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LPNs Supervising HCAs in the Performance of Activities of Daily Living
This article will help clarify the process of Licensed Practical Nurses (LPNs) assigning activities of daily living (ADLs) to Health Care Aides (HCAs) and the responsibilities that come with assigning ADLs.
Assigning tasks to HCAs can come with certain risks depending on the nature of the ADL and the circumstances of the client, so the College of LPNs and HCAs of Alberta (CLHA) has developed guidance to support safe, competent, and ethical care.
Full information on this topic can be found in the practice guideline, Supervision of Health Care Aides Performing Activities of Daily Living.
How Are ADLs Defined?
ADLs are activities that a client would normally perform on their own behalf to maintain their health and well-being. In other words, these are tasks that the client would complete for themselves if they were not hindered by a health condition. Examples of ADLs include simple wound care, catheter care, and blood glucose testing.
Performing ADLs is included in the HCA scope of practice as defined by the Health Professions Act. ADLs must be assigned by an authorized supervising health professional, such as an LPN.
This article deals primarily with high-risk ADLs. High-risk ADLs are tasks that require specific precautions, skills, and competence to perform.
There is no exhaustive list of high-risk ADLs that HCAs can perform. Some examples of high-risk ADLs that an HCA may perform include:
- ADLs that are otherwise considered restricted activities, such as intermittent catheterization, performing blood glucose testing, flushing a gastrostomy tube (G tube), or providing tracheostomy care.
- Medication assistance as outlined in the HCA Medication Assistance policy. Note that HCAs are not permitted to dial up insulin pens or inject insulin under any circumstances.
When Can High-Risk ADLs Be Assigned to HCAs?
LPNs assigning high-risk ADLs are responsible for determining the tasks that are appropriate for HCAs to perform. In other words, is the right health professional being assigned to complete the right task? When considering whether an HCA should be assigned a task, LPNs should consider the following.
- Determine if the task is an ADL: would the client perform the task if they were physically able?
- The HCA’s competence: does the HCA have the knowledge, skills, training, and judgement to provide the ADL safely and ethically?
- The client’s condition: including potential risks and outcomes of the ADL as well as the capacity of the client or family to provide direction.
- Whether the HCA is the most appropriate provider: is a nurse the more appropriate provider to perform a high-risk ADL rather than an HCA?
- The availability of an appropriate level of supervision: high-risk ADLs require either direct, indirect, or remote supervision. The LPN is responsible for determining the appropriate level of supervision after all the factors are considered.
For a full list of considerations, review the checklist on page five of the Supervision of Health Care Aides Performing Activities of Daily Living guideline.
Process for Assigning ADLs
An LPN may assign ADL tasks related to the care of a client to an HCA if the ADL is within the HCA’s regulatory scope of practice, employer requirements, and individual competency. Prior to assigning, the LPN is required to:
- conduct a nursing assessment of the client;
- develop a plan of care;
- follow employer requirements, such as the HCA’s job description and the employer’s policies;
- understand and evaluate the HCA’s individual competence, which may include teaching and evaluating the HCA’s ability to perform the task;
- assess the risks and potential outcomes related to assigning the ADL; and
- ensure the right level of supervision is provided.
LPN Responsibilities
When assigning ADLs, LPNs are responsible for their own practice and documenting the care they directly provided. This includes assigning the ADL, following up with the HCA, performing an evaluation of the treatment or assessing the client, as well as meeting any other requirements of their regulatory college.
Decision Making and High-Risk ADLs: Practice Examples
The following examples illustrate how providers should approach assigning and accepting assignments for high-risk ADLs.
A client has been admitted to a medicine unit due to urinary retention. The HCA reports to their supervisor, an LPN, that the client hasn’t voided all shift despite drinking sufficient amounts of fluids. The LPN wants the HCA to perform a bladder scan on the client.
However, using the checklist in the Supervision of Health Care Aides Performing Activities of Daily Living guideline, the LPN determines that bladder scanning is not an ADL because it is not a task that the client could perform if they were physically able. Therefore, the LPN or another authorized health professional must perform the bladder scan.
A home care client has been administering their own nutrition via a Percutaneous Endoscopic Gastrostomy tube (PEG tube) for five years. Due to the loss of fine motor skills, that client can no longer perform PEG tube feeds themselves. An LPN assesses this client and includes PEG tube feeds into that client’s care plan. Administering nutrition through a PEG tube is considered a restricted activity, but it may also be an ADL performed by an HCA because:
- the purpose of PEG tube feeding is to maintain the client’s health and well-being,
- the client was able to perform PEG tube feeds prior to losing fine motor skills,
- the PEG tube feeding produces a predictable and stable response,
- this is a task an HCA could safely perform with training; and
- in this particular scenario, the client is able to direct the HCA in the performance of this high-risk ADL if needed.
The LPN provides client-specific education for the HCA, evaluates their performance of the task, and deems them competent to perform PEG tube feeds for this specific client with remote supervision.
Later, the HCA observes that the client’s condition begins to change. They report this change to the LPN, who assesses that the outcomes of PEG tube feeding are no longer predictable. Therefore, the task is no longer considered an ADL, and other arrangements need to be made for an authorized health professional to perform this restricted activity.
It’s important to note that ADLs are assigned on a client-specific basis. If the HCA in this scenario is assigned another client who requires PEG tube feeding, the LPN would still need to assess the client and provide training.
For support in understanding and applying regulatory requirements, contact the Professional Practice Team.