Nursing Practice in California

1. Nursing Practice in California Hon. Tricia Hunter RN, MN

2. Who am I? • Board of Registered Nursing • California State Assembly • Office of Statewide Health Planning and Development • California Medical Assistance Commission • Region 13 Disability Board • OSHPD Advisory Committee

3. STATUTES

4. Regulations: develop and grow through administrative efforts within the Executive Branch

5. Licensing • Protect the Public • Purview of the State • Individual Licensure versus Facility • California Medical Practice Act

6. Scope of Medical Practice • diagnose mental and physical conditions • use drugs in or upon human beings • sever or penetrate tissues • other methods in treatment of disease, injury deformities or other physical or mental conditions.

7. Business and Professions CodeSection 2051-2052 • The physician’s and surgeon’s certificate authorizes the holder to use drugs or devices in or upon human beings and to sever or penetrate the tissues of human beings and to use any and all other methods in the treatment of diseases, injuries, deformities, and other physical and mental conditions.

8. 2051 – 2052 Continued…. • Any person who practices or attempts to practice, or who advertises or holds himself or herself out as practicing, any system or mode of treating the sick or afflicted in this state, or who diagnoses, treats, operates for, or prescribes for any ailment, blemish, deformity, disease, disfigurement, disorder, injury, or other physical or mental condition of any person, without having at the office so doing a valid, unrevoked, or unsuspended certificate as provided in this chapter, or without being authorized to perform such act pursuant to a certificate obtained in accordance with some other provision of law, is guilty of a misdemeanor

9. Business and Professions Code Section 2038 • Whenever the word “diagnose” or “diagnosis” are used in this chapter, they include any undertaking by any method, device, or procedure whatsoever, and whether gratuitous or not, to ascertain or establish whether a person is suffering from any physical or mental disorder. Such terms shall also include the taking of a person’s blood pressure and the use of mechanical devices or machines for the purpose of making a diagnosis and representing to such person any conclusion regarding his or her physical or mental condition. Machines or mechanical devices for measuring or ascertaining height or weight are excluded from this section.

10. Court Case

11. People v. Fowler, 32 Cal.App2dSupp.737 (1938); 21 Ops.CalAtty Gen.228 • Constitutes the practice of medicine as penetration of tissues of a human being in the treatment of disease or injury, or for test or analysis purposes.

12. Legal Precedent • Delegation

13. Court Case

14. Magit v. Board of Medical Examiners, 57 Cal 2d 74, 84 (1961) • Unless one engaging in the practice of medicine is licensed under the state Medical Practice Act or is otherwise authorized to engage in such acts he is liable for violation of STATUTES which, like section 2141, prohibit the unlicensed practice of medicine, and supervision by a duly licensed medical doctor.

15. Delegation • Delegation is a legal term used to describe the transfer or responsibility for the performance of a task from one individual to another, while retaining accountability for the outcome. • Principles for Delegation, American Nurses Association, 2005

16. DELEGATION • STATUTORY DELEGATION • DELEGATION BY LICENSURE • STATUTORY AUTHORITY TO DELEGATE

17. Statutory Delegation • Glucagon, Epinephrine, Diastat • IEP Individual Education Plan • 504

18. Nurse PracticeAct

19. SCOPE OF RN PRACTICEBPC Section 2725 Independent license to practice Nursing. Nursing: • Dynamic field • Continually evolvingSophisticated Patient Care Activities

20. LEGISLATIVE INTENT: RN Clear legal authority for functions and procedures in common acceptance and usage. Recognize existence of overlapping functions nurse physician Permit additional sharing of functions Within organized health care system.Acute care, home health, clinics,physician offices, public & communityhealth services. NPA Section 2725(a)

21. Practice of Nursing means functions that: help people cope with difficulties in daily living actual/potential health/illness problems treatment require a substantial amount of scientific knowledge or technical skill

22. RN ASSESSMENT FUNCTIONSDirect & Indirect • Safety • Comfort • Personal Hygiene • Protection of Patients • Disease Prevention • Restorative Measures NPA Section 2725(b)(1)

23. RN ASSESSMENT FUNCTIONSDirect & Indirect Administration of medications and therapeutic agents to implement treatment, disease prevention or rehabilitative regime ordered by and within scope of practice of a licensed physician, dentist, podiatrist, or clinical psychologist. NPA Section 2725(b)(2)

24. RN FUNCTIONS • Skin tests • Immunization techniques • Withdrawal of blood from veins and arteries NPA Section 2725(b)(3)

25. RN ASSESSMENT Observations of signs and symptoms of illness, reactions to treatment, general behaviors, or general physical condition, and (A) determination of whether the signs, symptoms, reactions, behaviors, or general appearance exhibit abnormal characteristics, and (B) implementing, based on observed abnormality, of appropriate reporting, or referral, or standardized procedures, or the initiation of emergency procedures.

26. RN ASSESSMENT RN assessment includes the interpretation, analysis and synthesis of patient response to illness, treatments, reactions, procedures, medications, including correlation of laboratory values and imaging reports regarding the patient condition and determining what nursing and medical action is needed for the patient. RN acts on nursing assessment information.

