Wyo. State Board of Nursing Issues


	Congratulations to our 2009-2010 School Nurse of the Year Beth Strom

Report to WSNA Membership

Issues with the State Board of Nursing

Part A

Introduction

In the fall of 2007, discussions started regarding trying to understand how the SBON works. Those involved were Jan Nykodym, Susan Fabian and Chris Bartholomew. We weren’t familiar with how the BON works, what their processes are and how to have discussions with them. Chris initiated a call to Mary Beth Stepans, with whom Chris worked with in the early 1990’s. Mary Beth is the practice coordinator and is the interim director. Mary Beth offered to meet with us and discuss these things and how school nursing fits in. Mary Beth invited Cheryl Koski to attend (who already was finished at the SBON).

It was a “fact-finding trip” at the basic level. When we met, it was an open discussion on school nursing in general and Mary Beth and Cheryl truly had little idea how school nursing had expanded and developed over the years. We talked a lot about how school nurses are “boxed in” by Federal and State laws that guarantee accommodations in schools but yet, we are restricted from delegating to unlicensed persons in the schools.

Our basic question to the BON is how to we provide safe, effective care to the students in this state within all of these guidelines? We asked for guidance on how to proceed to accomplish this goal. We talked about, in general, geographic barriers, funding barriers, lack of school nurse peers in smaller districts, lack of substitutes in many places in order to get to meetings and CEU programs, discrepancy in pay scales around the state, national issues and the potential impact of the nursing shortage. It was an overview of how we see school nursing in Wyoming. The meeting was left open with Mary Beth to get back to us after she and Cheryl visit.

After our visit, Mary Beth called Chris and asked us to do a presentation to the entire board about school nursing in January. Chris, Jan, and Susan met and discussed how to go about this. Pam Shults joined us when she expressed an interest to be included. Part B is the outline of what was presented in the 15 minutes we had with the board. The board chair assigned our question to the Practice Committee and Mary Beth would follow up with us.

Part B Handout Used at the Board of Nursing Meeting, January 9, 2008

Presented by:

Chris Bartholomew, RN, MS, NCSN

Susan Fabian, RN

Jan Nykodym, RN, NCSN

Outline

A. Introductions

B. Objectives of presentation:

-Share information with the board members

-Provide resources to the board members

-Request guidance in addressing challenged faced by school nurses

C. Historical perspectives on school nursing

-Students with severe illnesses stayed home after hospitalizations or exacerbation of their illnesses

-Federal and state laws were very limited or didn’t exist

-Consumer activism was limited

-Students with disabilities were institutionalized, duration often long term, or were cared for by family members

-Previous opinions from the Wyoming Attorney General’s office determined approach to providing student care in schools.

-Followed guidelines in Nurse Practice Act for “friends” delivering care in the schools.

D. Current status in schools throughout Wyoming

1. Overview:

-evolving role which is dynamic in nature

-unlike other areas in nursing or facilities who request non-nurses to provide nursing care

-reactive role according to the individual medical needs of students

2. Students are returning to school more quickly after hospitalizations or diagnosis/exacerbation of illnesses

3. Students with severe disabilities are encouraged to be in school and are often mainstreamed

4. Language of the Legal requirements that affects school nursing:

-IDEAIA – Individuals with Disabilities Act

-FAPE – Free and Appropriate Public Education

-LRE – Least Restrictive Environment

-State laws – Inhaler and emergency Medication Laws

-FERPA (Family Educational Rights and Privacy Act) vs. HIPPA

-lawsuits by consumers or organized from groups representing students with specific diseases

-Federal and state special education laws

5. Increased workloads of school nurses:

-recommended 1:750 regular education students

-1:250 ratio of nurse to special needs students

E. Current dilemmas facing school nurses in Wyoming:

1. Meeting the legal requirements to support students in receiving an education

2. Staffing issues in the state

3. Collecting data about school nursing

4. Geographic concerns:

-distances between schools

-differences between schools with high and low student populations

-isolation of school nurses

5. Lack of healthcare providers or EMT services in some communities

6. Delegation issues in schools:

-there are difficulties with administrators being the persons who delegate provision of care in schools.

-differentiating delegation issues of school nursing from those in jails, residential treatment centers or other non-RN supervised settings.

7. No state school nurse consultant in the department of education

8. Schools generally do not have medical advisors who support school nurses

9. Educational opportunities for school nurses are very limited in the state

10. Lack of substitutes or replacement nurses in smaller communities

F. Other factors:

1. National Association of School Nurses

2. Wyoming School Nurses Association

G. Request for guidance from the Wyoming State Board of Nursing:

1. How to meet the needs of students in this state that balances Board of Nursing guidelines and other legal requirements.

