently retain responsibility for self-administration of medications (e.g. mentally challenged client) but a care monitor (i.e., personal care owner/ manager, teacher etc.) retains the responsibility for monitoring the client s status and overall performance of the support worker. In these situations the nurse is responsible to provide (or arrange for another health professional) the necessary education of the support worker and instructions for monitoring, such as when to contact a health care professional. The person designated to monitor care assumes responsibility for ongoing monitoring. Medication Administration through Delegation If there is no person (e.g., client, family or care monitor) available to monitor the client s status and the overall performance of the support worker, the RN authorizes the administration of the medications to the support worker through delegation. In this situation the RN retains responsibility for monitoring and supervision of the support worker s performance and the client s health status (i.e., therapeutic effects of the medication). Support Worker Responsibilities When a support worker is authorized to administer medications through either method, the support worker is not responsible for monitoring the therapeutic effects of the prescribed medication regime as this is beyond the support worker s scope of practice. The support worker will however be responsible for carrying out their role safely, which includes but is not limited to; a) ensuring the correct medication is given to the client at the proper time b) assisting the client to take the medication c) reporting if the client was unable to follow the prescribed regime d) reporting any observable changes in a client s condition e) documenting in accordance with the employer policies and/or practices Agency Responsibilities Employing agencies of the nurse, and where appropriate, the support worker are responsible for establishing policies on the role of support workers in medication administration. They should identify procedures that support workers are to follow when monitoring client s adherence to medication schedules, documentation requirements, and reporting of any changes to a health care professional. 15 ARNNL.CA 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca

Performance of Nursing Tasks by Support Workers in Community Settings Appendix F Framework for Professional Decision-Making STEP 1 Need for support worker(s) to perform nursing task identified by RN Do Not Authorize. Seek appropriate resources with Board/Agency No Assess Own Competence Regarding Task Yes Review Criteria for Authorization Review Employer Policies Policies written/clear Process for supervision & monitoring satisfactory Process for addressing unexpected client problems established Assess Client/Situation Client health needs stable & predictable Task is routine activity of daily life Assess Support Worker Competency Support worker s ability to obtain competency in task Safeguards & resou rces available No Yes Yes Yes No Do Not Authorize Discuss with appropriate manager/supervisor Do Not Authorize RN to perform task No Do Not Authorize RN to perform task Discuss with appropriate manager/supervisor STEP 2 Determine the most appropriate method of authorization (See Appendix B) STEP 3 Implement Authorization Process Educational Pr ogram (Group/Individual) Supervised Practice Assign Monitoring responsibilities Implement appropriate follow up processes 16 55 Military Road St. John s NL Canada A1C2C5 Tel: (709) 753-6040 1 (800) 563-3200 Fax: (709) 753-4940 info@arnnl.ca ARNNL.CA

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