Jobscience

Nurses and EMS Personnel:

Collaboration, Delegation and Accountability

Emergency Medical Service (EMS) personnel are trained to provide emergent and nonemergent care under the supervision of a physician in those areas for which they are certified. Their expertise applies in certain, specific and limited areas. Some EMS personnel are employed as health care employees outside of the usual prehospital arena. This can create some problems if the registered nurse is unfamiliar with the responsibilities and limitations of EMS personnel working in an Unlicensed Assistive Personnel (UAP) role. EMS paramedics have the skills and expertise to give medications in the field, for example, but would not be able to do this in the role of the UAP. The following are frequent questions heard from staff nurses regarding working with UAPs.

"What do professional organizations say about using UAPs?"

The Emergency Nurses Association states that the "ENA believes that the registered professional nurse is responsible and accountable for emergency nursing practice. All non-RN caregivers, involved in providing nursing care within the emergency care setting, shall be directly supervised by and responsible to professional emergency registered nurses."

The American Nurses Association defines UAPs as "individuals who are trained to function in an assistive role to the registered professional nurse in the provision of patient/client care activities as delegated by and under the supervision of the registered professional nurse."

"What is the definition of delegation?"

The ANA defines delegation as "the transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome."

Direct patient care activities for the UAP includes assisting the patient/client in meeting basic human needs within the institution, at home, or other health care settings. It may involve the collection, reporting and documentation of data related to the above activities. This data is reported to the RN who uses the information to make a clinical judgement about patient care. Delegated activities to the UAP do not include health-counseling, teaching, assessment, or require independent, specialized nursing knowledge, skill or judgement.

(Source: ANA position statement on RN use of UAPs, 1997)

The Iowa Board of Nursing states the definition of delegation is "transferring to a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains accountability for the delegation."

(Source: Delegation: Concepts and Decision Making Process – IBON Home Page)

"How much education do EMS personnel receive compared to the least amount that RNs receive?"

  • EMT-Basic: 110 hours of classroom instruction

    • 18 hours of clinical time

  • EMT-Intermediate: 60 hours of classroom instruction

    • 100 hours of clinical and ambulance/rescue field experience

  • EMT-Paramedic: 300 hours of classroom instruction

    • 300 hours of clinical and ambulance/rescue field experience

    *In addition, all are required to attend 20 hours of defibrillation training.

[Source: Iowa Administrative Code 132.5 (1)]

  • RNs~ADN level: 743 hours of classroom instruction (liberal arts plus nursing courses)

    • 1029 hours of clinical and lab time

(Source: NLN standards for nursing education curriculum)

"What can EMS personnel perform in their role as ambulance workers?"

EMS scope of practice:

According to Iowa Administrative Code 132.2(4) emergency medical skills may be performed if there is documentation of training, and the skill is both within the provider and service program level of authorization, a written protocol exists, and the skill is approved by the service program's medical director.

First Responder

EMT - Basic

EMT - Intermediate

EMT - Paramedic

AED

First responder skills plus

First responder skills, EMT-B skills, plus

First responder skills, EMT-B and EMT-I skills, plus

Oral airway suctioning

Monitoring and maintenance of non-medicated IVs

Initiation of non-medicated IVs

Endotracheal intubation

Oxygen administration

Spinal immobilization (C-collar with manual stabilization, short board, long board)

EGTA

Pharmacological intervention

Esophageal/tracheal/double-lumen airway

Patient assisted meds (inhaler, nitro, epi-pen)

Gastric tube insertion

Maintenance and monitoring of intravenous infusion of blood and blood products

Vitals, including BP

M.A.S.T.

  

Tension pneumothorax decompression

Bandaging

Extremity immobilization or splint

  

Cricothyrotomy and transtracheal insufflation

Over the counter medications

    

Nasogastric tube insertion

C-collar with manual stabilization

    

Rotating tourniquets
     

Urinary catheterization
     

Intraosseous infusion
     

Rhythm strip interpretation
     

Obtaining a 12-Lead EKG
     

12-Lead interpretation if trained

"I work in a county hospital emergency department where EMS personnel help out with care of patients. They are employees of the ambulance service, but are based at the hospital. Are they working under my license?"

If EMS personnel are helping the regular nursing staff care for patients, then they are functioning in the role of a UAP and should be delegated to appropriately. They are not functioning as EMS personnel.

