244 CMR 3.00:		REGISTERED NURSE AND LICENSED PRACTICAL NURSE

Section

3.01:   Definition ‑ Registered Nurse
3.02:   Responsibilities and Function ‑ Registered Nurse
3.03:   Definition ‑ Practical Nurse
3.04:   Responsibilities and Functions ‑ Practical Nurse
3.05:   Delegation and Supervision of Selected Nursing Activities by Licensed Nurses to Unlicensed
         Personnel

3.01:   Definition ‑ Registered Nurse

Registered Nurse is the designation given to an individual who is licensed to practice professional nursing, holds ultimate responsibility for direct and indirect nursing care, is a graduate of an approved school for professional nursing, and is currently licensed as a Registered Nurse pursuant to M.G.L. c. 112.  Included in such responsibility is providing nursing care, health maintenance, teaching*, counseling, planning and restoration for optimal functioning and comfort, of those they serve.

3.02:   Responsibilities and Functions ‑ Registered Nurse

A registered nurse shall bear full and ultimate responsibility for the quality of nursing care she/he provides to individuals and groups. Included in such responsibility is health maintenance, teaching, counseling, collaborative planning and restoration of optimal functioning and comfort or for the dignified death of those they serve.  A registered nurse, within the parameters of his/her generic and continuing education and experience, may delegate nursing activities to ther registered nurses and/or health care personnel, provided, that the delegating registered nurse shall bear full and ultimate responsibility for:

(1)   making an appropriate assignment;

(2)   properly and adequately teaching, directing and supervising the delegatee; and

(3)   the outcomes of that delegation.  A registered nurse shall act, within his/her generic and continuing education and experience to:
(a)   systematically assess health status of individuals and groups and record the related health data;
(b)   analyze and interpret said recorded data; and make informed judgments therefrom as to the specific problems and elements of nursing care mandated by a particular situation;
(c)   plan and implement nursing intervention which includes all appropriate elements of nursing care, prescribed medical or other therapeutic regimens mandated by the particular situation, scientific principles, recent advancements and current knowledge in the field;
(d)   provide and coordinate health teaching required by individuals, families and groups so as to maintain the optimal possible level of health;
(e)   evaluate outcomes of nursing intervention, and initiate change when appropriate;
(f)   collaborate, communicate and cooperate as appropriate with other health care providers to ensure quality and continuity of care;
(g)   serve as patient advocate, within the limits of the law.

3.03:   Definition ‑ Practical Nurse

Licensed practical nurse is the designation given to an individual who is a graduate of an approved practical nursing program, and who is currently licensed as a practical nurse pursuant to M.G.L. c 112.  The licensed practical nurse functions within the framework specified by the nursing statutes and regulations of the Commonwealth.

*  Defined as assignment consistent with the education, experience and demonstrated competence of the assignee and consistent with the needs of the patient(s).

3.04:   Responsibilities and Functions ‑ Practical Nurse

A licensed practical nurse bears full responsibility for the quality of health care s/he provides to patients or health care consumers. A licensed practical nurse may delegate nursing activities to other administratively assigned health care personnel provided; that the delegating licensed practical nurse shall bear full responsibility for:

(1)   making an appropriate assignment,

(2)   adequately teaching, directing and supervising the delegatee(s), and

(3)   the outcome of that delegation: all within the parameters of his/her generic and continuing education and experience.

(4)   A licensed practical nurse participates in direct and indirect nursing care, health maintenance, teaching, counseling, collaborative planning and rehabilitation, to the extent of his/her generic and continuing education and experience in order to:
(a)   assess an individual's basic health status, records and related health data;
(b)   participate in analyzing and interpreting said recorded data, and making informed judgements as to the specific elements of nursing care mandated by a particular situation;
(c)   participate in planning and implementing nursing intervention, including appropriate health care components in nursing care plans that take account of the most recent advancements and current knowledge in the field;
(d)   incorporate the prescribed medical regimen into the nursing plan of care;
(e)   participate in the health teaching required by the individual and family so as to maintain an optimal level of health care;
(f)   when appropriate evaluate outcomes of basic nursing intervention and initiate or encourage change in plans of care;
(g)   collaborate, cooperate and communicate with other health care providers to ensure quality and continuity of care.

