Unlicensed Assistive Personnel

You asked for information on “unlicensed assistive personnel” (UAP), specifically have they been licensed or certified in any states. You are particularly interested in Maine and Rhode Island.

According to the American Nurses Association (ANA), the term “unlicensed assistive personnel” (UAP) applies to an unlicensed individual who is trained to function in an assistive role to the licensed nurse in providing patient/client activities as delegated by the nurse. The team includes, but is not limited to, nurse's aides, orderlies, assistants, attendants, and technicians. These activities can generally be categorized as either direct or indirect care in the ANA's view. Direct patient care activities are delegated by the registered nurse and assist the patient in meeting basic human needs. This includes feeding, drinking, positioning, ambulating, grooming, toileting, dressing, and socializing, and may involve the collecting, reporting and documenting related to these activities. “Indirect patient care activities” focus on maintaining the environment and the systems in which nursing care is delivered and only indirectly involve direct patient contact. These activities assist in providing a clean, efficient and safe patient care environment and typically encompass categories such as housekeeping and transporting, clerical, and stocking and maintaining supplies (see ANA's “Position Statement on RN Utilization of UAP”—Attachment 1).

A number of states allow delegation of patient care tasks by a variety of individuals. Maine allows delegation of selected nursing tasks by licensed nurses to “certified nursing assistants.” Such assistants must complete a training program, receive a certificate from that program, and be listed on a state registry of certified nursing assistants.

Massachusetts defines unlicensed personnel to include nurse's aides, orderlies, assistants, attendants, home health aides and other health-related aides. A variety of activities generally considered within the scope of nursing practice may be delegated.

New Jersey allows delegation of certain tasks to practical nurses and “ancillary nursing personnel,” which includes aides, assistants, attendants, and technicians.

Oregon recognizes certified nursing assistants as unlicensed individuals who have successfully completed a state-approved training program and are listed on a registry.

Rhode Island defines a “nursing assistant” as a nurse's aide or orderly, or home health aide who is a paraprofessional trained to give personal care and related assistance based on his level of preparation. A nursing assistant is supervised by an RN and must have a certificate of registration from the state health department. Such assistants must complete a training program and a registry is kept by the state.

Texas recognizes unlicensed personnel functioning in a complementary or assistive role to the registered nurse. The term includes nurse's aides, orderlies, assistants, technicians, home health aides and medication aides.

Maine law recognizes the category of “certified nursing assistant” as an individual with duties assigned by a registered professional nurse. A certified nursing assistant must successfully complete a training program or course with a curriculum prescribed by the state nursing board, hold a certificate of training from that program or course, and be listed on the Maine Registry of Certified Nursing Assistants (see Maine Statutes Title 32 § 2102). Provision is also made for those certified prior to the state's adoption of this requirement in 1987.

An educational institution or health care facility wishing to conduct an educational program for nursing assistants to prepare them for certification and registry listing must apply to the state Department of Education. It must submit evidence that it can: (1) carry out the curriculum for nursing assistants as prescribed by the board, (2) meet those standards established by the board, and (3) meet those standards for educational programming and faculty as established by the education department (Chap. 32 § 2104).

Selected nursing services can be delegated to a nursing assistant by registered nurses. Regulations pertaining to such delegation as well as regulations of the prescribed curriculum for nursing assistants are included in Attachment 2.

The Maine State Board of Nursing has established a UAP Task Force that has been in operation for a year. The task force recently received funding approval to conduct a “job analysis process study” which is intended to look at a variety of unlicensed personnel and the duties they can and cannot perform, and to identify necessary curricula to prepare individuals to do these various tasks. In addition to certified nursing assistants, the task force will examine nurse's aides, personal care givers, home health personnel, attendants, technicians, and other unlicensed health-related personnel.

Massachusetts' regulations define unlicensed personnel as “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” (244 CMR 3.05(1)).

The following activities are generally considered within the scope of nursing practice to be delegated, and may be delegated provided it is done in compliance with state regulation: (1) nursing activities which do not require nursing assessment and judgment during implementation; (2) collection, reporting, and documentation of simple data; (3) activities which meet or assist the patient in meeting basic human needs, including but not limited to nutrition, hydration, immobility, comfort, socialization, rest, and hygiene (244 CMR 3.05(4)).

The activities that are not within the scope of sound nursing judgment to delegate include: (1) nursing activities requiring nursing assessment and judgment during implementation; (2) physical, psychological, and social assessment requiring nursing judgment, intervention, referral, or follow-up; (3) formulation of the plan of nursing care and evaluation of the patient's response to the care provided; and (4) administration of medications except as permitted by state law.

