Delegation Considerations for Colorado School Nurses and Child Care Health Consultants

According to the National Center for Children’s Health (2022), it is estimated that more than 40% of school-aged children and adolescents in the United States have at least one chronic health condition. Children may require nursing and/or health services while attending school, school-sponsored events, or child care, to access the educational and child care settings and benefit from special education services called for in the Individual Education Program (IEP). 

Unlicensed assistive personnel (UAP) may be considered to assist the school nurse with the delivery of health services through the nursing delegation process. Nursing delegation requires a multifaceted approach with an essential goal of keeping the public safe. Nursing delegation is an essential skill that registered nurses are expected to perform competently and requires the application of laws, rules, and nursing standards.  The employer, nurse leader, delegating nurse, and UAP have responsibilities in meeting this goal. The National Guidelines for Nursing Delegation describes these responsibilities further.

This document provides guidance and best practices for school nurses in the Colorado K-12 public school setting and for Child Care Health Consultants in licensed child care settings, including preschools. The terms “school nurse” and “child care health consultant” are used interchangeably, as are the terms “school” and “child care programs.”

Definitions:

• School Nurse:  Per Colorado Department of Education (CDE), a school nurse is an individual licensed to practice as a Registered Nurse (RN) in Colorado who is also licensed as a CDE Special Service Provider with an endorsement as a school nurse, per the Exceptional Children's Educational Act (ECEA) Rules March 2016, 1 CCR 301-8, 2.37(3)(m)
• Child Care Health Consultant (CCHC): Per Healthy Child Care Colorado, a CCHC must hold a current Colorado license as a registered nurse, pediatric nurse practitioner, family nurse practitioner, or physician with knowledge and experience in maternal and child health and apply for CCHC Qualifications in the Professional Development Information System (PDIS).

The purpose of this document is to help registered nurses explore the essential considerations related to nursing delegation in the school and child care settings. School nurses should acquire knowledge and competence related to nursing delegation and that reflects the appropriate application of the Colorado State Board of Regulations 3 CCR 716-1, chapter 1.13. 

Colorado Nursing Rules and Regulations 3 CCR 716-1, Rule 1.13 F, limits the delegation of medication administration in the school and licensed child care settings to registered nurses (RNs) or advanced practice registered nurses (APRNs) who are employed or contracted by the school or licensed child care facility. Licensed practical nurses (LPNs) are not listed as licensed providers who can delegate medications in schools or child care settings.

According to the Colorado State Board of Education Rules for Administration of Medications 1 CCR 301-68 1.01:

• “Appropriate Staff” means employees of the school whom the principal or equivalent executive, in consultation with the School Nurse, determines to be appropriate.”

Colorado Nurses and Nurse Aides Practice Act 

Healthcare Professions and Occupations Article 255: Nurses and Nurse Aides 12-255-131

• No delegation shall be made without the delegating nurse making a determination that, in his or her professional judgment, the delegated task can be properly and safely performed by the delegatee and that the delegation is commensurate with the patient’s safety and welfare.
• The delegating nurse shall be solely responsible for determining the required degree of supervision the delegatee will need, after an evaluation of appropriate factors, which shall include but not be limited to the following:
  • The stability of the patient;
  • The training and ability of the delegatee
  • The nature of the task being delegated; and
  • Whether the delegated task has a predictable outcome.

Here are some examples of national and state nursing delegation definitions: 

• American Nurses Association: Delegation involves “the transfer of responsibility for the performance of a task from one individual to another while retaining accountability for the outcome.”
• National Association of School Nurses: “Nursing delegation in the school setting is the assignment by the school nurse – not a school administrator – to a competent unlicensed individual (also called unlicensed assistive personnel [UAP]) the performance of a selected nursing task in a selected situation for an individual student.”
• Colorado Nursing Rules and Regulations: 
  • “Delegation” means the assignment to a competent individual the authority to perform in a selected situation a selected nursing task included in the practice of practical nursing as defined in section 12-255-104(10), C.R.S., or in the practice of professional nursing as defined in section 12-255-104(8), C.R.S.
  • “Supervision” means the provision of guidance and review by a PN, RN, or APRN for the accomplishment of a nursing task or activity, with initial direction of the task, periodic inspection of the actual act of accomplishing the task or activity, and evaluation of the outcome (Rule 1.13 Rules and Regulations Regarding the Delegation of Nursing Tasks).

