School Nurse Orientation Part II

1. School Nurse OrientationPart II Courtyard by Marriott December 5, 2013

2. Nurse Practice Act, Delegation, Medication Administration Pat Krin, MSN, APRN, FNP-BC, NCSN, FNASN

3. Session Objectives • Review of the Connecticut Nurse Practice Act • Overview of the concepts of delegation as they pertain to schools • Introduction to laws, regulations, appropriate policies and procedures for the administration of medications in the school setting

4. Connecticut Nurse Practice Act

5. Connecticut Nurse Practice ActChapter 378 § 20-87 C.G.S. • § 20-87(a) Definition of nursing • § 20-87(b) Definition of advanced nursing practice • §20-87(c) Definition of practical nursing

6. Connecticut Nurse Practice Act • The nurse practice act pertains to nurses in every setting, including schools.

7. Connecticut Nurse Practice Act • Declaratory Rulings (Memoranda of Decision) • February 7, 1989-LPN Scope of Practice • April 5,1995-Delegation by Licensed Nurses to UAPs

8. Connecticut Nurse Practice Act • February 6, 2002 BOEN Minutes • SCOPE OF PRACTICE – FOLEY CATHETER • After discussion, as in the past, the “Foley Catheter” remains a licensed function. This is not a task that can be delegated to unlicensed personnel.

9. Connecticut Nurse Practice Act • April 3, 2002 BOEN Minutes • PHLEBOTOMIST STATUTE • There was discussion regarding this statute and the finger stick glucose. Aides can do the finger stick glucose as long as the RN delegates, teaches, and supervises the aides to assure competence.

10. Connecticut Nurse Practice Act • March 5, 2008 BOEN Minutes • RNs performing Pregnancy Tests • The Board stressed the language that a “prescriber relationship” must exist, which then would tie into having a MD/PA/APRN order.

11. Delegation

12. Definitions • Unlicensed Assistive Personnel (UAP) • Direct Care Activities • Indirect Care Activities • Accountability • Responsibility • Delegation • Assignment • Supervision • Nursing Judgment

13. UAP An unlicensed individual who is trained to function in an assistive role to the licensed registered nurse in the provision of patient/client care activities as delegated by the nurse. The term includes but is not limited to health aides, clerks, or assistants (American Nurses’ Association [ANA], 1992).

14. Direct Care Activities Assist the patient/client in meeting basic human needs. This includes activities such as assisting the patient with feeding, drinking, and socializing. They may involve collecting, reporting and documentation of data reported to the RN who then makes a clinical judgment about patient care. Do not include health counseling, teaching or require independent specialized nursing knowledge, skill or judgment (ANA, 1992).

15. Indirect Care Activities Are necessary to support the patient and their environment, and only incidentally involve direct patient contact. These activities assist in providing a clean, efficient, and safe patient care milieu and typically encompass chore services, companion care, housekeeping, transporting, clerical, stocking and maintenance tasks (ANA, 1992).

16. Accountability • Beinganswerablefor actions or inactions of self or others in the context of delegation.

17. Responsibility • Assuming the obligation of performing the task. The actual “doing” of the task.

18. Delegation The transfer of responsibility for the performance of an activity from one individual to another while retaining accountabilityfor the outcome (ANA, 1992).

19. 5 Rights of Delegation • Right Task • Right Circumstance • Right Person • Right Direction or Communication • Right Supervision

20. Delegation • No task can be delegated without the consent of the delegating nurse (RN/LPN) • Nurse must determine the task can be properly and safely performed by the person to whom it is delegated and the delegation is consistent with the client’s safety and welfare

21. Delegation • Institutional policy does not abdicate the nurse’s responsibility to ensure the appropriate delegation of the appropriate act to the appropriate unlicensed personnel at the appropriate time and circumstances.

22. Assignment The downward or lateral transfer of both responsibility and accountability of an activity from one individual to another. (ANA, 1992).

23. Supervision Provision of guidance by a qualified nurse for the accomplishment of a nursing task or activity and periodic inspection of the actual act of accomplishing the task or activity. Total nursing care of an individual remains the responsibility and accountability of the nurse. (NCBSN, 1987).

24. Training • What constitutes appropriate training and supervision remains the responsibility of the RN responsible for the overall plan of care for the client. • What determines skill competency?

25. Nursing Judgment • The intellectual process that the nurse exercises in forming an opinion and reaching a clinical decision based upon analysis of the the evidence of the data (ANA, 1992).

28. Delegation Criteria • Nurse Practice Act • Permits delegation? • Authorizes tasks to be delegated or authorizes the nurse to decided delegation? • Delegator Qualifications • Within scope to delegate? • Appropriate education, skills, and experience? • Evidence of current competency?