27. RN Functions Determine abnormal characteristics: • signs • symptoms • reactions • behaviors • general appearance BPC Section 2725 (b)(4)(B)

28. RN Functions Implementation of Care: based on observed abnormalities: report; refer; implement standardized procedures change treatment based on standardized procedures initiation of emergency procedures BPC Section 2755 (b)(4)(B)

29. Standardized Procedures Legal authority for RN practice to overlap the practice of medicine

30. Licensed Vocational Nurses • Board of Licensed Vocational Nurses and Psychiatric Technicians • BUSINESS AND PROFESSIONS CODE SECTION 2859-2872.2

31. LVN Role • To assist the School Nurse: • Same duties as health clerk • First aid, records, communication, reports, clerical duties • Observations • Administer medications, injections • Basic nursing care • Sample Job Description – Green Book

32. LVN / RN Relationship • The RN must directly observe the patient, assess, plan, implement and evaluate the data collected by him/herself and the LVN • RN uses data to: • Make a nursing diagnosis • Determine appropriate interventions • Make appropriate assignments of tasks and activities

33. LVN Role • LVN contributes in planning, executes interventions as per treatment plan and the nursing care plan, and contributes to evaluation of interventions • The LVN can define the reaction to care but not make a conclusion

34. Who Can Provide

35. AB 1667 (Saldana) Chapter 414 amended Section 49423.5 of the Education Code • This amendment provided that any individual with exceptional needs who requires specialized physical health care services, during regular school day, may be assisted by a certain specified individuals, including designated school personnel. • (d) “Specialized physical health care services” as used in this section, include catheterization,gastric tube feeding, suctioning, or other services that require medically related training. • Requires 504 or ISHP

36. Medications and Unlicensed Staff

37. Medications: substances used to prevent, diagnose, cure or relieve signs and symptoms of disease Includes: Prescription Controlled Substances Over the Counter Herbal Alternative Research What are Medications?

38. Health and Safety Code 11154(a) • Controlled substances • Ritalin , Adderall, Focalyn • ONLY LICENSED PERSONNEL MAY GIVE CONTROLLED SUBSTANCES

39. Assist versus Administer • Administration is the act of measuring the dosage, per a doctor’s order, and giving it to a person to take or injecting the medication. • Assisting is watching someone take the medication from the container. Assist can mean taking off the lid for someone who finds this difficult. Assist is making sure they don’t take to much.

40. Diastat

41. SB 161 Established • in the absence of a credentialed school nurse or other licensed nurse onsite at the school or charter school, a school district, county office of education, or charter school may elect to participate in a program, pursuant to this section, to allow nonmedical employees to volunteer to provide medical assistance to pupils with epilepsy suffering from seizures, upon request by a parent or guardian pursuant to subdivision

42. Volunteer • Federal law (Fair Labor Standards Act) -defines a volunteer as an individual who provides services without any expectation of compensation, and without any coercion or intimidation.

43. Unlicensed School Employee • A medication Administration volunteer is an unlicensed school employee who agrees, without any expectation of compensation and free from coercion, influence, or threat of retribution, to accept responsibility for giving mediation to student (s) pursuant to a physician’s order, A person is not a volunteer if his/her job description includes administering medications.

44. SB 161 Volunteer Defined • The school or charter school shall distribute an electronic notice no more than twice per school year per child to all staff that states the following information in bold print: (A) A description of the volunteer request, stating that the request is for volunteers to administer an emergency antiseizure medication to a pupil experiencing a severe epileptic seizure, in the absence of a school nurse, and that this emergency antiseizure medication is an FDA approved, predosed, rectally administered gel that reduces the severity of epileptic seizures. • (B) A description of the training that the volunteer will receive pursuant to paragraph (1). • (C) A description of the voluntary … of the volunteer program, which includes the information described in paragraph (2). • (D) The volunteer rescission timelines described in paragraph (3). (5) The electronic notice described in paragraph (4) shall be the only means by which a school or charter school solicits volunteers.

45. Training • Now that there is a law authorizing RN to train volunteer school personnel to administer Diastat and the student has a physician order to administer Diastat; the RN can train the school volunteer. • Thanks for the question • Janette Wackerly, MBA, RN • Supervising Nursing Education Consultant

46. FDA APPROVED DRUGS

47. Ca Supreme Court Decision • The Court concluded that California law does permit trained, unlicensed school personnel to administer prescription medications, including insulin, in accordance with written statements of individual students “treating physicians” with parental consent and that the person who act under the authority do not violate the Nurse Practice Act.

48. Crux of the Supreme Court Decision (1) • Education Code Section 49423 • “Any pupil who is required to take, during the regular school day, medication prescribed for him or her by a physician an surgeon…may be assisted by the school nurses or other designed school personnel… • …..”medications are administered only in accordance with medical orders and parental consent.”

49. Crux of the Supreme Court Decision (2) • Section 601 defines “other designated school personal” who are thus authorized to act as “including any individual employed by the local school agency who: Has consented to administer the medication to the publi or otherwise asist the pupil in the administration of the medication

50. Interpretation The Court determined that the words “assist” means able to administer. The court implied the sections talking about legally able or licensed were additions not requirements. As allowed by law… The Supreme Court says section 604 and 605 discussing assist allows unlicensed school personal under the law.