Nursing Delegation in Ontario

Delegation Overview

• Delegation is the process of a regulated health professional, like a nurse, authorizing someone else, like a PSW, to perform a controlled act they aren't normally allowed to do.
• The Nursing Act of 1991 determines how nursing is regulated in Ontario.
• It contains the nursing scope of practice statement
• It contains regulations that guide nursing practice.
• The Regulated Health Professions Act (RHPA) of 1991 includes permission guidelines for actions and processes of all regulated health professionals in Ontario; also exists in BC, Alberta and NS.
• There are 14 controlled acts, with 5 related to nursing.
• A controlled act can cause harm if done by someone who isn't competent, and this legislation stops unqualified individuals from performing professional actions.
• The tasks only nurses can legally perform are listed in regulated health professions legislation and nursing acts.
• These tasks are called "reserved acts" in British Columbia.
• Delegation is called "transfer of function" in British Columbia.
• These tasks are called restricted activities in Alberta
• These tasks are called controlled acts in Ontario

Assignment vs Delegation

• Assigning involves giving someone a task within their job description, scope of practice and within the agency's scope of employment
• Assigning involves determining or allocating the responsibility to an individual for specific aspects of care
• The task assigned may or may not be a controlled act.
• A range of care needs, not specific procedures, are ideally assigned.
• Nurses can assign care to PSWs if they have the required knowledge and judgement.
• A controlled act is a task that can only be performed by authorized individuals.

Assigning tasks to PSW's

• Activities of daily living include dressing, personal hygiene, mobility, feeding, and toileting
• Instrumental activities of daily living include handling finances, managing medications, transportation, shopping, housework and basic home maintenance, communication devices
• Social and recreational activities
• Household management skills like housecleaning and meal preparation
• Basic support care tasks such as measuring height, weight and vital signs

Defining Delegation

• Unregulated healthcare workers aren't typically authorized to perform authorized acts.
• If a nurse properly delegates it, an unregulated worker is allowed to perform an authorized act.
• The nurse gives authority to the worker during delegation.
• Delegation, or transfer of function, is a mechanism that the regulated health professional uses to grant authority of a controlled act to another person, such as a PSW, who cannot legally perform the act independently.
• Nurses can delegate when a controlled act is determined to be a routine ADL or IADL
• When delegating, the nurse keeps their delegating authority
• The support worker does not have the right to further delegate the controlled act to another individual

Routine Activities

• A routine activity of living is required consistently.
• This activity has already been safely and consistently performed on the patient by a nurse, with predictable outcomes
• Administering an enema for a paralyzed patient is a routine activity, whereas administering one before surgery is not
• Support workers are assigned or delegated the task and are not responsible for deciding when to do a task.

Rules for Delegation

• Nurse must teach the task and meets 6 requirements
• The nurse possess knowledge, skill and judgement to perform the procedure competently
• The nurse knows how to teach that procedure
• The nurse accepts sole accountability for the decision to teach the procedure after considering all factors, risks, predictably outcome, and client's specific factors
• The nurse determines that the PSW has learned the necessary skills
• The nurse can the judge that the skill can be taught and applied for other clients
• The nurse evalutes competence and finds no gaps in practice
• It is important to note that delegation guidelines vary, and nurses should understand the law in their area.
• The nurse takes the PSW aside to discuss the delegating task, provide notes, resources and phone numbers

Continued Rules for delegation

• The PSW demonstrates the task on another occasion in the nurse's presence
• The nurse and PSW will debrief after the task and observe for any concerns
• Unless the client's condition changes, the equipment ceases to works or the PSW is uncomfortable, the PSW can performs delegated tasks.
• The nurse should provide feedback and clear communication

Controlled Acts

• Performing a prescribed procedure below the dermis or mucous membrane.
• Administering a substance by injection or inhalation.
• Putting an instrument, hand or finger.
• Dispensing a drug
• Treating, by means of psychotherapy technique

Performing Procedures

• Inserting IV's
• Venipuncture to collect blood samples.
• Performing wound care below the dermis like cleaning and dressing an open wound.

Substance Administration

• Injection examples include intramuscular, subcutaneous or intradermal injections.
• Inhalation therapy examples include oxygen administration, nebulizers or puffers.

Using instrument, hand or finger.

