A scoping review of registered nurses' delegating care and support to unlicenced care and support workers

AIM

To scope the international literature about registered nurses delegated models of care to unlicenced workers, identify gaps and reflect upon how the evidence relates to nursing in multiple contexts.

DESIGN

Scoping review of the peer reviewed literature from the year 2000 onwards, using the PRISMA-ScR checklist.

METHODS

The study searched the following databases in February 2022: CINAHL, Medline, ProQuest, and SCOPUS, and included keywords, Boolean operators and subject headings relevant to registered nurses delegating the provision of care to unlicenced workers.

RESULTS

A total of 49 articles met the eligibility criteria for this study, and relevant data were extractedThree models of delegation were highlighted within the literature: direct, indirect and a mixture of both. The data highlighted that direct delegation mainly occurred in acute contexts, with delegation decreasing with increasing patient acuity and/or complexity but the threshold of when this would occur was not clear. There was one intervention study that measured patient outcomes which could aid in the determination of what is effective delegation. For studies that did report on it (n = 6), there were few examples of better patient outcomes in cases where care was delegated from registered nurses to unlicenced workers.

CONCLUSIONS

The scoping review highlighted heterogeneity in practice areas and methods of delegation practice. A key gap in literature is the absence of studies focusing on patient outcomes, with a clear baseline to measure and identify effective delegation practices. Additionally, the legal and logistical implications presented in both direct and indirect delegation practices is not evident in the literature.

IMPLICATIONS FOR THE PROFESSION

Decisions related to delegation are often made at the service level and prescribed to those who work within the service, suggesting that models of indirect delegation are in fact not delegation at all, rather a re-distribution of nurses' work.

RELEVANCE TO CLINICAL PRACTICE

Delegation is a vital component of the scope of practice of registered nurses. This review has highlighted unique differences in delegation by practice context, where the proliferation of unlicensed workers in certain contexts places a vastly different professional and legal burden on the registered nurse.

Medication Administration Practices in United States' Schools: A Systematic Review and Meta-synthesis

Schools often provide medication management to children at school, yet, most U.S. schools lack a full-time, licensed nurse. Schools rely heavily on unlicensed assistive personnel (UAP) to perform such tasks. This systematic review examined medication management among K-12 school nurses. Keyword searches in three databases were performed. We included studies that examined: (a) K-12 charter, private/parochial, or public schools, (b) UAPs and licensed nurses, (c) policies and practices for medication management, or (d) nurse delegation laws. Three concepts were synthesized: (a) level of training, (b) nurse delegation, and (c) emergency medications. One-hundred twelve articles were screened. Of these, 37.5% (42/112) were comprehensively reviewed. Eighty-one percent discussed level of training, 69% nurse delegation, and 57% emergency medications. Succinct and consistent policies within and across the United States aimed at increasing access to emergency medications in schools remain necessary.

Are School Nurses an Overlooked Resource in Reducing Childhood Obesity? A Systematic Review and Meta-Analysis

BACKGROUND

Schools are a key setting for childhood obesity interventions, yet nurses are not often included in delivering these interventions. The objective of this systematic review and meta-analysis was to examine school-based interventions involving nurses in a role beyond anthropometric measurement for effect on change in body measures.

METHODS

We performed a systematic review and meta-analysis of these papers.

RESULTS

The literature search produced 2412 articles. Eleven met inclusion criteria for the systematic review (4 randomized controlled trail [RCT], 7 quasi-experimental) and 8 for the meta-analysis. None have been included in prior meta-analyses. Four studies restricted eligibility to overweight and/or obese children; 7 included all children regardless of body weight. Random effects meta-analytic models represent data from 6050 (body mass index [BMI]), 5863 (BMIz), and 416 (BMI percentile) children, respectively. Pooled analyses demonstrated statistically significant decreases in BMI (6 studies: -0.48 [95% CI -0.84, -0.12]; I(2) =91.2%, Q=68.1), BMIz (5 studies: -0.10 [95% CI: -0.15, -0.05]; I(2) =0, Q=2.3), and BMI percentile (3 studies: -0.41 [95% CI: -0.60, -0.21]; I(2) =0, Q=2.0).

CONCLUSIONS

These findings are similar to those of other meta-analyses of school-based interventions and suggest that school nurses can play a key role in implementing sustainable, effective school-based obesity interventions.

Effectiveness of health education teachers and school nurses teaching sexually transmitted infections/human immunodeficiency virus prevention knowledge and skills in high school

BACKGROUND

We examined the differential impact of a well-established human immunodeficiency virus (HIV)/sexually transmitted infections (STIs) curriculum, Be Proud! Be Responsible!, when taught by school nurses and health education classroom teachers within a high school curricula.

