Position Statement

Registered Professional Nursing’s Utilization of Unlicensed Assistive Personnel

The purpose of this position statement is to provide guidance to the registered nurse in the appropriate utilization of unlicensed assistive personnel (UAP) in the delivery of nursing care.

Position

It is the position of the New York State Nurses Association that the registered professional nurse bears responsibility for:

1. Developing, implementing and evaluating nursing care as part of the interdisciplinary plan of care.
2. Verifying the preparation and competence of unlicensed personnel.
3. Identifying health-related tasks and circumstances on a case by case basis which can be assigned to unlicensed assistive personnel.
4. Recognizing that inappropriate utilization of unlicensed assistive personnel to perform professional nursing responsibilities is illegal, impedes quality of care and places patients and practitioners in positions of potential jeopardy.

Background

Historically, the nursing profession has recognized the contribution of unlicensed personnel in assisting professional nurses in delivering care. In recent years, unlicensed personnel have been used as substitutes for professional nurses rather than in their appropriate roles under the supervision of the professional nurse.

“Society grants the nursing profession authority over functions vital to itself and permits them considerable autonomy in the conduct of their affairs. In return, the professions are expected to act responsibly, always mindful of the public trust. Self-regulation to assure quality in performance is at the heart of this relationship.” (ANA Social Policy, 2003, pg 2).

The registered professional nurse has both legal and ethical obligations to society in rendering safe and competent care. Based on the ethical principles of respect, beneficence, fidelity, and justice, the nurse is expected to abide by the ANA Code of Ethics for Nurses. Legal responsibility is defined by the Nurse Practice Act. In New York State, the practice of the profession of nursing as a registered professional nurse is defined as: “diagnosing and treating human responses to actual or potential health problems through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being” (Nurse Practice Act, Education Law, Section 6902).

Nursing practice is based on specialized knowledge, judgment and skill derived from principles of basic and applied sciences and standards of professional performance. ANA Standards of Professional Performance describe a competent level of behavior, including activities related to quality of practice, education, professional practice evaluation, collegiality, collaboration, ethics, research, leadership, and resource utilization. The registered nurse considers factors related to safety, effectiveness, costs, and impact on practice in the planning and delivery of nursing services (ANA Professional Performance: Standard 14. ANA Scope & Standards, 2004 pg 42).

While the registered professional nurse assumes responsibility for the total nursing care of the patient, the New York State Nurses Association believes that tasks and activities that are not exclusively nursing functions should be assigned to assistive personnel. Utilization of assistive personnel enables the professional nurse to fulfill responsibilities and duties exclusive and inclusive to the practice of nursing. The New York State Codes, Rules and Regulations (NYCRR) requires that all hospitals provide “…at all times…transporter services, nurse aides, housekeeping services and other ancillary support services in a manner sufficient to meet patient care needs, and to prevent adverse impact on the delivery of medical and nursing care” (10 NYCRR 405.3 (b) (5)).

Functions that are not exclusively within the protected scope of nursing practice have been described as either health-related or non-nursing functions. Non-nursing functions are those activities that do NOT involve direct patient care. Health-related are those patient care related activities not legally protected, which when performed use standard procedures, and do not require clinical judgment. Subsequently, health-related activities can be assigned to unlicensed assistive personnel who have received appropriate training and are deemed competent to perform (see Attachment I: Examples of Health-related Activities & Non-Nursing Functions).

Since 1975, the New York State Nurses Association has sponsored legislation known as the Exempt Clause Repeal Bill. Enactment of this bill would stop the dangerous and anachronistic custom of allowing unlicensed personnel to practice nursing including the administration of medications in state institutions under the jurisdiction of the office of Mental Health (OMH) and the Office of Mental Retardation and Developmental Disabilities (OMRDD).

The Department of Health holds hospitals accountable for the provision of orientation and training programs for nursing personnel (10 NYCRR 405.5(a)(6)). Simultaneously, regulatory authorities affirm the registered nurses’ responsibility with regard to patient care delivery, including appropriate supervision, delegation and assignment of tasks. The NYCRR for hospitals states a “registered nurse shall plan, supervise and evaluate nursing care for each patient” and “shall assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the preparation and competence of such other nursing personnel” (10 NYCRR 405.5(b)(2)(ii)). The New York State Board of Regents has declared that “…delegating professional responsibilities to a person when the licensee delegating such responsibilities knows or has reason to know that such person is not qualified, by training, by experience or by licensure, to perform them” is an example of unprofessional conduct and reportable to the Office of Professional Discipline (Section 29.1, “Regents Rules on Unprofessional Conduct,” (b)(10)).

