The American Association of Nurse Attorneys (TAANA) Recommendations Regarding Unlicensed Assistive Personnel (UAP)
Unlicensed assistive personnel ("UAP") are defined by the American Nurses Association 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."
In practice a UAP may include:
- certified nurses aide
- clinical assistant
- home health aide
- nursing assistant
- personal care assistant
- orderlies or attendants
- certified phlebotomist
UAPs have been used for many years in various settings to assist health care providers, usually registered nurses, in providing care to their patients. The use of UAPs has increased dramatically in recent years partially as a result of managed care and Medicare reductions in reimbursement. UAPs are now being employed in health care settings such as acute care hospitals where their use was limited in those settings in years past. Additionally, UAPs are being required to perform increasingly complex tasks and the nurses supervising the UAPs have been asked to take on an increased amount of responsibility for the care provided by the UAPs. The increased use of UAPs has caused concern among health care professionals because of concerns about safety and quality of care for patients and professional liability issues for the supervising nurses. In 1997 more than 25 state legislatures introduced legislation to regulate some aspect of unlicensed assistive personnel. Additionally, many professional nursing organizations have studied the use and impact of UAPs and are adopting position statement regarding their use.
The purpose of The American Association of Nurse Attorneys ("TAANA") white paper regarding UAPs is to set forth recommendations regarding the use of UAPs working under the supervision or direction of registered nurses. TAANA recognizes that the forces controlling the structure, financing and organization of health care are exceedingly complex and that it is these forces, which have led to the use of UAPs. Given the increasing use of UAPs and TAANA"s unique ability to evaluate both the nursing and legal aspects of their use, TAANA adopts this white paper to provide guidance and recommendations to assist in maximizing patient safety and quality care.
TAANA proposes the following recommendations:
- Education - Many nurses practicing today are not trained in nursing school in the team nursing approach that teaches, among other skills, supervision and delegation of various components of nursing tasks. TAANA recommends that schools of nursing that do not currently include such education revise their curriculum to include team nursing and/or supervision and delegation skills to assist nurses in functioning in a health care setting which uses UAPs.
- Regulation of Registered Nurses - In addition to the lack of education regarding working with UAPs, many nurses have worked in states where there is no guidance concerning delegation to and supervision of UAPs by registered nurses. TAANA recommends that the appropriate body for providing this guidance and direction is the state board of nursing which regulates the practice of professional nursing in the state. This guidance should set forth criteria for determining which tasks can be delegated and which cannot be delegated because they are non-delegable duties. Additionally, these guidelines or regulations should provide the registered nurse with direction on what type of supervision is necessary.
- Certification/Registration of UAPs - TAANA further recommends that certain standards be established by the appropriate state agency setting forth standardized curriculum and testing procedures for UAPs. These procedures could be similar to those for nursing assistants in long term care facilities established by federal law in the Omnibus Budget Reconciliation Act of 1987. These standards should establish initial educational criteria, demonstration of competency and resulting certification as well as continuing education requirements.
- Patient Care Restructuring Teams - TAANA recommends that before the use of UAPs is instituted in a health care setting that a multidisciplinary patient care team be convened to evaluate, formulate and implement the use of UAPs. This team should include registered nurses, physicians, administration and an unlicensed assistive person. The team"s task would include drafting job descriptions for the UAPs and registered nurses supervising them. The team"s duties should also include developing the mix of team members responsible for providing care to the patients and drafting and training orientation materials and protocols.
- Monitoring and Reevaluation - The use of UAPs should be periodically monitored and reevaluated after a certain period of time. This process should help to identify job descriptions that may need revision, changes to the team mix and inservice educational needs. TAANA recommends that the multidisciplinary team discussed above perform this monitoring and conduct a formal reevaluation at six (6) months and one (1) year after initially instituting the use of UAPs.
- Continuing Education and Inservice - TAANA recommends that facilities using UAPs include in their inservice and education classes for both UAPs and registered nurses concerning the areas of delegation and supervision.
TAANA recognizes that the use of UAPs presents both opportunities and concerns. When used appropriately, unlicensed assistive personnel can contribute to the care of patients and provide personal care needs or nursing tasks that do not require the skill and judgment of the registered nurse. Patients must be protected so that only those unlicensed assistive personnel who have been screened, trained and periodically evaluated are assisting in care. TAANA recognizes that nurses are ultimately responsible for the provision of nursing care provided to their patients. That responsibility includes accountability for the results and outcome of the care provided including the nursing tasks performed by UAPs. For the safety of patients and reduction in liability for the nurse, TAANA recognizes that quality patient care outcomes will be more readily achievable if the above recommendations are followed.