METHODS

Group-randomized intervention study of 1357 ninth and tenth grade students in 10 schools. Twenty-seven facilitators (6 nurses, 21 teachers) provided programming; nurse-led classrooms were randomly assigned.

RESULTS

Students taught by teachers were more likely to report their instructor to be prepared, comfortable with the material, and challenged them to think about their health than students taught by a school nurse. Both groups reported significant improvements in HIV/STI/condom knowledge immediately following the intervention, compared to controls. Yet, those taught by school nurses reported significant and sustained changes (up to 12 months after intervention) in attitudes, beliefs, and efficacy, whereas those taught by health education teachers reported far fewer changes, with sustained improvement in condom knowledge only.

CONCLUSIONS

Both classroom teachers and school nurses are effective in conveying reproductive health information to high school students; however, teaching the technical (eg, condom use) and interpersonal (eg, negotiation) skills needed to reduce high-risk sexual behavior may require a unique set of skills and experiences that health education teachers may not typically have.

Reducing the risks of delegation: use of procedure skills checklists for unlicensed assistive personnel in schools, Part 1

School nurses are challenged by federal civil rights laws and the standards of school nursing practice to care for a burgeoning population of students with special health care needs. Due to the realities of current school nurse-to-student ratios, school nurses are frequently responsible for directing unlicensed assistive personnel (UAPs) to support the health and safety needs of students, where State Nurse Practice Acts, state legislation, and local policy mandates allow. The delegation of health care tasks to UAPs poses many professional, ethical, and legal dilemmas for school nurses. One strategy to reduce the risks of delegation is through the use of procedure skills checklists, as highlighted by the experience of one large urban school district. Part 1 of this two-part article will explore the scope of the problem and the principles of delegation, including legal and ethical considerations.

Redefining the school nurse role: an organizational perspective

PURPOSE

This paper aims to identify organizational readiness for change towards adoption of a redefined role of the school nurse as a strategic option in the context of a health promoting school approach. This new role is consistent with planned change directed at life habits and life conditions.

DESIGN/METHODOLOGY/APPROACH

A questionnaire based on a modified version of the organizational readiness for change (ORC) framework was e-mailed to 122 top and middle managers (response rate of 74 percent) in 42 local health organizations in the Province of Quebec, Canada, during the fall of 2009.

FINDINGS

In total, 90 percent of participants perceived the proposed role as a solution to fulfil their school health program needs, especially to plan and integrate health promotion projects. The lack of resources and nursing support emerged as factors hampering the capacity of school nurses to play such a role.

RESEARCH LIMITATIONS/IMPLICATIONS

Additional implications of the ORC framework are needed in order to better address organizational readiness for complex changes in specific health-related settings.

PRACTICAL IMPLICATIONS

Access to information technology and the development of computer skills would help enhance this encompassing role in health promotion.

ORIGINALITY/VALUE

Findings have the potential to better inform health authorities regarding the new role of the school nurse as a strategic option in health promotion. This study also provides an application of the theoretical framework showing the need for additional empirical tests.

Determinants of the intention of elementary school nurses to adopt a redefined role in health promotion at school

Background

The quest for greater efficiency in the provision of primary healthcare services and the implementation of a "health-promoting school" approach encourage the optimal redefinition of the role of school nurses. School nurses are viewed as professionals who might be significant actors in the promotion of youth health. The aim of this study was to identify the determinants of the intention of elementary school nurses to adopt a new health-promotion role as a strategic option for the health-promoting school.

Methods

This study was based on an extended version of the theory of planned behaviour (TPB). A total of 251 respondents (response rate of 70%) from 42 school health programs across the Province of Québec completed a mail survey regarding their intention to adopt the proposed health-promotion role. Multiple hierarchical linear regression analyses were performed to assess the relationship between key independent variables and intention. A discriminant analysis of the beliefs was performed to identify the main targets of action.

Results

A total of 73% of respondents expressed a positive intention to accept to play the proposed role. The main predictors were perceived behavioural control (β = 0.36), moral norm (β = 0.27), attitude (β = 0.24), and subjective norm (β = 0.21) (ps < .0001), explaining 83% of the variance. The underlying beliefs distinguishing nurses who had a high intention from those who had a low intention referred to their feelings of being valued, their capacity to overcome the nursing shortage, the approval of the school nurses' community and parents of the students, their leadership skills, and their gaining of a better understanding of school needs.

Conclusions

Results suggest that leadership is a skill that should be addressed to increase the ability of school nurses to assume the proposed role. Findings also indicate that public health administrators need to ensure adequate nurse staffing in the schools in order to increase the proportion of nurses willing to play such a role and avoid burnout among these human resources.