Performance of health-related tasks by unlicensed persons is predicated upon an assessment and determination by the registered nurse that the health-related activity under consideration is appropriate for performance by each unlicensed person with each individual patient. Non-nursing functions not involving direct patient care require professional nursing knowledge and oversight, but do not need case by case assessment and decision making by the registered nurse. It is the nurse's obligation to judiciously determine tasks that can reasonably be assigned to unlicensed persons.

Recommendations

The New York State Nurses Association will:

1. Support identification and measurement of core competencies appropriate to all settings for unlicensed assistive personnel. ( See Attachment II: Qualifications, Competencies, and Guidelines for Training of Unlicensed Assistive Personnel).
2. Promote standardized training for unlicensed assistive personnel in the acute care setting (2002 NYSNA Voting Body Resolution).
3. Support staffing legislation that would provide sufficient resources for nurses to fulfill professional nursing responsibilities, including monitoring and supervision of unlicensed assistive personnel.
4. Continue to provide consultation and education regarding appropriate utilization of RNs, LPNs, and UAPs in all settings.
5. Consult with state agencies and professional associations for assistance in identifying areas exclusive to nursing scope of practice issues.

This position statement replaces:

• Professional Nursing Practice and Non-Nursing Functions, NP44 (1996)
• Role of the Professional Nurse Regarding Unlicensed Personnel, NP12 (1986)
• Ethical Guidelines for the Utilization of Unlicensed Assistive Personnel, NP64 (1996)

Approved by the Board of Directors on 9/22/89, Reviewed and revised by the expanded Council on Nursing Practice on 8/13/04, Approved by the Board of Directors on 9/15/04.

Note: The use of the term “patient” anywhere in this document is intended to be generic and refers to the recipient of nursing care.

References

American Nurses Association. (2002). Code of ethics for nurses. Washington, DC: Author.

American Nurses Association. (2003). Nursing's social policy statement. Washington, DC: Author.

American Nurses Association. (2004). Nursing: Scope and standards of practice. Washington, DC: Author.

New York State Nurses Association and New York Organization of Nurse Executives. (2003). Guidelines for utilization of RN's, LPN's and UAP's. Latham, NY: Author.

Nurse Practice Act. Education Law, Article 139, Nursing, Section 6902: Definition of practice of nursing. Binghamton, NY: Gould Publications.

Official Compilation Codes, Rules and Regulations of the State of New York. Title 8 (Vol. A) Education, Part 29 Unprofessional Conduct, Section 29.1 General Provisions.

Official Compilation Codes, Rules and Regulations of the State of New York. Title 10 (Vol. C), Health, Part 405 Hospital Minimum Standards, Section 405.3 Administration.

Official Compilation Codes, Rules and Regulations of the State of New York. Title 10 (Vol. C), Health. Part 405 Hospital Minimum Standards, Section 405.5 Nursing Services.

Attachment I

Examples of Health Related and Non-Nursing Functions (This list is illustrative and not all-inclusive)

Health Related Functions may include:

Making beds: occupied and unoccupied
Measuring vital signs: temperature, pulse, respiration, blood pressure
Bathing patients
Assisting with mobility: ambulation and range of motion exercises
Providing routine skin care
Assisting with routine bowel and bladder care
Collecting data, at the direction of the registered nurse (RN) and reporting of data to the RN

Non-Nursing Functions may include:

Housekeeping

General cleaning (utility rooms, closets, bathrooms, kitchen, furniture, floors)
Equipment cleaning (discharge units, wheelchairs, stretchers, televisions)
Special equipment cleaning (EKG monitors, respirators, suction apparatus, scales, inhalation)
Cleaning of operating room between and prior to procedures
Medication cart/room cleaning
Emptying trash
Stocking supplies (soap, paper towels)
Straightening supply closets/rooms
Stripping, cleaning and making unoccupied beds/units/stretchers
Moving equipment, stocking linen
Changing sharp disposal containers

