BACKGROUND

As the recognized authority in infusion nursing, the Infusion Nurses Society (INS) issued a position paper in 2009 addressing the use of nursing assistive personnel (NAP) in the provision of infusion therapy.1 At that time, INS strongly recommended that NAP should not be used in the direct provision of infusion therapy and believed that delegation of related procedures and activities to NAP may result in potential adverse outcomes to the patient and the public, and increased liability risk to the registered nurse (RN).1 Since then, major changes to the health care system and the nursing practice environment have occurred. In response to these changes, INS convened a task force of infusion therapy experts from various practice settings to review and update INS' position on the use of unlicensed assistive personnel (UAP) in the provision of infusion therapy.

As the demand on time and resources of licensed health care professionals continues to increase, and cost-containment measures continue to challenge organizations, the use of UAP in the provision of select patient care activities is expanding.2,3UAP is the common term used to describe the various assistive personnel to whom physicians, RNs, and other health care professionals may delegate patient care activities, with the potential inclusion of infusion therapy and vascular access. UAP do not hold a license or other mandatory professional requirements for practice, although many hold various certifications.4 There are 4 million UAP employed in the United States.5 Twenty-nine percent of UAP work in a hospital setting, and job growth for UAP is expected to increase by 20% by the year 2020.6 Their titles, training, roles, and responsibilities vary by institutional setting and according to state statutes. UAP hold various job titles, including but not limited to, NAP, nursing aides, nurse technicians, medical assistants (MAs), phlebotomists, patient care technicians, medication technicians, dialysis technicians, and other unlicensed technicians.7

A review of literature on the use of UAP in the provision of infusion therapy and vascular access yielded references from INS, including the 2009 position paper "The use of nursing assistive personnel in the provision of infusion therapy"1; the 2016 Infusion Therapy Standards of Practice (the Standards)8; a white paper, "Infusion teams in acute care hospitals: call for a business approach"9; and an article, "Development of an infusion alliance."10 There are statements by the American Nephrology Nurses Association related to dialysis technicians,11 and specific position statements, board policies, and advisory opinions of several states' Boards of Nursing.12-18 The 2012 American Nurses Association's (ANA's) Principles of Delegation by Registered Nurses to Unlicensed Assistive Personnel was reviewed,4 as well as ANA's and the National Council of State Boards of Nursing's (NCSBN's) joint statement on RN delegation of nursing care and duties to UAP.19 The statements from states with scope-of-practice laws for MAs20 were reviewed, as well as practice standards for medical imaging and radiation therapy,21-23 which outlined MAs' involvement with infusion therapy and vascular access.

To assist in the task of updating the 2009 INS position paper, a survey was conducted to identify issues, trends, and concerns with regard to the use of unlicensed health care personnel (UHCP) in the provision of infusion therapy in all practice settings. UHCP, instead of UAP, was the term used for the survey to eliminate the exclusivity to NAP and allow the inclusion of non-NAP. The term UAP, as defined in the previous paragraph, is used for the position paper, except when discussing the survey and its results. The INS UHCP online survey consisted of 16 questions. It was sent to all INS members, as well as to RN nonmembers via social media networks. The online survey was available for 4 weeks and had 504 respondents (n = 504).24

DISCUSSION

Increasing efforts to contain health care costs, changes in reimbursement structure, and an aging population requiring health care are cited as reasons for the increased use of UAP in many health care settings.7,25-27 As reliance on UAP increases, there must be an increased emphasis on safe and effective care delivery when RNs delegate certain tasks and aspects of patient care. The principles of delegation of ANA and NCSBN include the responsibility and accountability of the RN for patient care outcomes delegated to another member of the health care team.19 Many factors should be considered when determining if delegation of a task or component of care should occur. One of these factors includes the skill and competency of the person to whom the RN is delegating. The RN should be knowledgeable about the documented and validated competency of the UAP to whom a task is delegated.28 Nursing judgment and components of the nursing process may not be delegated.19 The role of delegator and supervisor increases the scope of legal liability for the RN. Liability is based on an RN's failure to determine which patient needs could safely be assigned to a UAP who requires such supervision. There is limited case law involving nurse delegation and supervision, but it is generally accepted that the RN is responsible for adequate supervision of the person to whom the task has been delegated.29 In situations when delegation from the physician requires the RN to supervise task performance, the RN is required to obtain clarification from the delegating physician about the role of each professional, especially who will hold accountability for the outcome of the delegated tasks.8^(pS13)