29. Assess the Situation • Identify the needs of the student, consulting the plan of care • Consider the circumstances/setting • Assure the availability of adequate resources including supervision

30. Plan for tasks to be delegated • Specify knowledge of each task and skills required • Require documentation or demonstration of current competence by the delegate • Determine the implications for the student, family and significant others

31. Assure appropriate accountability • As delegator, accept accountability for performance of the task • Verify that delegate accepts the delegation and responsibility for carrying out the task correctly

32. Supervise performance of the task • Provide directions and clear expectations • Monitor performance • Intervene when necessary • Ensure appropriate documentation

33. Evaluate the entire delegation process • Evaluate the student • Evaluate the performance of the task • Obtain and provide feedback

34. Reassess and adjust the overall plan of care as needed

35. Know Your Organization • What policies and procedures are in place in your district? • Who controls the delegation decisions? • Connecticut nurse practice act allows only nurses to delegate nursing functions • Which takes precedent-the nurse practice act or employer policies?

36. Know Yourself • Stages of Development • Emergent • Competent • Proficient • Expert

37. Know Yourself • By knowing yourself you will deliver safer, more effective school health services.

38. Know Your Delegate • Assistive personnel can help the school nurse to provide school health services. • Competence- the application of knowledge and the interpersonal, decision making, and psychomotor skills expected for the practice role, within the context of public health, safety and welfare” (NCBSN, 1997) • UAPs working in school health should be highly motivated to stay within their scope and provide safe care.Delegating a task to someone who does not want to do it can be a problem

39. Communicate • UAPs must have care plans or protocols that provide them with the tools to collect data, provide safe care and report information to the school nurse. • Protocols should guide assistive personnel in any area where nursing judgment would be needed.

40. Board of Nursing Website • http://www.dph.state.ct.us/index.html - click on “Health Care Quality” left side of page • http://www.dph.state.ct.us/hcquality/hcquality.htm click on Board of Examiners for Nursing center of page • http://www.dph.state.ct.us/Public_Health_Hearing_Office/hearing_office/Nursing_Board/BOEN.HTM

41. Medication Administration

42. Medication Administration • Guidelines • Purpose • Need for Guidelines • Objective of Medication Program • Policy and Procedure

43. Medication Administration • Connecticut General Statutes §10-212a. Administration of medications in schools • (a)1 a school nurse, any other nurse, principal, teacher, PT, OT, or coach…may administer medications • (b) records must be kept for controlled drugs • (c) Commissioner of PH may adopt regulations to specify conditions for coaches to administer meds (awaiting AG response) • (d) Paraprofessionals may administer epipens under certain circumstances.

44. Medication Administration • Definition of a School Nurse 10-212a(s) • appointed in accordance with §10-212-2 - Licensure, Education and Employment criteria • Definition of a Teacher 10-212a(v) • Employed full time, meets minimum standards, approved by school medical advisor and school nurse

45. Definition of a School Nurse • (a)Licensure-Each nurse or nurse practioner shall be a registered professional nurse, designated as R.N., as defined in §20-87a of the General Statutes, and currently licensed in the state of Connecticut. • (b)Experience-Each nurse or nurse practitioner shall have at least the equivalent of one year full time working experience as a registered nurse within five (5) years immediately prior to employment as a school nurse.

46. Definition of a School Nurse(Cont.) • (c)Education-Each nurse or nurse practitioner shall have academic preparation to include (12) academic credits at a licensed or accredited institution of higher learning or (18) continuing education units (CEUs) or one hundred eighty (180) workshop or inservice hours distributed as follows:

47. Definition of a School Nurse(cont.) • (1) Six (6) credits or nine (9) CEUs or ninety (90) workshop hours in at least two of the following subject areas: • Growth and Development, Health Assessment, Public or Community Health or School Health, • Six (6) credits or nine (9) CEUs or (90) workshop hours in two or more of the following subject areas:

48. Definition of School Nurse(cont.) • Administration of Organization of Health or School Services, Child or Adolescent Psychology, Crisis Intervention, Growth and Development,Handicapping Conditions, Health Assessment, Health Education, Mental Health, Public or Community or School Health, Sociology, Sports Medicine

49. Medication Administration • §10-212a-2 Administration of medications • (a) not required in school • (b) (1)BOE establish policies and procedures • (2)review and revise at least biennially • (c)must have • (1) written doctor’s order • (2) written parental authorization

50. Medication Administration • §10-212a-2 Administration of medications • (2)(d) taken only by person for whom prescribed • (e) teachers may administer oral, topical, inhalant. Injectable only for diagnosed allergic condition and Glucagon • (f)establish policies and procedures for medication emergency • (g) Schedule II-V controlled drugs