  • Iowa Code Chapter 147A Emergency Medical Services states that "an emergency medical care provider shall not routinely function without the direct supervision of a physician, physician assistant, or a registered nurse."

"I'm work with a very talented paramedic who works part-time in the ICU as a patient care technician. He starts IVs in the field, why can't he start them here when I'm too busy?"
  • Iowa Law states that EMS personnel employed as UAPs must function within a written job description [Iowa Code: 641-132.2 (2)]. In addition, the Iowa Nurse Practice Act states that no nursing judgement or nursing assessment can be delegated to another individual.
  • Facilities have placed certain EMS specific skills in their job description: i.e. 'flight paramedics' starting IVs and intubating patients, but the facility retains responsibility for ongoing competency assessment and in accordance with the National Council of State Boards of Nursing, it is the RN who ultimately decides the appropriateness of delegation.

(Source: National Council of State Boards of Nursing, Inc., 1997)

"I delegated placing a Foley catheter to a UAP who is also a paramedic. The UAP broke sterile technique while placing the Foley and the patient ended up dying with urosepsis. What can happen to me?"
  • The nurse delegating a duty retains accountability for the outcomes of that action.

(Source: National Council of State Boards of Nursing and Iowa Nurse Practice Act)

The nurse delegating the task should know prior to delegation:

  1. Is the UAP trained in this particular skill?
  2. Is this in the UAP's written job description?
  3. Is there documentation of ongoing competency testing at my facility?

If you can answer yes to these questions, then you have done the appropriate assessment and delegation. If not, then your delegation was inappropriate.

  • UAPs need a written job description which clearly delineates appropriate duties, responsibilities, qualified skills and registered nurse supervision.
  • UAPs must have performance expectations and a mechanism for ongoing performance appraisal (competency assessment) established and maintained.

(Source: Emergency Nurses Association Position Statement on the use of Non-RN Caregivers in Emergency Care)

What should NOT be delegated to UAP caregivers?
  • Iowa State Practice Acts states: "those activities which require the knowledge and skill level currently ascribed to the registered nurse" along with using the professional judgment on which tasks may be delegated, to whom, and under what circumstances.
  • ENA Position Statement states "nursing activities that include the core of the nursing process (assessment, diagnosis, outcome identification, planning and evaluation) and require specialized knowledge, judgement and/or skill." Additionally it states that "any nursing intervention which requires professional knowledge, judgement, and skill should not be delegated."

 

The 5 'rights' of Delegation
  1. Right Task -

    2. What is the nursing task’s potential for harm to the patient? All decisions to delegate a nursing task must include the basic premise that the nurse is to protect the health, safety and welfare of the public. The Board of Nursing states that the RN cannot delegate to the EMS personnel/UAP any activity beyond that which is delegated to the LPN, otherwise the RN is vulnerable to discipline by the Iowa Board of Nursing for improper delegation (IABON).

  2. Right Circumstance –

    3. What is the complexity of the nursing task? If the activity is complex, the RN should not delegate the nursing task. Activities involving more complex psychomotor skills, expert nursing assessment and judgment should be performed only by a Registered Nurse (AACN).

  3. Right Person –

    4. If a problem arises will the UAP/EMS personnel have the skills necessary to resolve the problem? Competence to perform the task and problem solving skills are useful when doing a foley insertion with sterile technique, taking vital signs and measuring intake and output.

  4. Right Direction/Communication –

    5. How predictable are the outcomes of nursing activity? Guidelines and protocols are available to give direction to the EMS personnel/UAP. Directions from the RN to the EMS personnel/UAP must include parameters for information feedback.

  5. Right Supervision -

    6. Will delegation of a nursing task help or hinder the patient’s plan of care and outcomes for treatment? Nurses must have some interaction with the client to effectively monitor, evaluate and intervene in the patient’s plan of care. The RN should supervise the delegation of nursing tasks with feedback from the UAP/EMS personnel for appropriate patient care.

