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Introduction   

Unlicensed assistive personnel (UAP) are valuable members of the healthcare team that can carry out delegated care duties in the assistance of patients including vital signs, personal hygiene, assisting with meals, and toileting. In some cases, UAPs, when additional education is given, may monitor patient’s blood glucose, cognition status, wound care with dressing, and insert foley catheters or intermittent urinary catheters. UAPs come from a variety of different levels of training and are held to different standards based on state law, facility policy, the state’s board of nursing, and the setting that they are employed within. The use of UAPs across the healthcare continuum is advocated by the American Nurses Association and the National Council of State Boards of Nursing to assist with the nursing shortage and ensure that patients receive care that is quality-based and safe. 

Defining the Role of the UAP 

The role of the UAP is varied and broad depending on the setting, needs of the patient, staffing levels, and the level of training provided to the employee. Regardless of the type of facility or practice the UAP is employed in, clear guidelines and barriers must be defined to ensure the UAPs scope is understood by all levels of personnel and management. Leadership must ensure that their policies and procedures align with that state’s nursing practice act (1).  

The term UAP can cover many different titles as this is an unregulated position that may cover clinical, administrative, or a blended role of both these areas. As a healthcare paraprofessional, the UAP may be any of the following: nurse aide, ambulatory assistant, clinical unit clerk, nursing assistant, or nurse technician. 

The benefits of employing the UAP are to improve staff satisfaction and retention, increase the equity of duty sharing, and lower attrition rates. The balance of duties and responsibilities that may ultimately fall on the nursing staff can be shared. Jobs that do not specifically require nursing knowledge and expertise may be fulfilled by the UAP. This allows nursing staff more time to focus on the clinical aspects of patient care, carry out care plans, and increase the number of hours spent at the bedside (3). The benefits that are reaped by the UAP include gaining employment as a healthcare paraprofessional without having to pursue a degree, opportunities for further responsibility and training to higher level positions, and experience if pursuing a degree in the healthcare field. 

 Onboarding 

The onboarding and orientation of a UAP should be rigorous in acclimating the new employee to the facility’s culture and team environment. This should include policies and procedures that clearly define the roles, expectations, and assignments that are appropriate to each function. The UAP must understand their role within the nursing care team and the delegating relationships between the RN, LPN/LVN, and UAP roles. The UAP should be provided with a checklist of competencies that explain the skills and assignments that are appropriate to their roles. This training should also encompass the job functions outside of their scope of work to ensure that boundaries are understood.  

The UAP must understand the delegation relationship that is a unique part of the nursing/UAP team. Open conversation, collaboration, and shared decision-making promotes work environments that support a culture of safety and healthy relationships (1). A culture of safety has been shown to increase retention rates, increase staff satisfaction, and enhance engagement. All of these contribute to improved patient perception of care, higher scores on quality assessments and publicly reported survey scores (9).  

At minimum, orientation should provide the following:  

• Introduction to the facility’s mission, vision, and values 

• Review of policies and procedures 

• Patient-centered care focus 

• Individualized topics that relate to work focus 

• Communication expectations 

• Mindfulness with colleagues, patients, and family members 

• Codes of conduct 

The American Nurses Association advocates for an orientation that shifts from the previous trend of an in-service layout that introduces an overwhelming amount of new content presented by leaders from across the organization to a toned down, tailored format. The new model is geared towards a multiple day layout where one or two competencies are focused on each day. These competencies are developed from the Quality and Safety Education for nurses’ foundations and cover topics including teamwork and collaboration, patient-centered care, evidence-based practice, quality improvement, informatics, and patient safety (9). 

Competency-Based Orientation 

A robust education with orientation is essential to the success of the UAP, regardless of their background. As previously discussed, UAP may have varying levels of experience within the healthcare field. There are training certificate programs that provide individuals with basic patient care skills to assist with activities of daily life, obtaining vital signs, and completing simple nursing tasks such as wound care and administering oral medications that are taken on a regular basis. These programs are typically geared towards graduating as a nurse aide or assistant.  

While nursing programs embed patient safety education into their programs, the staff that have significant, direct involvement typically have limited training or are new to the healthcare environment. This requires facilities and healthcare organizations to be proactive in determining the role and scope that the UAP will fulfill and ensure that these topics are covered sufficiently for a base understanding. It is important to develop the knowledge, skills, and attitudes that are imperative to carry out evidence-based interventions (2).  

A competency-based orientation should be built around a standardized set of best practices that implement and drive forward quality patient care. The minimum time frame to develop these skills that will shape safe patient care and define the responsibilities of the UAP should take approximately six months total. A set of time, typically six to eight weeks, should be scheduled as a preceptorship when the employee begins working on their assigned unit.  