2. Supportive language for the unique needs of school nurses needed

3. How do school nurses attack these problems?

4. Re-visit Board Advisory Opinion : 06-169 Teaching Glucagon administration of Glucagon to Non- Licensed Personnel in an Emergency

Part C Selections from Other State Boards of Nursing Rules/Advisory Opinions Regarding Delegation/School Nursing

As Wyoming Director to NASN, Chris collected much information from the NASN administrators’ list serve regarding school nurses working with their state boards of nursing. This is the collection which we decided to look at and see what other states have done and what ideas we could come up with. The abbreviation for each state precedes the entry. Chris has the complete file if anyone wants more info-where to find it in the law or state board of nursing info on the websites.

2/08

References:

SC #51

The South Carolina Board of Nursing recognizes that in school districts where the school nurse is responsible for more than one school it is difficult, at best, to insure the safe and legal administration of medication, provision of quality nursing services, and assessment and planning for the healthcare needs of individual students in order to support their education in the least restrictive environment. The Board is aware that, increasingly, students with chronic health conditions and who may be medically fragile attend school. The Board also recognizes the often complex health care needs of students in regular as well as special education classrooms. It is because of the frequent need for specialized healthcare for students during regular school hours that the Board recommends that school districts in South Carolina make it a priority to employ at least one licensed school nurse for each school. In view of the ongoing and growing need for provision of preventive, as well as restorative, maintenance, and emergency healthcare to students and staff, assistance to parents in the healthcare of their children, and development of coordinated school health programs, it is increasingly difficult for school districts to adequately support the academic achievement of all students. The presence of a school nurse in each school is a reasonable expectation for the safe provision of quality school health services for students and staff.

The registered nurse (RN) assigned to a school or the licensed practical nurse (LPN) assigned to a school in consultation with the RN responsible for the LPN’s clinical supervision may select, train, determine competency of and evaluate unlicensed school personnel in the provision of select nursing tasks required in order for a student to attend school. The skills taught to unlicensed school personnel by the licensed nurse are to be used only for meeting the needs of the specific student(s) for which training has been provided. The skills may be used only at school or school related functions and are not transferable to other settings. The unlicensed school employees trained may not delegate the tasks to others or supervise others in performing the tasks.

The South Carolina Board of Nursing has adopted the following guidelines as minimally acceptable standards for licensed nurses to follow.

A. Definitions

1. Nursing Tasks: Nursing tasks are defined as those nursing services that are routine in nature, do not require nursing judgment, pose little risk to the student if done inappropriately or incorrectly, and whose outcomes are stable and predictable. Tasks which may be performed by an unlicensed person and evaluated by a licensed nurse may include, but are not limited to, tasks for meeting students’ needs for personal hygiene, meeting students’ needs relating to nutrition, meeting students’ needs relating to ambulation, meeting students’ needs relating to elimination, taking vital signs, maintaining asepsis, and observing, recording, and reporting any of the tasks previously noted. Such tasks may include diapering (personal hygiene), gastric tube feeding (nutrition), and intermittent urethral catheterization (elimination).

2. Evaluation: Evaluation of the unlicensed school employee trained by the licensed nurse refers to observing and directing the performance of the unlicensed school employee in the provision of the treatments and/or medications for which the licensed nurse has provided training and determined competency.

3. Unlicensed School Personnel / Unlicensed School Employee: Unlicensed school personnel are employees of a school district who are not currently licensed to practice nursing by the South Carolina Board of Nursing.

B. Determination of Training Appropriateness

1. The RN assigned to the school shall determine if the nursing tasks required for meeting the needs of a student may be provided safely by unlicensed school personnel.

2. To determine if training of unlicensed school personnel is appropriate the RN shall consider the following:

whether the task is delegable according to the laws governing nursing practice;
whether the student’s condition is stable and predictable;
the nature and complexity of the nursing task;
the risk to the student if the task is performed inappropriately or incorrectly;
the necessary knowledge, skills and abilities needed to perform the task;
the competency and availability of unlicensed school personnel;
whether the outcome anticipated is stable and predictable; and
the number of unlicensed school personnel that can safely be evaluated by the licensed nurse.

3. The RN shall consult with the student’s healthcare practitioner, as necessary, for advice regarding training unlicensed school personnel to provide specific nursing tasks.

4. A school administrator or his/her designee cannot by law require a school nurse to delegate the practice of nursing in any way that is contrary to the requirements of the Nurse Practice Act, nor can a school administrator or his/her designee who is not a licensed nurse legally delegate nursing tasks. The licensed nurse cannot legally be required by unlicensed persons to delegate the practice of nursing, nor to delegate nursing tasks to UAP where, in the nurse's judgment, the safety of the student would be endangered.