In New Jersey, certain tasks may be delegated to practical nurses and ancillary nursing personnel. “Ancillary nursing personnel” includes aides, assistants, attendants, and technicians. No task may be delegated which is within the scope of nursing practice and requires: (1) the substantial knowledge and skill derived from completion of a nursing education program and the specialized skill, judgment and knowledge of a registered nurse and (2) an understanding of nursing principles necessary to recognize and manage complications which may result in harm to the health and safety of the patient.

The following are guidelines concerning the contributions ancillary personnel may make in the delivery of care:

1. taking vital signs, temperature, pulse, respiration, and blood pressure;

2. measuring height, weight, and intake and output;

3. monitoring blood glucose;

4. collecting specimens—urine, stool, and sputum;

5. recording information;

6. reporting to the registered professional nurse changes in the condition of the patient;

7. providing personal hygiene and activities of daily living;

8. assisting with ambulation, positioning, and turning;

9. assisting with psychosocial activities;

10. providing for a safe environment;

11. assisting with feeding;

12. transporting patients;

13. performing elimination activities—enemas (cleansing and treatment), established ostomy care;

14. setting up traction equipment;

15. performing vaginal irrigations;

16. maintaining oxygen administration; and

17. providing post mortem care.

State law defines an unlicensed person as “an individual who is not licensed to practice nursing, medicine, or any other health occupation requiring a license in Oregon, but who provides basic or special tasks of nursing/client care.” For purposes of delegation rules, unlicensed persons do not include members of the client's immediate family. A “certified nursing assistant,” under Oregon law, is an unlicensed person who has successfully completed a nursing-board approved training program, passed the state competency evaluation program, and is listed on the nursing assistant registry (§ 851-47-010(6)).

Rhode Island law defines a “nursing assistant” as a “nurse's aide, or orderly, or home health aide who is a paraprofessional, trained to give personal care and related health care and assistance based on his or her level of preparation to individuals who are sick, disabled, dependent, or infirmed and who are residents of or who receive services from health care facilities . . . or receiving services from agencies . . .” (Rhode Island Statutes § 23-17.9-2(a)). By regulation, the director of Rhode Island's Department of Health can establish different levels of nursing assistants.

Nursing assistants must be supervised by registered nurses and other appropriate professional members of a health care facility or physician (§ 23-17.9-2(d)). These provisions do not apply to individuals designated solely as personal care attendants (§ 23-17.9-2(e)).

A nursing assistant employed as an assistant offering services as such must have a certification registration from the health department. Before receiving a certificate, the nursing assistant must successfully complete a training program unless otherwise exempt by law. All nursing assistants must register with the health department which costs $20. The department keeps a registry of all those issued certificates of registration (§ 23-17.9-6).

Standards for training or competency evaluation programs for nursing assistants and exemption from requirements must be consistent with federal requirements and be defined under state health department regulations (§ 23-17.9-3). The national standards pertaining to nursing assistants, nurse aides-home health aides, and the national home caring council (or its successor) and other appropriate standards must serve as guidelines in developing regulatory standards for other levels of nursing assistants. The department can charge up to $250 as an application fee for biennial training and competency evaluation program certification (§ 23-17.9-3).

The health department may suspend or revoke any nursing assistant's certificate of registration, or reprimand, censure, or take other disciplinary measures, or deny a registration application after a hearing if there is proof that the nursing assistant (1) is unfit or incompetent because of negligence, habits, or other causes; (2) has willfully or repeatedly violated the law as a nursing assistant, or wilfully or repeatedly acted in a way inconsistent with the health and safety of a patient; (3) has been convicted in court of a felony, either in or out of state; (4) has otherwise violated the law on nursing assistants; or (5) has engaged in conduct detrimental to the health, safety, and welfare of patients (§ 23-17.9-8).

Texas defines an unlicensed person as an individual who is not licensed as a health care provider, who functions in a complementary or assistive role to the registered nurse in providing direct client care or carrying out common nursing functions. The term includes, but is not limited to, nurse's aides, orderlies, assistants, attendants, technicians, home health aides, medication aides permitted by the Texas health department, and others providing personal care/assistance or health-related services.

In order for the nursing task to be delegated, it must not require the unlicensed person to exercise judgment or intervention except in emergency situations (§ 218.3(4)).

Specific nursing tasks which can and cannot be delegated within the scope of sound professional nursing practice are included as Attachment 5.