(Source: National Council of State Boards of Nursing, Inc., 1997)

Resources used in preparing this document:

Iowa Administrative Code: Emergency Medical Services

Nurse Practice Act, Chapter 6

ANA position statement on use of Unlicensed Assistive Personnel

ENA position statement on non-registered nurse caregivers in the Emergency Department

National League of Nursing Standards on nursing curriculum requirements

Delegation Decision-making Grid

The Delegation Decision-making Grid was developed as a tool to assist nurses in making delegation decisions. The tool can provide a scoring mechanism for seven elements that should be considered when making delegation decisions. The use of this grid builds on the overall assumption that the activity/task being performed is within the nurse's scope of practice, and that the Nursing Practice Act and Rules support delegation. The proposed delegation should also be consistent with agency policy. The grid can be used to support sound delegation decisions. This document is intended to be used in conjunction with the resource describing the Five Rights of Delegation and provides a framework for assessing the client's needs, the skills of the UAP, the licensed nurse, the activity, and the potential harm in delegating an activity.

The rating of the identified elements assists the nurse in evaluating the circumstances, client needs and available resources (including UAP and nurse competence) to support the delegation decision. A low score would indicate that the activity could be safely delegated, a high score would caution against delegation. For example, if the level of client stability is ranked 3 (client condition is unstable or acute or is has a strong potential for change) and the UAP being considered for performing the activity also is rated 3 (novice in performing activities and in working with defined client population), that activity should not be delegated to that UAP. Each facility or agency would be expected to establish a policy regarding the level of score deemed acceptable for delegation.

Suggestions for Use:

The grid can be used:

  • By nurses in planning care for a group of patients. Each worksheet can be used to score the needs of up to four clients and allows comparison of those client situations.

  • By nurse managers to evaluate the delegation needs of a client unit or a client caseload.

  • For staff education regarding delegation

  • For orientation of new staff, both nurse and UAP.

  • For nursing education programs providing basic managerial skills for students.

  • For Member Boards responding to questions about delegation (to assist in identification of elements to be considered). (Boards may consider including this tool as part of a delegation information packet.)
  • For orientation of new board members and attorneys.

  • For Member Board workshops and presentations regarding delegation issues.

  • For evaluation of discipline complaints involving concerns regarding delegation.

The Delegation Decision-making Grid is based on a concept developed by the American Association of Critical Care Nurses, used in their unlicensed assistive personnel materials.

National Council of State Boards of Nursing, Inc., 1997

The rating of the identified elements assist the nurse in evaluating the circumstances, clients’ needs and available resources to support the delegation decision. A low score would indicate that the activity could be safely delegated, a high score would caution against delegation. Each facility or agency would be expected to establish a policy regarding the level of score deemed acceptable for delegation.

Elements for

Review


Client

A

Client

B

Client

C

Client

D

Activity/task

Describe activity/task:





Level of Client Stability

Score the Client’s level of Stability

  1. client condition is chronic/stable/predictable
  2. client condition has minimal potential for change
  3. client condition has moderate potential for change
  4. client condition is unstable/acute/strong potential for change
        

Level of UAP Competence

Score the UAP competence in completing delegated nursing care activities in the defined client population:

  1. UAP-expert in activities to be delegated, in defined population
  2. UAP- experienced in activities to be delegated, in defined population
  3. UAP-experienced in activities but not in defined population
  4. UAP- novice in performing activities and in defined population
        

Level of Licensed Nurse competence.

Score the licensed nurse’s competence in relation to both knowledge of providing nursing care to a defined population and competence in implementation of the delegation process.

  1. Expert in the knowledge of nursing needs/activities of defined client population and expert in the delegation process
  2. Either expert in knowledge of needs/activities of defined client population and competent in delegation or experienced in the needs/activities of defined client population and expert in the delegation process
  3. Experienced in the knowledge of needs/activities of defined client population and competent in the delegation process
  4. Either experienced in the knowledge of needs/activities of defined client population or competent in the delegation process.
  5. Novice in knowledge of defined population and novice indelegation
        

Potential for Harm

Score the potential level of risk the nursing care activity has for the client (risk is probability of suffering harm):

  1. None
  2. Low
  3. Medium
  4. High
        

Frequency

Score based on how often the UAP has performed the specific nursing care activity:

  1. Performed at least daily
  2. Performed at least weekly
  3. Performed at least monthly
  4. Performed less then monthly
  5. Never performed
        

Level of Decision-making

Score the decision-making needed, related to the specific nursing care activity, client (both cognitive and physical status) and client situation:

  1. Does not require decision- making
  2. Minimal level of decision –making
  3. Moderate level of decision- making
  4. High level of decision making
        

Ability for self care

Score the client’s level of assistance needed for self-care activities:

  1. No assistance
  2. Limited assistance
  3. Extensive assistance
  4. Total care or constant attendance
        



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