School Nurse Orientation
Part II
Courtyard by Marriott
December 5, 2013
Nurse Practice Act, Delegation,
Medication Administration
Pat Krin, MSN, APRN, FNP-BC, NCSN, FNASN
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
3
Connecticut Nurse
Practice Act
Connecticut Nurse Practice
Act
Chapter 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
5
Connecticut Nurse Practice
Act
• The nurse practice act pertains to
nurses in every setting, including
schools.
6
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
7
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.
8
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.
9
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.
10
Delegation
Definitions
•
•
•
•
•
•
•
•
•
Unlicensed Assistive Personnel (UAP)
Direct Care Activities
Indirect Care Activities
Accountability
Responsibility
Delegation
Assignment
Supervision
Nursing Judgment
12
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).
13
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).
14
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).
15
Accountability
• Being
answerable for
actions or
inactions of self
or others in the
context of
delegation.
16
Responsibility
• Assuming the
obligation of
performing the
task. The actual
“doing” of the
task.
17
Delegation
The transfer of
responsibility for the
performance of an
activity from one
individual to another
while retaining
accountability for the
outcome (ANA, 1992).
18
5 Rights of Delegation
•
•
•
•
•
Right
Right
Right
Right
Right
Task
Circumstance
Person
Direction or Communication
Supervision
19
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
20
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.
21
Assignment
The downward or
lateral transfer of
both responsibility
and accountability
of an activity from
one individual to
another. (ANA,
1992).
22
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).
23
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).
26
27
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
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
51
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
52
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
53
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
54
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
55
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
56
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
57
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.
58
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
59
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
60
Medication Administration
§10-212a-8
• Administration of Medications by Coaches
and Licensed Athletic Trainers during
intramural and interscholastic events.
61
Medication Administration
§10-212a-9
• Administration of medications by
paraprofessionals pursuant to Section 10212a(d) of the Connecticut General
Statutes
62
Medication Administration
• §10-212a-10
• Administration of medication in school
readiness programs and before- and
after-school programs.
63
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
64
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
65
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.
66
Medication Administration
• The Five Rights of Medication Administration
–
–
–
–
–
Right
Right
Right
Right
Right
Person
Medication
Dosage
Route
Time
67
Medication Administration
• UAP Training-Documentation
–
–
–
–
–
Name of school building
Name of responsible school nurse
Date
Name of person being trained
Procedural aspects
–
–
–
–
Student specific needs
Medication idiosyncrasies
Desired effects
Potential side effects
• safe handling and storage
• recording
68
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
69
Medication Administration
Hot Topics (for another day)
• Standing Orders
– Emergency Medications
• Field Trips
70