Clinical Task Delegation in Iowa

I received the following question from a clinical quality practice leader in Iowa regarding medical assistants performing clinical tasks in inpatient settings. These types of questions are increasing because of the need to use medical assistants more extensively during the COVID-19 crisis.

I am a registered nurse [RN] and the clinical quality practice leader at a multi-clinic system in Iowa. We are accredited under The Joint Commission accreditation standards for hospitals. In working through pandemic surge planning, the question surfaced regarding the use of medical assistants in a supporting role in the inpatient setting. Would it be within the scope of a medical to perform certain clinical tasks based on a physician’s order and under the supervision of an RN?

To answer this question, note the following from the rules of the Iowa Board of Nursing (Chapter 6: “Nursing Practice for Registered Nurses/Licensed Practical Nurses”):

655—6.2(152) Minimum standards of nursing practice for registered nurses.

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6.2(5) The registered nurse shall recognize and understand the legal implications of accountability. Accountability includes but need not be limited to the following:

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c. Using professional judgment in assigning and delegating activities and functions to unlicensed assistive personnel. Activities and functions which are beyond the scope of practice of the licensed practical nurse may not be delegated to unlicensed assistive personnel.

Unlicensed assistive personnel (UAP) are defined in the Iowa nursing law as follows:

655—6.1(152) Definitions.

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“Unlicensed assistive personnel” is an individual who is trained to function in an assistive role to the registered nurse and licensed practical nurse in the provision of nursing care activities as delegated by the registered nurse or licensed practical nurse.

Medical assistants are considered UAP when functioning in an assistive role to RNs, often in inpatient settings.

The legality of RNs delegating clinical tasks to medical assistants is determined by the answers to the following two questions:

1. Are these tasks within the scope of practice of licensed practical nurses (LPNs) under Iowa law? If not, the tasks are not delegable to any UAP, including medical assistants.
2. Does the performance of these tasks require the exercise of independent clinical judgment or the making of independent clinical assessments or evaluations? If so, the tasks are not delegable to any UAP, including medical assistants.

If the medical assistant is competent and knowledgeable in these tasks, my legal opinion is that Iowa law does not forbid the delegation of these tasks to competent medical assistants working under RN direct/on-site supervision.

It may also be prudent to ask the malpractice insurance carrier for the health system whether it would cover any negligence by a UAP (such as a medical assistant) in performing these tasks.

The clinical quality practice leader followed my advice and asked the malpractice insurance carrier. This was the insurer’s response:

Tasks legally delegable to unlicensed assistive personnel may be delegated to medical assistants by the chief nursing officer, and supervision would have to be exercised by a registered nurse. The list of delegated tasks, the required competencies, and the dates the competencies were assessed and periodically reassessed must be in writing.

The medical assistants must report to the supervising RN if there is an emergency.

Our insurance will provide coverage for medical assistants performing these tasks, but we request the role be clearly delegated and documented as above.