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The Role of Unlicensed Assistive Personnel (Nursing Assistive Personnel) in the Care of Women and Newborns

  • Association of Women's Health, Obstetric and Neonatal Nurses

      Position

      The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) recognizes that unlicensed assistive personnel (UAP) also known as nursing assistive personnel (NAP) can function as supportive members of the health care team under the direction of the professional registered nurse (
      • Association of Women's Health, Obstetric and Neonatal Nurses
      Guidelines for professional registered nurse staffing for perinatal units.
      ). The professional registered nurse is ultimately responsible for the coordination and delivery of nursing care to women and newborns.

      Background

      A health care system that delivers optimal care for women and newborns is dependent on a high degree of collaboration among registered nurses and other members of the health care team, including UAPs/NAPs. Characteristics that distinguish the professional registered nurse from UAPs/NAPs include but are not limited to the type and amount of education, depth of knowledge, and critical thinking skills. The knowledge base and clinical skills of the professional registered nurse provide the foundation for nursing assessment and diagnosis, critical thinking and decision making, outcome identification, planning, implementation, and evaluation that are requisite for high quality outcomes for women and newborns.
      When UAPs/NAPs participate in direct care, parameters for the education and supervision of these nursing support personnel must be in place and should include the following:
      • Define UAPs/NAPs as unlicensed personnel who are not professional registered nurses but who are accountable to and work under the direct supervision of a professional registered nurse to implement specifically delegated patient care activities.
      • Evaluate the individual state's current nurse practice act to ensure that UAP/NAP job descriptions and delegated activities are consistent with established rules, regulations and statutes.
      • Provide written job descriptions that clearly delineate duties, responsibilities, qualifications, skills, and supervision of UAPs/NAPs.
      • Ensure that UAPs/NAPs are readily identifiable by the patient as non-licensed.
      • Establish competence-based performance expectations and systems for ongoing performance appraisals.
      • Provide orientation and education for UAPs/NAPs, including didactic content as needed and appropriate for the clinical setting, evaluation of knowledge, and verification of clinical skills consistent with performance expectations and role responsibilities.
      • Clearly define parameters in writing to ensure that all UAPs/NAPs are supervised directly by and responsible to professional registered nurses.
      • Monitor and evaluate adherence of UAPs/NAPs to patient care guidelines and their effect on patient outcomes.

