Requires the Board of Nursing to adopt rules by January 1, 2028, to address appropriate nurse delegation parameters.
Nurse Delegation.
A registered nurse (RN) may delegate certain tasks of nursing care within the nurse's scope of practice to other individuals. Acts that require nursing judgement may not be delegated. When delegating a task, the nurse must determine the competency of the individual to perform the task, evaluate the appropriateness of the delegation, and supervise the actions of the person performing the delegated task. The determination of the appropriateness of delegation of a nursing task is at the discretion of the RN.
Registered nurses may only delegate the administration of medications in enumerated circumstances, including in-home health or hospice agencies or in community-based care settings. An RN may not delegate acts requiring substantial skill or that pierce or sever tissue, except for insulin injections and glucose monitoring and testing. When delegating insulin injections, the RN must instruct on and demonstrate insulin injections and supervise and evaluate the individual performing the injections.
For delegation in community-based care settings and in-home care settings, an RN may only delegate to a registered or certified nursing assistant or a certified home care aide. Delegation in these settings is limited to individuals that have a stable and predictable condition.
The RN must verify that the nursing assistant or home care aide has completed the required core nurse delegation training before delegating any task.
The RN is accountable for his or her own actions in the delegation process and RNs acting within their delegation authority are immune from liability for any action performed in the course of their delegation duties.
Nursing Assistants and Home Care Aides.
Nursing Assistants Registration and Certification.
A nursing assistant is a person who assists in the delivery of nursing and nursing-related activities to patients in a health care facility. Nursing assistants work under the direction and supervision of RNs or licensed practical nurses. There are two levels of credentialing for nursing assistants, registered nursing assistants and certified nursing assistants. Registered nursing assistants may not be assigned to provide care until the nursing assistant demonstrates the skills necessary to perform competently all assigned duties. To become certified, a nursing assistant must successfully complete an approved training program and pass a competency evaluation. Certification is required for nursing assistants working in a nursing home but is voluntary for those working in other health care facilities unless required by law.
Home Care Aide Certification.
Most long-term care workers must become certified as home care aides within 200 days of being hired. To become certified as a home care aide, a long-term care worker must complete 75 hours of training, pass a certification examination, and pass state and federal background checks.
Accepting Delegation of Nursing Care Tasks.
A nursing assistant or home care aide who provides care to individuals in community-based care settings or in-home care settings, may accept delegation of nursing care tasks by an RN. Before commencing any nursing care tasks under delegation, the nursing assistant or home care aide must have completed courses relating to nurse delegation, and if administering insulin injections, a specialized diabetes nurse delegation course, and provide the certificates of completion to the nurse delegating the task.
Nursing assistants and home care aides are accountable for their own actions in the delegation process, however, while accurately following written delegation instructions, delegated duties are immune from liability. Nursing assistants and home care aides may not be subject to employer reprisal or disciplinary action for refusing to accept a delegated nursing task based on patient safety issues and providers of community-based care and in-home services agencies may not discriminate or retaliate against any person who made a complaint or cooperated in an investigation.
Nurse Delegation.
An RN may delegate tasks to other individuals in any setting where an RN determines it is in the best interest of the patient and within the nurse's scope of practice. When delegating a task, the nurse must determine the competency of the individual to perform the tasks, including verifying certification or documentation as required by rule; evaluate the stability of the patient and appropriateness of the delegation; and supervise the task. Setting specific requirements and restrictions are eliminated as are specific requirements related to the injection of insulin.
A nurse may delegate tasks to credentialed medical assistants. If trained and delegated the task by an RN, a nursing assistant or home care aide may administer medications, including those that pierce the skin through subcutaneous injections, and may perform capillary blood sticks. An RN may not delegate the administration of medication through intramuscular or intravenous means, tasks involving piercing or severing tissues, or acts that require substantial skill or nursing judgement.
Requirements that an RN verify that a nursing assistant or home care aide has completed the required nurse delegation training before authorizing delegation are removed (however, the RN must verify any certification or documentation required by rule prior to delegating a task).
Education and training provided by an RN to a parent, guardian, or family member designated to provide care for a patient is not delegation of a nursing care task.
By January 1, 2028, the Board of Nursing must adopt rules to address appropriate delegation parameters.
Accepting Delegation of Nursing Care Tasks.
Requirements that nursing assistants and home care aides complete a specialized diabetes nurse delegation course before administering insulin and requirements to provide certificates of completion of the nurse delegation core training and diabetes delegation course to the delegating nurse are eliminated.
Nursing assistants and home care aides accurately following delegation instructions, rather than written delegation instructions, from a nurse are immune from liability regarding the performance of their duties. No facility or employer (rather than a provider of community-based care or in-home services agency) may discriminate or retaliate against a person because the person made a complaint or participated in an investigation. Nursing assistants and home care aides are not subject to any liability, reprisal, or disciplinary action when administering medication in an emergency response situation if the patient has a prescribed and available medication for that specific type of emergency event.
The substitute bill:
(In support) This bill will expand the ability of many health care professionals to provide care and services for the people of Washington. This bill modernizes Washington's nurse delegation statute, which is outdated, overly prescriptive, and difficult to apply consistently across today's health care settings. As health care delivery has evolved, particularly in long-term care and home health, clear and flexible delegation is essential.
The current statutory framework limits nurses' ability to delegate safely and efficiently, contributing to care delays and missed opportunities to optimize care. This bill authorizes the Board of Nursing to establish responsive nurse delegation standards through administrative rulemaking. This would align Washington with national best practices, as most states regulate nurse delegation through rule rather than statute. This allows boards of nursing to maintain clear and up-to-date standards that can adapt to changing health care needs. The current statute prevents delegation of nursing care tasks to nursing assistants in schools and does not recognize the existing ability of nurses to delegate to medical assistants.
Nurse delegation is a critical piece of care delivery in the long-term care setting, especially with the shortage of nurses that we currently face. Providers really depend on nurse delegation to care for patients. Nurse delegation allows individuals to remain in community settings for longer. This bill will also help protect these entry-level workers when administering life-saving treatments in emergency situations when the individual has a prescription for the medication.
This proposal will allow additional assistants to be practicing at the top of their license alleviating some of the concerns about workforce shortages.
(Opposed) There are concerns about the immunity provisions in this bill and a fear that the provisions may weaken patient safety and undermine professional nursing standards across Washington. This bill expands delegation of high-risk clinical tasks, including medication administration by injection and blood glucose testing to nursing assistants and home care aides in all settings. These activities require nursing judgment, ongoing assessment, and the ability to respond immediately to complications. While there is a lot of talk about workforce, the response should not be to weaken patient care and patient safety. While delegation might be a necessary tool for managing workload, immunizing nurses from liability when delegating tasks breaks the crucial link between patient care and accountability. This bill provides immunity when a nurse delegates, and it provides immunity when a nursing assistant or home care aide accepts the delegated task. So there may be a patient harmed through medical negligence and they may be left with no recourse.
(In support) Representative My-Linh Thai, prime sponsor; Alyssa Odegaard, LeadingAge Washington; Alison Bradywood, Washington State Board of Nursing; and Jeff Gombosky, Washington Health Care Association.