Infusion therapy and vascular access placement are treatment orders commonly prescribed for patients receiving care in different health care settings. Infusion therapy refers to the administration of solutions, medications, nutritional products, and blood and blood components via the parenteral route.30 Vascular access devices are catheters, tubes, or devices inserted in the vascular system, including veins, arteries, and bone marrow.8 The "Scope of Practice" of the 2016 Standards states that the role, responsibilities, and accountability for each type of clinician involved with infusion therapy delivery, according to the applicable regulatory boards, are clearly defined in organizational policy.8^(pS13) Infusion therapy tasks are delegated by the RN to UAP in accordance with rules and regulations promulgated by the states' Boards of Nursing and within the policies and procedures of the organization. The RN and the organization are responsible and accountable for the tasks delegated to UAP.8^(pS13) Many states' Boards of Nursing have statements affirming that the initiation, administration, and monitoring of infusion therapy and vascular access may not be delegated to UAP.12-16 A few states' Boards of Nursing have statements allowing the delegation of certain infusion therapy and vascular access procedures to UAP, such as the insertion of short peripheral catheters, provided all delegation criteria are met.17,18

The 2014 INS UHCP survey asked respondents (n = 422) to identify the tasks currently performed by UHCP at their place of employment. A list of tasks was provided, and respondents were asked to check all that applied. Of the tasks listed on the survey, 87% replied that UHCP provide basic personal care; 41% assist with patient intake/registration/insurance verification/check-in/scheduling; 35% perform venipuncture for procedures, such as blood draws and computerized tomography scans; and 23% perform discontinuation of infusion and removal of the peripheral catheter. Eighteen percent are involved with peripheral intravenous (IV) insertions/venipuncture and dressing changes, and 11% administer subcutaneous or intramuscular injections/vaccinations. Ten percent stated that UHCP monitor patients and IV sites during medication administration; 8% administer oral/topical medications, and 7% coordinate patient care between pharmacy/nursing departments. Two percent access ports, draw blood, and flush and deaccess ports; and 2% stated that they infuse only certain IV medications not on the high-risk drug list. One percent said that UHCP perform central venous catheter blood draws/dressing changes/flushes, and 1% indicated that they administer medication and solutions via central and peripheral devices.24

The delivery of infusion therapy has increased in nonacute settings, resulting in the expanding use of MAs in the direct provision of infusion therapy and vascular access device placement in medical offices. In a vast majority of states, MAs may perform basic clinical procedures under the direct supervision of a licensed independent practitioner (eg, physician, osteopath, podiatrist, and in some cases, physician assistants or nurse practitioners). However, the legal framework governing the delegation of clinical tasks to UAP varies greatly from state to state. While most states don't have laws or regulations specifically addressing the practice of medical assisting, the number of states with such laws has continued to grow in recent years. Many states that do not address medical assisting by name nevertheless have statutes or rules acknowledging a licensed practitioner's authority to delegate clinical tasks to an unlicensed assistant, as long as certain conditions are met.20 The MA-phlebotomist is essentially a phlebotomy technician who may perform capillary, venous, or arterial invasive procedures for blood withdrawal and other clinical tasks when delegated and supervised by a licensed independent practitioner.20 Ultimately, the responsibility for the appropriate use of unlicensed personnel in health care delivery in the physician-medical office or clinic rests with the physician.31 Direct supervision in the office setting does not mean the physician must be present in the same room with the MA. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the MA is performing services.32

The traditional role of an MA is as an auxiliary to a licensed physician, who supervises and remains professionally and legally responsible for the actions of the MA. In many jurisdictions, MAs also may accept delegated tasks from an RN or nurse practitioner.20 In those cases, McCarty states that delegation of clinical duties is controlled by state nursing practice laws, and the legal relationship is between the MA and the RN, not the MA and the physician.20 The 2016 Standards states that the individual licensed nurse is required to obtain clarification from the delegating physician about the role of each professional, especially who will hold accountability for the outcome of the delegated task.8^(pS13) A number of states' Boards of Nursing have developed policies on nurses' delegation of duties to UAP,12-19 based on ANA's Principles for Delegation by Registered Nurses to Unlicensed Assistive Personnel.4 The Texas Board of Nursing addresses the RN who may be supervising unlicensed personnel to whom the physician has delegated tasks. It states that the RN always has a responsibility to protect client safety, so the RN has a duty to intervene if he or she sees something being done incorrectly by the unlicensed personnel and to notify the delegating practitioner of the incident.18

In the hemodialysis setting, the administration of heparin and saline via an extracorporeal circuit is a routine clinical procedure. The scope of duties for dialysis technicians and/or patient care technicians in a hemodialysis facility may be determined by state statutes, regulations, nurse practice acts, and the state's Board of Nursing advisory opinions or position statements, all of which vary a great deal. In the absence of a specifically defined scope of duties for UAP, the RN must rely on her or his authority under the state's Board of Nursing delegation regulations to determine whether a specific duty may be delegated.11