      The Role of the Nurse

      The professional registered nurse is responsible and accountable for the delegation of certain tasks to and the supervision of the UAP/NAP. More specifically, the American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN) define these responsibilities as follows:
      • Accountability: Being responsible and answerable for actions and inactions of self or others in the context of delegation.
      • Delegation: Transferring to a competent individual the authority to perform a selected nursing task in a selected situation. Responsibilities related to making nursing judgments may not be delegated to UAP/NAP.
      • Supervision: The provision of guidance or direction, evaluation and follow-up by the professional registered nurse for accomplishment of a nursing task delegated to UAPs/NAPs (
        • American Nurses Association
        • National Council of State Boards of Nursing
        Joint statement on delegation.
        ).
      When the professional registered nurse decides to delegate, consideration should be given to the likely effects and consequences of delegation on patient well-being. The following factors should be assessed prior to delegating tasks to UAPs/NAPs:
      • Potential for harm,
      • Complexity of task,
      • Problem solving and critical thinking required,
      • Unpredictability of outcome,
      • Level of care giver-patient interaction, and
      • The practice setting (
        • American Association of Critical-Care Nurses
        AACN delegation handbook.
        ).
      Practice settings can include the inpatient setting, freestanding birthing center, surgery center, ambulatory care center, community health clinic, primary health care provider's office, and home care agency and/or home care environment (
      • American Nurses Association
      ANA's principles of delegation by registered nurses to unlicensed assistive personnel.
      ). The level of preparation, education, and competence of the person to whom the tasks are being delegated and how much supervision the professional registered nurse can and will be able to provide are important considerations in the delegation process.
      It is not appropriate to delegate nursing activities that comprise the core of the nursing process and require specialized knowledge, judgment, competence, and skill (
      • American Nurses Association
      ANA's principles of delegation by registered nurses to unlicensed assistive personnel.
      ). Assessment and evaluation of the effect of interventions on care cannot be delegated (
      • National Council of State Boards of Nursing
      Decision tree for delegation to nursing assistive personnel.
      ). These activities include but are not limited to performing initial and ongoing patient assessments, establishing diagnoses, working with patients and families to identify outcomes and an appropriate plan of care, implementing the plan, and evaluating the patient's progress or lack of progress toward achieving care goals. In addition, it is inappropriate to delegate any subsequent assessments or nursing interventions that require professional knowledge, judgment, and skill (
      • American Nurses Association
      • National Council of State Boards of Nursing
      Joint statement on delegation.
      ).
      Some examples of nursing activities for women and newborns that should not be delegated include the following:
      • Telephone triage,
      • Triage of women and their fetus(es) who present for care,
      • Initial and ongoing assessments of women and newborns,
      • Application of electronic fetal heart monitoring components,
      • Initial and ongoing assessment of maternal-fetal status, including auscultation and interpretation of electronic fetal heart rate pattern,
      • Ongoing assessment of
        • Women receiving oxytocin infusion,
        • Pain management needs of women and newborns,
        • Women receiving regional analgesia/anesthesia,
        • Women who have complications of pregnancy,
        • Progress of labor,
      • Management of the second stage of labor,
      • Circulator responsibilities for vaginal or cesarean birth,
      • Initial assessment during the postpartum period after vaginal or cesarean birth,
      • Assessments required for discharge from post-anesthesia care units,
      • Initial assessment of women and newborns during post-surgical care,
      • Assigning Apgar scores,
      • Newborn identification (e.g., assigning security device, placing identification bracelet),
      • Newborn assessment during the transition to extrauterine life,
      • Determining the plan of care based on nurse assessment,
      • Nursing interventions that require specialized knowledge, judgment, competence and skill,
      • Discharge planning,
      • Patient education,
      • Parent education, and
      • Evaluation of the outcome of nursing interventions.
      When nursing activities or tasks are delegated to UAPs/NAPs, professional registered nurses remain responsible and accountable for overall nursing care. Thus, assessment and diagnosis of patients, evaluation of outcomes, establishment and implementation of plans of care, and appropriate delegation and supervision of tasks all remain the responsibility of the professional registered nurse. It is appropriate to delegate the following activities to UAPs/NAPs:
      • Clerical duties,
      • Selected care tasks such as assistance with ambulation, feeding, mouth care, and bathing (activities of daily living), and
      • Gathering of data such as intake and output and vital signs.
      The professional registered nurse is responsible for determining the competence of UAPs/NAPs who will perform delegated tasks and for evaluating each patient's clinical situation. Delegated activities should be limited to clearly defined and thoroughly described repetitive tasks that do not require the professional judgment of a registered nurse. Federal regulations, state nurse practice acts, rules and regulations of boards of nursing, and institutional guidelines must be followed any time nursing activities are delegated.

      References

        • American Association of Critical-Care Nurses
        AACN delegation handbook.
        2nd ed. Author, Aliso Viejo, CA2004 (Retrieved from http://www.aacn.org/wd/practice/docs/aacndelegationhandbook.pdf)
        • American Nurses Association
        ANA's principles of delegation by registered nurses to unlicensed assistive personnel.
        Author, Silver Spring, MD2012 (Retrieved from)
        • American Nurses Association
        • National Council of State Boards of Nursing
        Joint statement on delegation.
        (Retrieved from https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf)
        Date: 2006
        • Association of Women's Health, Obstetric and Neonatal Nurses
        Guidelines for professional registered nurse staffing for perinatal units.
        Author, Washington, DC2010
        • National Council of State Boards of Nursing
        Decision tree for delegation to nursing assistive personnel.
        Author, Chicago, IL2005 (Retrieved from)