3.05:   Delegation and Supervision of Selected Nursing Activities by Licensed Nurses to Unlicensed
         Personnel

The qualified licensed nurse (Registered Nurse/Practical Nurse) within the scope of his/her practice is responsible for the nature and quality of all nursing care that a patient/client receives under his/her direction.  Assessment/ identification of the nursing needs of a patient/client, the plan of nursing actions, implementation of the plan, and evaluation of the plan are essential components of nursing practice and are the functions of the qualified licensed nurse.  The full utilization of the services of a qualified licensed nurse may permit him/her to delegate selected nursing activities to unlicensed personnel. Although unlicensed personnel may be used to complement the qualified licensed nurse in the performance of nursing functions, such personnel cannot be used as a substitute for the qualified licensed nurse.  The following sections govern the licensed nurse in delegating and supervising nursing activities to unlicensed personnel.  Delegation by Registered Nurses and Licensed Practical Nurses must fall within their respective scope of practice as defined in M.G.L. c. 112, § 80B, paragraphs 1 and 2.  Said delegation must occur within the framework of the job description of the delegatee and organizational policies and procedures and also must be in compliance with 244 CMR 3.05(4) and (5).

(1)   Definitions

Delegation ‑ The authorization by a qualified licensed nurse to an unlicensed person as defined in 244 CMR 3.05(1) to provide selected nursing services.

Supervision ‑ Provision of guidance by a qualified licensed nurse for the accomplishment of a nursing task or activity with initial direction of the task or activity and periodic inspection of the actual act of accomplishing the task or activity.

3.05:   continued

Unlicensed Person ‑ A trained, responsible individual other than the qualified licensed nurse who functions in a complementary or assistive role to the qualified licensed nurse in providing direct patient/client care or carrying out common nursing functions.  The term includes, but is not limited to, nurses' aides, orderlies,assistants,attendants, technicians, home health aides, and other health aides.

(2)   General Criteria for Delegation.  Delegation of nursing activities to unlicensed persons shall comply with the following requirements:
(a)   The qualified licensed nurse delegating the activity is directly responsible for the nursing care given to the patient/client, and the final decision as to what nursing activity can be safely delegated in any specified situation is within the specific scope of that qualified licensed nurse's professional judgment.
(b)   The qualified licensed nurse must make an assessment of the patient's/client's nursing care needs prior to delegating the nursing activity.
(c)   The nursing activity must be one that a reasonable and prudent nurse would determine to be delegatable within the scope of nursing judgment; would not require the unlicensed person to exercise nursing judgment; and that can be properly and safely performed by the unlicensed person involved without jeopardizing the patient's/client's welfare.
(d)   The unlicensed person shall have documented competencies necessary for the proper performance of the task on file within the employing agency; an administratively designated nurse shall communicate this information to the qualified licensed nurse(s) who will be delegating activities to these individuals.
(e)   The qualified licensed nurse shall adequately supervise the performance of the delegated nursing activity in accordance with the requirements of supervision as found in 244 CMR 3.05(3).

(3)   Supervision.  The qualified licensed nurse shall provide supervision of all nursing activities delegated to unlicensed persons in accordance with the following conditions:
The degree of supervision required shall be determined by the qualified licensed nurse after an evaluation of appropriate factors involved, including, but not limited to, the following:
(a)   the stability of the condition of the patient/client;
(b)   the training and capability of the unlicensed person to whom the nursing task is delegated;
(c)   the nature of the nursing task being delegated; and
(d)   the proximity and availability of a qualified licensed nurse to the unlicensed person when performing the nursing activity.

(4)   Delegation of Nursing Activities.  By way of example, and not in limitation, the following nursing activities are usually considered within the scope of nursing practice to be delegated, and may be delegated provided the delegation is in compliance with 244 CMR 3.05(2):
(a)   Nursing activities which do not require nursing assessment and judgment during implementation;
(b)   The collecting, reporting, and documentation of simple data;
(c)   Activities which meet or assist the patient/client in meeting basic human needs, including, but not limited to:  nutrition, hydration, mobility, comfort, elimination, socialization, rest and hygiene.

(5)   Nursing Activities That May Not Be Delegated.  By way of example, and not in limitation, the following are nursing activities that are not within the scope of sound nursing judgment to delegate:
(a)   Nursing activites which require nursing assessment and judgment during implementation;
(b)   Physical, psychological, and social assessment which requires nursing judgment, intervention, referral or follow‑up;
(c)   Formulation of the plan of nursing care and evaluation of the patient's/client's response to the care provided;
(d)   Administration of medications except as permitted by M.G.L. c. 94C.

3.05:   continued

(6)   Patient/Client Health Teaching and Health Counseling.  It is the responsibility of the qualified licensed nurse to promote patient/client education and to involve the patient/client and, when appropriate, significant others in the establishment and implementation of health goals.  While unlicensed personnel may provide information to the patient/client, the ultimate responsibility for health teaching and health counseling must reside with the qualifid licensed nurse as it relates to nursing and nursing services.

REGULATORY AUTHORITY

244 CMR 3.00:   M.G.L. c. 112, § 80B.