The rationale for delegating nursing tasks may includes the following: 

• The number of students with health needs varies at each school and may change throughout the school year. A student’s rights to access the educational setting are protected by state and federal laws. When appropriate, nursing delegation may be used to meet the health needs of students. Student’s rights are addressed in these three laws: 
  • Exceptional Children’s Educational Act (ECEA)
  • Individuals with Disabilities Education Act (IDEA)
  • Section 504 of the Rehabilitation Act of 1973 (OCR)
• The Colorado Department of Education (CDE) quality standards for evaluating school nurses and the National Association of School Nurses (NASN’s) Scope and Standards of Practice address delegation competency and expectations for school nurses. 
  • CDE Rubric for Evaluating Colorado Special Services Providers - School Nurses
  • Standard III
    • Trains, delegates, and supervises school staff to provide health services to students.
    • The school nurse trains and delegates school staff on the use of health-related technology to support student health. 
• NASN Scope and Standards of Practice, 4th edition includes:
  • Standard #5: Implementation
    • Competency 5.8 The school nurse delegates according to the health, safety, and welfare of the student while considering the circumstance, person, task, direction or communication, supervision, evaluation, as well as the state nurse practice act regulations, institution, and regulatory entities while maintaining accountability for the care.
  • Standard #17: Resource Stewardship 
    • Competency 17.5 The school nurse delegates in accordance with applicable legal and policy parameters, such as state nurse practice acts and the NCSBN National Guidelines for Nursing Delegation.
• Delegation allows the School Nurse RN to engage in activities that use the full extent of his or her education, training and experience. 

Delegatee Qualifications

When considering qualifications for a delegatee, these resources may be helpful:

Colorado Nursing Rules and Regulations: 

• “Delegatee” means an individual receiving the Delegation who acts in a complementary role to the PN, RN, or APRN, who has been trained appropriately for the task delegated, and whom the PN, RN, or APRN authorizes to perform a task that the individual is not otherwise authorized to perform.
• The Delegator shall assure that the Delegatee can and will perform the task with the degree of care and skill that would be expected of the PN, RN, or APRN.

National Association of School Nurses (NASN)  Recommended Qualifications for the Unlicensed Assistive Personnel 

The Colorado Nurses and Nurse Aid Practice Act Title 12 Healthcare Professions and Occupations Article 255: Nurses and Nurse Aides 12-255-131 includes the following: 

• Any licensed practical nurse, registered nurse, or advanced practice nurse may delegate any task included in the nurse’s scope of practice, subject to the requirements of this section. A licensed practical nurse, registered nurse, or advanced practice registered nurse may delegate nursing tasks to licensed, certified, registered, or unlicensed or unregulated assistive personnel. 
  • Remember, only an RN or APRN may delegate the administration of prescription and non-prescription medication in the school setting
• In no event may a registered nurse delegate to another person the authority to select medications if the person is not, independent of the delegation, authorized by law to select medications.
• Delegated tasks shall be within the area of responsibility of the delegating nurse and shall not require any delegatee to exercise the judgment required of a nurse.
• An employer of a nurse may establish policies, protocols, or standards of care that limit or prohibit delegations by nurses in specified circumstances.

The Colorado Nursing Rules and Regulations 3 CCR 716-1 Rule 1.13 describes the criteria for nursing delegation:  

• Criteria for Delegation
  • Any nursing task delegated by the PN, RN, or APRN shall be: 
    • Within the scope of practice and the area of responsibility of the delegator
    • Within the scope of knowledge, skills, ability of the delegator
    • Of a routine, repetitive nature and shall not require the delegatee to exercise nursing or midwifery judgment or intervention
    • A task that a reasonable and prudent nurse or certified midwife would  find to be within generally accepted nursing practice 
    • An act consistent with the health and safety of the client; and 
    • Limited to a specific delegatee, for a specific client, and within a specific time frame, except for delegation in schools or licensed child care facility (Rule 1.13 F) - which states: “not to exceed one school year”. 

According to the Colorado Nursing Rules and Regulations 3 CCR 716-1 Rule 1.13 the following activities can not be delegated in Colorado: 

• Delegation of the Administration of Medications in Schools and Licensed Child Care Facilities: A professional nurse shall not delegate administration of any medication that requires nursing judgment, or evaluation, during or immediately after administration
• Delegation of the Administration of Medications in Schools and Licensed Child Care Facilities 
  • The administration of stock Epinephrine and/or Naloxone by designated personnel is not a delegated nursing function and is described in Section (H)(4) of Rule 1.13.