Preceptor/Preceptee Relationship 

When a new hire is onboarded and oriented to their home unit, there is a period of time that is established for training and learning the UAP role. A preceptor is assigned to the new employee for a set period of time, and this is when the new employee starts off shadowing the experienced employee. This relationship may be solely partnered with one preceptor, or there may be many involved depending upon the staffing requirements and needs of the unit, facility, or work environment. Often the preceptor is an experienced team member with the same job title; however, this may not always be the case. The new UAP may also be paired with nursing staff to be acclimated to the workflow, expectations, and to form positive professional relationships with the patient care team. This type of multidisciplinary collaboration early on can limit misunderstandings of practice scopes and role clarification later as time goes on (1, 4, 6).  

At this time, the preceptor shows the new employee the skills required to successfully complete delegated tasks and duties. The new employee should be given sufficient time to practice the skills taught and have opportunities to ask questions. It is important to establish a respectful and nurturing relationship where the trainee feels comfortable asking questions (6). 

This time is a wonderful opportunity to build healthy working relationships and promote collaboration.  

Patient Care and Responsibilities 

The guidelines and standards that determine the scope a UAP can work within are based on tasks that do not require additional formal education or extensive clinical training.  

Often UAP are delegated duties that are simple, patient care tasks. These may include any of the following clinical, patient care activities (3, 5): 

• Measuring height and weight 

• Obtaining and charting vital sign measurements 

• Applying cardiac electrodes and recording an electrocardiogram (ECG) 

• Collecting urine and performing point-of-care urinalysis 

• Assisting with activities of daily care 

• Hygiene 

• Alarm response and notification to the nurse 

• Wound care/dressings 

There may be specialized job functions that may be delegated to the UAP after additional education with competency is determined through observation and a verification process. Some job functions that require extra training include (3, 5): 

• Insertion and removal of foley catheters 

• Removal of intravenous (IV) catheters 

• Phlebotomy/venipuncture 

• Foot care 

• Administration of vaccinations and certain injections 

It must always be kept in mind by the delegator that any job that is delegated to the UAP continues to be the responsibility of the professional that has assigned the duty for safety, efficacy, and proper completion. 

Delegation Decisions 

Delegation is a skill that requires critical thinking, knowledge of the UAPs skills and knowledge levels, and communication to ensure there is clear understanding of responsibilities and closed loop communication. Delegation has been defined by the ANA and NCBSN as the “…transfer of responsibility for the performance of a task from one individual to another while retaining accountability for the outcome” (5).   

There are five rights involved with delegation. These include (5): 

• Right task 

• Right circumstance 

• Right person 

• Right direction and communication 

• Right supervision and evaluation 

These principles must be promoted to encourage the delivery of patient care that is safe and retains quality. Focusing on the distribution of tasks that may be delegated to the UAP in order to alleviate the pressure and workload on the nurse is essential to allow RNs to effectively assess, intervene, and evaluate responses to treatment. The healthcare team and healthcare providers rely upon this essential information to guide clinical care. Research has shown that an increase in the hours that an RN spends on direct patient care improves patient outcomes and reduces mortality rates (6).  

When the UAP is working on a nursing unit, it is also important to ensure that the nursing staff have the managerial skills and comfort levels to properly delegate. There should be additional education and training in place to teach nursing staff the art of delegation to gain the most benefits from the added responsibility of delegating, monitoring, and ensuring patient care and safety is upheld (1). 
 

Policy and Protocols 

Executive and unit leadership must ensure that policies are clear in defining the role of the UAP. This will reduce role confusion and prevent close calls and/or adverse events related to the paraprofessionals’ lack of training or inexperience. Ideally, policies and protocols should ensure adequate and appropriate training is afforded to all UAPs that are new to the facility, regardless of their previous experience.  

Topics that should be covered in the policies and procedures include (1):  

• Nursing and UAP education standards 

• Licensing requirements 

• Scopes of practice 

• Standards of patient care 

• Codes of conduct 

• Disciplinary action repercussions and actions 

• Federal regulations that guide care 

• Staffing levels based on acuity 

• Facility and unit rules 

• Delineating the chain of command to address safety concerns 

Conclusion

UAPs are valuable members of the healthcare team that can be trained to provide safe patient care. Many nurses find that having UAP assistance on their unit has changed the flow of patient care and decreased the response time to urgent patient needs. There is a culture change that must occur to clearly establish the rights and responsibilities of delegation between the nurse and UAP. 

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