Transcript Nursing Practice in California

Hon. Tricia Hunter RN, MN
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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
are born out of legislation, reflecting
the will of the people
Regulations: develop and grow through
administrative efforts within the Executive Branch
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Protect the Public
Purview of the State
Individual Licensure versus Facility
California Medical Practice Act
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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.
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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.
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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
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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.
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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.
 Delegation
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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.
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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
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STATUTORY DELEGATION
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DELEGATION BY LICENSURE
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STATUTORY AUTHORITY TO DELEGATE
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Glucagon, Epinephrine, Diastat
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IEP Individual Education Plan
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504
Independent license to practice Nursing.
Nursing:
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Dynamic field
Continually evolving
Sophisticated Patient Care
Activities
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 & community
health services.
NPA Section
2725(a)
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help people cope with difficulties in daily
living
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actual/potential health/illness problems
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treatment
require a substantial amount of scientific
knowledge or technical skill
 Safety
 Comfort
 Personal Hygiene
 Protection of Patients
 Disease Prevention
 Restorative Measures
NPA Section
2725(b)(1)
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)
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Skin tests
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Immunization techniques
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Withdrawal of blood from veins
and arteries
NPA Section
2725(b)(3)
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.
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.
Determine abnormal characteristics:
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signs
symptoms
reactions
behaviors
general appearance
BPC Section 2725 (b)(4)(B)
Implementation of Care:
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based on observed abnormalities:
report; refer; implement standardized procedures
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change treatment based on standardized
procedures
initiation of emergency procedures
BPC Section 2755 (b)(4)(B)
Legal authority for RN
practice to overlap the
practice of medicine
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Board of Licensed Vocational Nurses and
Psychiatric Technicians
BUSINESS AND PROFESSIONS CODE
SECTION 2859-2872.2
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To assist the School Nurse:
Same duties as health clerk
◦ First aid, records, communication, reports, clerical
duties
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Observations
Administer medications, injections
Basic nursing care
Sample Job Description – Green Book
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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
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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
Mandate
Credentialed
SN
RN
LVN
Health Clerk
Minor First Aid
Yes
Yes
Yes
Yes
Assessment &
Mgmt of Trauma
Yes
Yes
Limited
No
General Health
Assessment
Yes
Yes
Basic,
Vital signs
No
Vision
Yes
No
No
No
Hearing
Yes
No
No
No
Scoliosis
Yes
No
No
No
IHPs, ECPs
Yes
Yes, maybe
No
No
SPHCS – Train,
supervise
Yes
No
No
No
SPHCS – Direct
Care
Yes
Yes, if
supervised
by SN
Yes, if
supervised
by SN
Yes, limited if
supervised by SN
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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
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Medications:
◦ substances used
to prevent,
diagnose, cure or
relieve
signs and
symptoms of
disease
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Includes:
◦ Prescription
◦ Controlled
Substances
◦ Over the Counter
◦ Herbal
◦ Alternative
◦ Research
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Controlled substances
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Ritalin , Adderall, Focalyn
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ONLY LICENSED PERSONNEL MAY GIVE
CONTROLLED SUBSTANCES
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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.
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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
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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.
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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.
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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.
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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.
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Thanks for the question
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Janette Wackerly, MBA, RN
Supervising Nursing Education Consultant
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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.
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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.”
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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
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.
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The Supreme Court concluded the Medicalorders exception does permit a layperson to
carry out a physician’s medical orders for a
patient, even orders that would otherwise fall
within the definition of nursing practice,
without thereby vilolating the rule against
unauthorized practice.
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This chapter does not prohibit: … The
performance by any person of such duties as
required in the physical care of a patient
and/or carrying out medical orders
prescribed by a licensed physician; provided
such person shall not in any way assume to
practice as a professional, registered,
graduate or trained nurse.
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The Supreme Court ruling leaves to each
student’s physician, with parental consent,
the question whether insulin may safely and
appropriately be administered by unlicensed
school personnel and further states no law,
except for controlled substances, prohibits
unlicensed persons in schools from
administering prescription medications,
generally, or insulin in particular, in caring
out the medical orders of licensed physicians.
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The legal advisory issues by the Department
of Education states:
……eighth category of authorized persons,
permitting insulin to be administered by a
“voluntary school employee who is unlicensed
but who has been adequately trained to
administer insulin pursuant to the student’s
treating physician’s orders as required by the
Section 504 Plan or the IEP.
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The school district shall obtain both a written
statement from the physician…
Detailing the name of the medication
Method
Amount
Time schedules by which the medication is to be
taken
◦ A written statement from the parent, foster parent
or guardian of the public indicating the desire the
school district assist the pupil in the matters set
forth in the statement of the physician
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Supervision is the Active process of directing,
guiding and influencing the outcome of an
individuals performance of a task. In the
context of healthcare, including the
administration of medication, there are three
types of supervision: immediate, direct and
indirect.
When dealing with licensing in California a
licensed act is delegated and a task is
assigned.
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Immediate Supervision: The supervisor is
physically present while a procedure is being
performed or medication is being administered.
Direct: The supervisor is present in the same
building as the person being supervised and is
available for consultation and/or assistance.
Indirect: The supervisor is available to eh
qualifed designated school personnel, either in
person or through electronic means to provide
necessary guidance, consultation and referral to
appropraite care and services as needed.
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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.
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Thanks for the question
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Janette Wackerly, MBA, RN
Supervising Nursing Education Consultant
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The courts have always held up licensed acts
cannot be delegated unless there is statutory
authority.
This Supreme Court Decision argues there is
statutory authority in the Education Code.
The Supreme Court Decision also argues
medical exception.
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Most RNs are aware of their responsibility to
supervise care provided by subordinates and to use
judgment in delegating functions to them; …...
incidents usually fall into one of three categories:
delegation of tasks beyond the competence of a
worker,
delegation of functions outside the legal scope of
practice of a worker,
or failure to assume responsibility when a worker
questions the appropriateness of care to be provided.
Consider your own performance in respect to these
categories as they are discussed here.
(a)
(b)
It is the intent of the Legislature that the governing
board of each school district and each county
superintendent of schools maintain fundamental
school health services at a level that is adequate to
accomplish all of the following: (1) Preserve pupils'
ability to learn. (2) Fulfill existing state
requirements and policies regarding pupils' health.
(3) Contain health care costs through preventive
programs and education.
The Legislature finds and declares that the
provision of these services may be in jeopardy due
to the current caseloads in the public schools, and
that failure to maintain adequate health services
and standards will result in pupils' poorer health
and ability to learn.
“Never doubt that a group of thoughtful
committed citizens can change the world.
Indeed, it is the only thing that ever has.”