school nurse orientation part ii

School Nurse OrientationSchool Nurse OrientationPart IIPart II

School Nurse OrientationSchool Nurse OrientationPart IIPart II

Courtyard by MarriottCourtyard by Marriott

December 5, 2013December 5, 2013

Nurse Practice Act, Delegation, Nurse Practice Act, Delegation, Medication AdministrationMedication Administration

Nurse Practice Act, Delegation, Nurse Practice Act, Delegation, Medication AdministrationMedication Administration

Pat Krin, MSN, APRN, FNP-BC, NCSN, FNASNPat Krin, MSN, APRN, FNP-BC, NCSN, FNASN

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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

Connecticut Nurse Connecticut Nurse Practice ActPractice Act

Connecticut Nurse Connecticut Nurse Practice ActPractice Act

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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

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Connecticut Nurse Practice Act

• The nurse practice act pertains to nurses in every setting, including schools.

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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

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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.

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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.

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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.

DelegationDelegationDelegationDelegation

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

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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).

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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).

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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).

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Accountability• Being

answerable for actions or inactions of self or others in the context of delegation.

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Responsibility• Assuming the

obligation of performing the task. The actual “doing” of the task.

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Delegation The transfer of

responsibilityresponsibility for the performance of an activity from one individual to another while retaining accountability for the outcome (ANA, 1992).

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

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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

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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.

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Assignment

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

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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).

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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?

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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).

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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?

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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

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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

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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

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Supervise performance of the task

• Provide directions and clear expectations

• Monitor performance• Intervene when necessary• Ensure appropriate documentation

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Evaluate the entire delegation process

• Evaluate the student• Evaluate the performance of the task• Obtain and provide feedback

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Reassess and adjust the overall plan of care as

needed

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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?

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Know Yourself • Stages of Development

– Emergent– Competent– Proficient– Expert

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Know Yourself • By knowing yourself

you will deliver safer, more effective school health services.

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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

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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.

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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.ht

mclick 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

Medication Medication AdministrationAdministration

Medication Medication AdministrationAdministration

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Medication Administration• Guidelines

– Purpose– Need for Guidelines– Objective of Medication Program– Policy and Procedure

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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.

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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

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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.

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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:

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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:

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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

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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

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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

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Medication Administration• §10-212a-3 Administration of medications• Training of School Personnel

– BOE to provide training• procedural aspects• medicaton needs of specific students

– maintain documentation that training has been done

– maintain list of teachers and principals trained

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Medication Administration• §10-212a-3 Training of School

Personnel– LPNs may administer meds if

• training in med administration in basic nursing program, or:

• successful completion of a pharmacology course and subsequent supervised experience, or;

• supervised experience while employed in health care facility

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Medication Administration• §10-212a-4 Self administration of

medications– doctors order for self admin– parents authorization for self admin– school nurse approval; documentation

and plan for supervision– principal and teachers informed– med maintained under student’s

control

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Medication Administration• §10-212a-5 Handling, storage and

disposal– meds delivered by responsible adult– kept in designated locked cabinet– access limited to persons authorized to

administer– original containers– refrigeration for those required– returned or destroyed– no more than 90 day supply

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Medication Administration• §10-212a-6 Documentation and Record

Keeping– medication administration record

• name of student, name, dosage, route of med• frequency of administration• name of physician, date ordered, quantity received• date to be reordered, allergies to food or meds• date time of admin including reason for omission• full legal signature, recorded in ink• made available to DOE on request

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Medication Administration• §10-212a-6 Documentation and Record

Keeping (cont.)– Physicians order and med administration

record filed in CHR– verbal order received only by school nurse,

followed by written order in three school days (faxed orders are acceptable)

– Policy for errors• Errors include missed doses unless student

absent

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Medication Administration• §10-212a-7 Supervision

– the school nurse is responsible for general supervision of administration of medications in the schools to which the nurse is assigned.

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Medication Administration

• §10-212a-7 Supervision– provide consultation– review orders or changes in orders– set up plan and schedule– provide training– support and assist other licensed

nursing personnel, principals and teachers

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Medication Administration

• §10-212a-7 Supervision– implementation of policies and prcoedures

regarding receipt, storage and administration

– monthly review of documentation– worksite observation of medication

administration by trained teachers and prinicpals

– periodic review with licensed nursing personnel, principals and teachers

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Medication Administration

§10-212a-8

•Administration of Medications by Coaches and Licensed Athletic Trainers during intramural and interscholastic events.

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Medication Administration

§10-212a-9

•Administration of medications by paraprofessionals pursuant to Section 10-212a(d) of the Connecticut General Statutes

Medication Administration• §10-212a-10

•Administration of medication in school readiness programs and before- and after-school programs.

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Medication Administration• PA 05-144 An Act Concerning (AAC)the

Emergency Use of Cartridge Injectors• PA 05-272 §35 AAC Revisions to

Department of Public Health Statutes• PA 09-155 AAC the Use of Asthmatic

Inhalers and Epi Auto-Injectors While at School

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Medication Administration• PA 12-198 AAC the Administration of

Medicine to Students with Diaetes, The Duties of School Medical Advisors, The Availability of CPR and AED Training Material for Boards of Educationa and Physical Exercise During the School Day

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Medication Administration• Who may we accept orders from?

– Physicians-doctors of medicine or osteopathy licensed to practice medicine in CT (Chs, 370 & 371 of C.G.S.)

– Podiatrists-licensed to practice podiatry in CT (Ch. 375 of C.G.S.)

– Optometrists-licensed to provide optometry in CT (Ch. 380 of C.G.S.)

– Dentists-doctors of dentistry licensed to practice dentistry in CT (Ch 379 of C.G.S.) or another state

– APRNs-licensed in accordance with § 20-94a of C.G.S.– PAs-licensed to prescribe in accordance with §20-12d

0f C.G.S.

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Medication Administration

• The Five Rights of Medication Administration

– Right Person– Right Medication– Right Dosage– Right Route– Right Time

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Medication Administration• UAP Training-Documentation

– Name of school building– Name of responsible school nurse– Date– Name of person being trained– Procedural aspects

• safe handling and storage• recording

– Student specific needs– Medication idiosyncrasies– Desired effects– Potential side effects

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Medication Administration

• Reminders for Non-Nursing Staff– All drugs have the potential for causing

side effects– Give meds exactly as prescribed– Do not use one child’s med for another

student– A “no-show” is not acceptable– 5 rights of medication administration– Use standard measuring device for liquids– Document that med was given– Report errors– Remain alert, errors can easily happen

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Medication AdministrationHot Topics (for another day)

•Standing Orders– Emergency Medications

•Field Trips