Medication administration is an important intervention for patients residing in long-term care and assisted living facilities, many of whom have multiple comorbidities. Depending on state regulations, many facilities use UAP to manage and administer oral, topical, and parenteral medications. Typically, these settings offer limited on-site oversight of medications by an RN, thus heightening concern about medication safety.33 Young et al reported an error rate of 28.2% out of 4886 total medications given in an assisted living facility, where a majority of medications were administered by UAP.33 The RN's involvement varies depending on state regulations, and if medication administration is delegated by the RN and if the principles of delegation and accountability apply.4,26

DEFINITIONS

1. Unlicensed assistive personnel (UAP): an umbrella term that describes a job class of paraprofessionals who assist individuals with physical disabilities, mental impairments, and other health care needs with their activities of daily living and provide care, including basic nursing procedures, under the supervision of an RN, state-licensed practical/vocational nurse, or other health care professionals. They provide care for health care consumers in need of their services in hospitals, long-term care facilities, outpatient clinics, schools, private homes, and other settings. By definition, UAP do not hold a license or other mandatory professional requirements for practice, although many hold various certifications.4

2. Unlicensed health care personnel (UHCP): a term used in an INS survey to include various non-NAP to whom physicians, RNs, and other health care professionals may delegate patient care activities, with the potential inclusion of infusion therapy and vascular access.24

3. Accountability: is related to both answerability and responsibility. Accountability is judgment and action on the part of the nurse for which the nurse is answerable to her- or himself and others for those judgments and actions. Responsibility refers to the specific accountability of liability associated with the performance of duties of a particular nursing role and may, at times, be shared in the sense that a portion of responsibility may be seen as belonging to another who was involved in the situation.4

4. Delegation: the transfer of responsibility for the performance of a task from 1 individual to another while retaining accountability for the outcome. The RN, in delegating a task to UAP, transfers the responsibility for the performance of the task, but retains professional accountability for the overall care.4

5. Direct infusion care: the provision of care including peripheral vascular access insertion, central vascular access insertion, site care and maintenance, and administration of IV medications to a patient as ordered by a licensed independent practitioner.24

6. Nursing process: a critical thinking model comprising the integration of singular, concurrent actions of 6 components: assessment, diagnosis, identification of outcomes, planning, implementation, and evaluation.4

7. Responsibility: ANA states that responsibility involves liability with the performance of duties in a specific role. Responsibility is a 2-way process that is both allocated and accepted. Assistive personnel accept responsibility when they agree to perform an activity delegated to them.4

8. Supervision: the active process of directing, guiding, and influencing the outcome of an individual's performance of a task.4 Similarly, NCSBN defines supervision as the provision of guidance or direction, oversight, evaluation, and follow-up by the licensed nurse for the accomplishment of a delegated nursing task by assistive personnel. Individuals engaging in supervision of patient care should not be construed to be managerial supervisors on behalf of the employer under federal labor law.19

STATEMENT OF POSITION

It is the position of the Infusion Nurses Society to promote patient safety and ensure safe practice by the RN that:

1. The role of UAP involved with infusion therapy is defined in the organization's policies and procedures.

2. The role of UAP involved with infusion therapy is limited to tasks for which documented education, training, competency assessment and validation, and outcomes monitoring are demonstrated.

3. When working with UAP in any health care setting, RNs are knowledgeable about the ANA principles of delegation, associated risks and benefits, and state laws and regulations governing RNs' scope of practice.

ACKNOWLEDGMENTS

The author wishes to thank the members of the Unlicensed Assistive Personnel Task Force, Julia Burgess, MSN, RN, ACNS-BC, CNS, CCRN-CMC; Diane Jiles, RN, CRNI(R), VA-BC; and Sue Nittler, BSN, RN, CRNI(R); and INS board members, Cheryl Dumont, PhD, RN, CRNI(R); Richelle Hamblin, MSN, RN, CRNI(R), RN-BC; Ann Plohal, PhD, APRN, ACNS-BC, CRNI(R); Lisa Bruce, BSN, RN, CRNI(R), IgCN; Diedre Bird, BSN, RN, CRNI(R); Max Holder, BSN, RN, CEN, CRNI(R), VA-BC; Donald Filibeck, PharmD, MBA; Britt Meyer, MSN, RN, CRNI(R), VA-BC, NE-BC; and Dora Hallock, MSN, RN, CRNI(R), OCN(R), CHPN. Lastly, the author thanks Lisa Gorski, MS, RN, HHCNS-BC, CRNI(R), FAAN; Lynn Hadaway, MEd, RN-BC, CRNI(R); Mary E. Hagle, PhD, RN-BC, FAAN; Mary McGoldrick, MS, RN, CRNI(R); and Marsha Orr, MS, RN, for their review.

REFERENCES