Policy 8482: Student Health Services and Delegation of Services (Rules)

Beliefs and Principles

Delegation of health care services by the professional school nurse is based on the following principles and beliefs:

1. Every student will receive the best care that is feasible within the school setting.
2. Relevant resources will be used efficiently.
3. The District will comply with legal mandates regarding delegation of nursing care.
4. School personnel who provide delegated health services will receive training and supervision in order to protect them from exposure to communicable disease and legal liability.
5. Administration of medication to students will be in conformance with Board policies including the policy related to the administration of medication to students (Policy 8670).
6. Children with known medical diagnoses or treatments/medications will be referred to school nursing services. 

Definitions and Conditions: 

Delegation is the transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome and is a nursing activity regulated by the Michigan Public Health Code. At home, the parent/guardian makes all the decisions regarding necessary health care for his/her child. In the school setting, the nurse decides whether delegation occurs and to which staff person the health care service can be delegated. 

Supervision must be provided when health care services are delegated. Supervision is the provision of guidance by a qualified nurse for the accomplishment of a nursing task or activity with initial assessment and planning for the task or activity and periodic evaluation of the actual act of accomplishing the task or activity. 

In the school setting, all nursing care of a student remains the responsibility of the nurse who remains accountable. In overseeing nursing care, the following standards, at a minimum, will be achieved:

1. The continuous availability of direct communication in person or by radio, telephone, or telecommunication between the supervised individual and a licensed health professional;
2. The availability of a licensed health professional on a regularly scheduled basis to review the practice of supervised individuals, to review records, and to further educate the supervised individual(s) in the performance of the individual’s functions; and
3. The provision by the licensed supervising health professional of predetermined procedures and drug protocols. 

Unlicensed Assistive Personnel: An unlicensed individual who is trained to function in an assistive role to the licensed registered nurse in the provision of patient/client care activities as delegated by the nurse. The term includes, but is not limited to, health aides and other school personnel. 

Licensed Practical Nurse: The practice of nursing based on less comprehensive knowledge and skill than that required of a registered professional nurse and performed under supervision of a registered professional nurse, physician, or dentist. 

Practice of Nursing: The systematic application of substantial specialized knowledge and skill, derived from the biological, physical, and behavioral sciences to the care treatment, counsel, and health teaching of individuals who are experiencing changes in the normal health processes, or who require assistance in the maintenance of health and the prevention or management of illness, injury, or disability. 

Registered Professional Nurse: An individual licensed to engage in the practice of nursing whose scope of practice includes teaching, direction, and supervision of less skilled personnel in the performance of delegated nursing activities.

Health Aide/Trained Secretary: A person who is qualified to carry out basic, specialized health care procedures, including first aid, in the care of students under the supervision of a registered professional nurse. 

Nursing Process for Delegation of Health Services: 

1. The nurse will assess children with known medical diagnoses and treatments/medications to determine if health care is needed at school.
2. When a student requires health care in school, an individualized health care plan (IHP) and/or emergency action plan (EAP), based upon a nursing assessment, will be developed by the school nurse in collaboration with the parent/guardian, the student’s health care providers, and the student or other school staff, as appropriate. Guidelines for the Delineation of Roles and Responsibilities for Health Procedures will guide what procedures can be delegated. In delegating medical procedure, the RN must ensure appropriate: 
   • Assessment: 
     1. Identify the needs of the student including:
        1. Procedures required at school
        2. Parent/Guardian information
        3. Physician information as needed
     2. Determine student stability/acuity.
     3. Identify that the procedure can be routinely performed and documented without need for modification.
     4. Consult the GRPS policy Guidelines for the Delineation of Roles and Responsibilities for Health Procedures to determine if the task can be delegated based on assessment of the student and the public health code.
     5. Determine to whom the procedure will be delegated in collaboration with the school principal.
     6. Determine the level of supervision performing the procedure requires. 
   • Planning and Implementation for Delegation:
     1. Specify the nature of the task, identify the knowledge and skills required to perform the task, and define the task in the Nursing Care Plan/IHP.
     2. Verify that the person to whom the task is to be delegated (delegate) accepts the task and accepts accountability for his/her actions in carrying out the task correctly.
     3. Provide step-by-step instructions using Spectrum Health procedures or other approved references as a guide.
     4. Provide clear instructions and expectations on how the task is to be performed. May include the following:
        1. Explanation of rationale for the procedure
        2. Written instructions (Action Plan format)
        3. Verbal instructions
        4. Demonstration of the procedure
        5. Return demonstration of the procedure by the delegate
        6. Instructions on the procedure for “worrisome” signs and “emergency” action 
   • Evaluation/Supervision:
     1. Documentation of the training and/or task performance of delegate.
     2. Documentation of successful completion of instruction:
        1. Verbalization of understanding of task and procedure by delegate
        2. Correct return demonstration of procedure and/or satisfactory completion of written test by the delegate
     3. RN available at all times to delegates for as needed consultation
     4. RN to provide periodic monitoring, supervision, evaluation, and documentation of the quality of the task performed by the delegate.
     5. The IHP will identify the student’s health care needs and adaptations required for school, as well as the responsibilities for service delivery.
3. The IHP and/or EAP will be included in the student’s Cumulative Record file.
4. A copy of the IHP and/or EAP will be kept in the Student Health Information notebook in each school. This should be arranged in alphabetical order by student last name.
5. The IHP and/or EAP will be updated annually or as needed in both of these locations: student cumulative record and the Student Health Information notebook. 

The special health care procedures that some children will need while they attend the Grand Rapids Public Schools are listed in the Guidelines for the Delineation of Roles and Responsibilities for Health Procedures. This matrix delineates the persons who are qualified to perform each of the procedures and the circumstances under which persons would be deemed qualified. It should be noted that the term “qualified” assumes that the individual has received appropriate training in the procedures.