Clerical

Ordering supplies (central supply, pharmacy, laundry)
Process requests for laboratory, blood bank, x-rays, etc.
Making labels and labeling specimen collection devices (prior to specimen collection by healthcare personnel)
Answering the telephone/paging
Preparation of charts (stamping, forwarding, new charts, discharge charts)
Charting temperatures, pulses, respirations, blood pressures
Securing routine test results (laboratory, x-ray)
Charting laboratory results
Scheduling clinic appointments
Checking patients’ clothing and valuables
Calling for repairs and replacements
Obtaining and maintaining supplies

Transportation

Escorting non-acute patients (laboratory, x-ray, new unit, etc.)
Moving equipment (bed, stretchers, wheelchairs, EKG monitors, oxygen)
Transporting discharged patients
Transporting bodies to the morgue
Delivering medications to and from pharmacy
Delivering supplies, specimens, and blood
Delivering linen

Dietary

Distributing and collecting routine and isolation meal trays
Distributing nourishments
Providing for special dietary needs (food, individual refrigerators)
Documenting food and oral fluid intake

Miscellaneous

Orientation of medical staff
Reminding physicians to clarify orders
Ordering of stock medications
Enforcing visiting rules
Assisting with visitors

Attachment II

Recommended Qualifications, Training Guidelines, and Competencies of Unlicensed Assistive Personnel

The New York State Nurses Association recognizes that the phrase "unlicensed assistive personnel" refers to multiple categories of healthcare personnel. The following guidelines are recommended to address the qualifications, training and competencies of unlicensed assistive personnel providing direct care.

The term, "unlicensed assistive personnel" is used generically in the development of these guidelines. The term may include, but is not limited to, home health aides, personal care aides, nurse technicians and nursing assistants.

Qualifications:

1. a secondary-school education or equivalent;
2. good moral character – no evidence of having been convicted of a crime which raises a
   reasonable question as to the individual’s moral character (as described by the NYS Regents Rules as it pertains to individuals licensed to practice a profession); and
3. successful completion of an “approved” training program.

Training Guidelines: The unlicensed assistive personnel shall complete an approved training program which includes:

1. instruction, supervision and evaluation by a registered professional nurse;
2. formal periodic evaluation of performance that is documented in written format,
3. curriculum content which incorporates basic principles of:
   1. health and illness, hygiene, frequently used medical terminology and activities of daily living;
   2. infection control including standard, universal and category-specific precautions;
   3. normal aging process and age-appropriate care;
   4. body mechanics;
   5. patient safety and restraints and seclusion management;
   6. care of chronically ill;
   7. death and dying;
   8. cultural, ethnic, spiritual, and religious appropriateness;
   9. confidentiality and privacy;
   10. patient/client/resident rights including: respect, dignity, choices, and freedom from abuse;
   11. pain and its personal and subjective nature;
   12. emergency preparedness; and
   13. communication skills and courtesy; and
4. explanation of the UAP role responsibilities, limitations and relationship as a member of the health care team.

Competencies:

1. At the direction of the registered nurse, unlicensed assistive personnel may assist in collecting data that must be reported to the registered professional nurse. Data may include:
   1. measurement of temperature, pulse, respiration, blood pressure, height, weight, and intake and output;
   2. collection of specimens;
   3. observation of:
      1. changes in patient's condition, including patient’s report of pain;
      2. changes in the patient's environment, especially that which is potentially unsafe;
      3. patient's interactions with family, significant others, healthcare workers, and other social contacts; and
      4. patient's reaction to his/her care.
2. Unlicensed assistive personnel contribute to the nursing plan of care by performing activities of daily living, comfort measures and:
   1. mobility measures
      1. transfers: bed to chair, wheelchair to car, with/without lifting devices;
      2. ambulation with/without assistive devices;
      3. active and passive range of motion exercises;
   2. support for nutrition and fluid balance;
   3. normal skin care maintenance (intact skin);
   4. bladder and bowel care;
   5. maintenance of a safe environment; and
   6. assistance with administration of medication by self-directed patients (in the home and in select OMH/OMRDD settings).
      
3. Unlicensed assistive personnel may also assist with:
   1. environmental cleaning;
   2. laundering;
   3. shopping; and
   4. meal preparation.

For more information on nursing practice, contact NYSNA's Education, Practice and Research Program at 518.782.9400, ext. 282 or by e-mail.

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