Framework for Use of Unregulated Healthcare Workers

Definition and Delegation

Unregulated healthcare workers (UHWs) are constituents of many healthcare provision teams. Though traditionally LPNs, RNs, and RPNs have been the principal patient care providers; such a situation is changing in countries such as Canada where the use of UCPs is increasing (ARNNL & CLPNNL, 2009; Statistics Canada, 2008). Such increased use of UCPs has partially resulted from a high number of care clients that outstrips the capacity of available nursing professionals (International Council of Nurses – ICN, 2006).  With the higher degree of care being charged to UCPs and the lack of a formal system of their regulation, concerns that inappropriate care may be provided to clients have arisen (ARNNL & CLPNNL, 2009).

The unregulated care providers have a range of names according which they are referred. The College of Registered Nurses of Manitoba – CRNM – (2002) however defines UHWs as “caregivers who provide personal care or support for activities of daily living to individuals” (p. 3). On the other hand, the Canadian Nursing Association – CNA (2008) recognises that assistants providing such clinical skills as administering medication, changing dressings or any other delegated duty by licensed health professionals could form part of the UCPs. While in hospitals UHWs may perform duties in acute care, complex continuing care, pharmacy and rehabilitation under the supervision of health professionals; in home or community care settings such are employees of agencies and thus may act as the principal care giver according to the care plan prescribed by the centre (CNA, 2008). UHWs employed in communities may also play specific roles such as being the community’s health representatives (CNA, 2008). The College of Nurses of Ontario – CNO (2009) gives a clear picture of who constitutes UHWs by including “personal support workers, health care aides, homemakers, family visitors, personal attendants, psychiatric assistants and lay visitors” as part of the definition (p. 4). Many people that assist in care provision who are not subjected to regulation by professional bodies may thus fit the UCP tag.

This diverse designation and range of duties that UCPs perform makes it difficult to establish a regulatory framework applicable across board. Various organizations have however established guidelines for delegation of duties to UCPs. For instance, CRNM (2002) minimal requirements for a task to be delegated are that: the health status of the client should be stable and his response to the task being delegated predictable; the UHW should be capable of performing the task delegated safely; and there should be support and supervision of the UHW from a health professional with the degree of such supervision being established by the health professional (CRNM, 2002, p. 3). Similarly CNO (2009) guidelines on delegation contend that the health professional working with an UCP is accountable for: ones actions and decisions; knowing and comprehending the roles and obligations of UCPs; and taking the responsibility for action to guarantee client safety (CNO, 2009). Such accountability however does not extend to “decisions or actions of other care providers when … [the nurse has] no way of knowing about those actions” (CNO, 2009, p. 6). Accordingly before delegation a nurse should assess whether client’s state, risks associated with the state and available support in addition to the competency of the UCP allows the performance of delegated tasks satisfactorily (CNO, 2009). Only when all these evaluations are affirmative should the procedures be delegated (CNO, 2009). Guidelines with similar provisions have also been addressed by a joint issue by Newfoundland and Labrador’s Association of Registered Nurses and College of Licensed Practical Nurses (2009); and a Practice Support issue by the College of Registered Nurses of British Columbia (2007).

These guidelines also address issues related to UCPs accountability. In the CNRM (2002) guidelines issue UCPs obligations are identified as: (a) performance of assigned tasks, (b) learning the limit of procedures they can perform with the delegated approval, and (c) rejecting performance of delegated tasks until appropriate authorization and training for safe performance is received from their employers. As such UCPs are at least accountable to three different groups – the health professionals, the employer organizations and the care recipients. While to the registered care providers they bear the responsibility of performing assigned tasks and procedures; to the employers and clients they are responsible for competent performance of such allocated procedures (CNRM, 2002). Despite the presence of these guidelines, the lack of information such as statistics on UHWs numbers and qualifications, presents a challenge to effective planning and formulation of healthcare policies on aspects such as delegation, training and regulation (CNA, 2008). Go to part 3 here.

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