According to the Colorado Nurses and Nurse Aid Practice Act Title 12 Healthcare Professions and Occupations Article 255: Nurses and Nurse Aides 12-255-131. Delegation of nursing tasks - rules 

• In no event may a registered nurse delegate to another person the authority to select medications if the person is not, independent of the delegation, authorized by law to select medications.
• Delegated tasks shall be within the area of responsibility of the delegating nurse and shall not require any delegatee to exercise the judgment required of a nurse.
• Guidance from the American Nurses Association includes the following:
  • The RN may delegate tasks or elements of care but does not delegate the nursing process itself.
• The nursing process is a critical thinking model comprising the integration of singular, concurrent actions of these six components: 
  • assessment 
  • diagnosis
  • identification of outcomes
  • planning
  • implementation 
  • evaluation

National Association of School Nurses 

• “The nursing process can never be delegated”.

Nursing Delegation in Colorado

Colorado Nursing Rules and Regulations 3 CCR 716-1 Rule 1.13 F. Delegation of the Administration of Medications in Schools and Licensed Child Care Facilities:

“A RN or APRN employed or contracted by a School or Licensed Child Care Facility may delegate the administration of prescription and non-prescription medication with an order from an appropriate health care provider to a specific Delegatee(s) who has successfully completed appropriate training for the population of a School or Licensed Child Care Facility, within a specific time frame not to exceed one school year.”

Student circumstances should be considered when determining whether or not to continue delegation: 

• Student condition no longer stable
• Task no longer has a predictable outcome/requires nursing judgment
• Student no longer on caseload of School Nurse 

Staff circumstance should be considered when determining whether or not to continue delegation:   

• School Nurse no longer assigned to manage the care of the student
• UAP unable to demonstrate competence or is otherwise unsafe to perform the task
• UAP or School Nurse leaves their position, or is no longer available 

The Colorado Board of Nursing has been working to empower Colorado nurses to determine their own scopes of practice. Using the following guidelines, a nurse may decide what is within scope, and to make certain the task or practice is documented in facility or institution policies and procedures. 

Scope of Practice Algorithm (DORA)

Ask the following question: Is this task/practice within my scope of practice?

• Was the skill/task taught in your basic nursing program?
• If it was not included in your basic nursing education, have you since completed a comprehensive training program that included clinical experience?
• Has this task become so routine in the nursing literature and in nursing practice, it can be reasonably and prudently assumed within scope?
• Is the skill/task in your hiring agency policy and procedure manual?
• Does carrying out the duty pass the "Reasonable and Prudent" standard for nursing?

If you can answer "yes" to all the above questions, the task is within your scope of practice.

Task 

• Within the area of responsibility of the nurse
• Within the scope of practice of the nurse
• Routine, repetitive nature, follows established steps
• Does not involve assessment, judgment, interpretation of results

Circumstance

• Student condition is stable
• Outcome of the task is predictable & without potential harm
• Appropriate resources are available to perform the task

Person

• School Nurse determines level of care required, expected student outcomes, and competency levels of the UAP
• UAP must be willing and available 

Direction and Communication 

• Each delegation situation is specific to the student, delegatee, and School Nurse
• School Nurse must provide training and communicate instructions
• Two-way communication should be established 

Supervision and Evaluation 

• School Nurse must evaluate UAP competence
• School Nurse must provide ongoing supervision 
• School Nurse must evaluate student outcomes 

• Instructions for the procedure or task must be specific and broken into its individual components.
• Specific steps for the procedure/task that will be delegated must be documented.
• For complicated procedures/ tasks, consider having the delegatee and RN initial each step in the document.
• Document each time the procedure/task is demonstrated by the UAP, and include the date and signatures of both the RN and the delegatee.
• The nursing task or procedure can be delegated once the delegatee has demonstrated competence through this training process.
• The delegating nurse should determine frequency of evaluation.
• Errors in carrying out a task must be documented along with the corrective actions taken. 
• Errors should be reported to district or licensing agency according to policy

Delegation is determined on a case-by-case basis by the professional registered nurse.

• Confirm school and/district delegation policies
• Assess student and identify health needs
• Determine your scope of practice, knowledge, ability
• Establish what should and can be delegated safely
• Identify appropriate UAP
• Train & verify competency to perform the delegated task
• Instruct how to intervene in any foreseeable risks associated with the task
• Determine and provide appropriate supervision
• When task is performed more than once, employ a system for ongoing monitoring & supervision of the UAP
• Perform ongoing evaluation of student outcomes
• Document

• CDE Training and Delegation Resources 
• Children’s Hospital Colorado - School Nurse Resources
• Colorado Kids with Diabetes - Training and Delegation
• Kennedy Krieger Institute - Information for School Nurses
• National Association of School Nurses - Nursing Delegation in the School Setting
• National Library of Medicine - Five Rights of Nursing Delegation