Background: In 1995, Washington State implemented law reforming the state's long-term care system, favoring provision of service in less restrictive, lower-cost settings. Purpose: The purpose was to systematically evaluate one facet of the new law regarding the implementation of a policy authorizing delegation of designated nursing tasks by registered nurses in community-based residential care settings. Method: This was a descriptive study driven by the inductive process of grounded theory. Qualitative data sources included interviews, public forums, document review, and open-ended survey questions to facility operators, nurses, nursing assistants, and inspectors. Discussion: The study identified an overarching social process, balancing freedom with risks involving tension at the intersections, which is evident from 3 main perspectives: consumer, professional, and the health care system. Conclusions: The study has implications for regulatory consistency, nursing practice and education, collaboration between overlapping providers of skilled nursing services in residential settings, and subsequent health policy.
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