• Going beyond the external ear canal
• Going beyond the nasal passages normal narrowing
• Giong beyond the larynx
• Going beyond the opening of the urethra
• Going beyond the labia majora
• Beyond the anal verge
• Entering an artificial opening into the body

Examples of items beyond artificial openings

• An example of a procedure into an artificial opening of the body is the suctioning of a tracheostomy
• Inserting a urinary catheter to patient's bladder is an example of putting an instrument beyond the opening of the urethra
• Inserting a rectal suppository is an example of putting a finger beyond the anal verge.
• Inserting an NG tube is an example of going beyond the point in the nasal passages
• Inserting a speculum is an example of a procedure that is beyond the labia majora.

Dispensing drugs

• Selecting, preparing and transferring medication doses based on prescription for administration to a client at a later time

Psychotherapy

• Delivered through a therapeutic relationship, an individual's serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual's judgement, insight, behaviour, communication or social functioning.
• Defined as an intense relationship which includes examination of mental health issues, destructive behavior and trauma Focusing on modification, cognition and functioning requires knowledge, skill and judgement

Delegated activities

• In/out catheterization
• Suctioning a permanent tracheostomy
• Giving an enema
• Taking glucometer readings
• Wound care
• Tube feedings
• Administering medication (apply topical medicated cream)
• Giving an insulin injection
• Pouring and giving oral medication

Exceptions for Delegation

• A procedure is a routine activity of living when the need for response and outcome are predictable.
• Two controlled acts cannot be delegated; dispensing a drug and treating by means of psychotherapy.

Key reminders

• Delegation should extend nurses and not replace them
• Nurses are responsible for client care during delegation
• PSWs are responsible for actions to employer and ensuring actions are done correctly

People nurses delegate to

• Client family members, HH, Homemakers, CNAs. PSWs, PSW Assistants, and health care aides

Why delegation occurs

• Increases nurses capacity for patients by authorizing an individual to act on behalf
• Time constraints particularly in Long term care in the mornings
• Finances because can reduce costs for community

Key terms

• Assigningappointing someone to take on a task or responsibility Examples include assisting with ADLs, IADLs, social/recreational activity, household management and basic support care
• Task a function procedure or activity that a person assists the client with or performs for the client this is not the same as an order
• Routine Tasks ones that occur often and predictable outcomes
• RHPA: Regulated Health Professions Act
• Controlled Act Activity considered to be potentially harmful if performed by unqualified individuals regulated health care providers like nurses, have the authority to perform them
• Nursing Act 1991 controlled acts are laid out in this document 3 apply to nurses
• UCP Unregulated care provider
• Delegator - a registered staff who is delegating
• Delegatee- the UCP that is being delegated to
• Delegation- an active process responsibility for interventional transfer
• 5 Rights- Eval by UCP and nurse before process
• Supervision- process of direction assignment and guiding and monitoring people

The Delegation Process for Nurses

• Nurse must have authority
• Nurse must check for health and safety first
• Check policy and if it is something can be delegated policy, PST training and experience
• Determine assess SW to delegate cant have the student and new grads
• Ensure client condition stable
• Supervise and what’s written down

Aspects of Nursing Supervision

• Supervision is essential
• Supervision entails direction, inspection, and action needed
• It's a direct guide monitoring the performance
• The time of supervision may change over time
• Supervision can be direct, indirect, or indirect remote

Types of Supervision

• Direct- the nurse is is observing providing guidance to a UCP they perform an intervention
• Indirect- the nurse is not observing the UCP AS they perform intervention but is ready for consult or provide guidance
• Remote: the nurse is not physcially present but via phone for consult and guidance

More of the Nurses Role in delegation.

• If there is appropriate supportive worker perform the task considering the clients addition risk and support
• Will it support where can be adequately supervised in the setting
• is and knows if a nurse is variable to help if client condition is changing or arising
• Is it what can be delegated
• Does the SW understand or not to perform task and that it's documented

PSW Role in delegation

• Understand the delegated tax it's not transferrable to just u to see
• Support workers can not decide and when to
• Report any observations

5 rights as the PSW

1. the right task can it be delegated
2. right circumsatces, social emotional all
3. right person support has adequate training
4. directions are there and clear
5. supervision and support does the person After effects the client is a client give feedback

Key Reminders

• regulated provider to the client safe
• Delegation properly
• Be accountable for a job when to perform tests beyond the scope practice explain and call supervisors

Case scenarios

• Adam is semester 2 PSW student
• PSW busy in on her way cream zenskis
• PSW can be too
• Do not use cream as not delegated nor given
• Task is a new new care the the the the team
• Ensure can still be performed or ask for another method