C. Selection of Unlicensed Persons to Assist Students

2. Training may be offered to all staff or faculty members who volunteer. However, the RN will recommend only those trainees who complete the training and pass the outlined competency requirements to the school administrator or his/her designee for assignment to provide specific nursing tasks for a specific student.

3. The school administrator or his/her designee, with written authorization from a student’s parent(s) or legal guardian(s), may assign one or more of the individuals recommended by the RN the duties of providing specific nursing tasks for a student(s) at school and/or at school related functions.

4. With the recommendation and approval of the RN assigned to the school, an unlicensed school employee may be trained to provide specific nursing tasks for more than one student.

D. Training & Determining Competency

1. A RN must provide the initial training and competency determination of unlicensed school employees. A licensed nurse may train and determine competency of unlicensed school personnel to provide select nursing tasks, if the school district has:

a written policy that authorizes the training of unlicensed school personnel by a licensed nurse and provides for error reporting and error tracking, and
written procedures outlining task specific trainings and quality assurance measures including competency determination, post-emergency evaluation, error reporting, and error tracking.

2. Training updates that include procedural changes shall be treated as an initial training and, therefore, must first be provided by the RN. If there are no procedural changes, the RN may delegate to a LPN the performance of training updates. The RN may also delegate to a LPN the periodic reevaluation of an unlicensed school employee’s competency, after the RN has determined the competency of the LPN to provide the necessary training, observations and testing for competency. The RN should develop a checklist for the LPN to use during the reevaluation process.

3. Training for unlicensed school employees may include the administration of medications that have been prescribed by a student’s healthcare provider for use during medical emergencies. See Board of Nursing Advisory Question 49 for special guidance regarding the role of the nurse in training unlicensed school personnel to administer medications that may be needed in case of a medical emergency.

4. An unlicensed school employee may be trained to meet the needs of more than one student. If the unlicensed person will provide nursing tasks for more than one student, the training must include content that focuses on the individual needs of each student for which the unlicensed person will provide care.

5. The instructional plan must include:

Step by step instructions and rationale for the task;
Return demonstration of the task to evaluate competency and to assure accuracy and safety;
Observation of the unlicensed school employee performing the task to evaluate competency and to assure accuracy and safety;
An evaluation of knowledge related to the task to measure understanding of pertinent concepts;
Provision of written instructions as a reference;
A plan for seeking emergency assistance from qualified medical personnel;
A plan for ongoing evaluation of student outcomes by a RN;
Documentation of instruction provided and a plan for training updates at least annually; and
Documentation of initial competency and periodic re-evaluation of competency at least annually.

6. Upon completion of all training sessions, the licensed nurse providing the training must advise trainees that the skills taught are to be used only for meeting the needs of the specific student(s) for which they have been assigned to provide care while at school or school related functions and are not transferable to other settings. The unlicensed school employees trained cannot delegate the tasks to others or supervise others in performing the tasks.

7. If a portion of the training involves course content for which the licensed nurse is certified to teach to unlicensed persons (e.g. first aid, cardiopulmonary resuscitation instruction, and use of automated external defibrillators) and the licensed nurse provides the training according to the specifications of the certifying body, that portion of the training is transferable to other settings and the nurse will provide the trainee with the appropriate certificate.

E. Evaluation

1. The RN shall maintain a training file on each school employee trained.

2. The RN shall ensure that the competencies of unlicensed school employees trained to provide select nursing tasks are re-evaluated at least annually and that training updates of procedural changes are offered in a timely manner.

3. The RN may delegate training updates that do not include procedural changes and periodic re-evaluations of an unlicensed person’s competency to a LPN after the RN has determined and documented that the LPN is competent to provide the training and complete the necessary observations and tests for determining competency. The RN should develop a checklist for the LPN to use during the re-evaluation process.

4. Frequent contact with the unlicensed person shall be maintained to evaluate student responses to care. Contact must always be available by telecommunication.

5. The frequency of direct observation and evaluation of the unlicensed school employee shall be determined by the RN based upon the school setting, the student’s status, the complexity of the nursing task, the risk to the student, and the proximity of the RN.

6. The licensed nurse assigned to the school shall evaluate the student on a regular basis to determine progress toward goals of care. If the outcomes of the evaluation do not meet the expected quality of care, the RN must intervene. The RN may need to provide additional instruction to the unlicensed person or recommend that the administrator or his/her designee rescind the assignment.

7. A plan for backup assistance must be outlined.

8. A plan for intervening in an emergency situation must be outlined.

SC 52

Recognizing the health risks for children and the legal implications for school districts when medications are not given appropriately, the Board of Nursing cautions school districts that it is in the best interest of students to have a full-time RN and/or LPN employed at each school.

Registered nurses develop and write individual health care plans for students (Section 59-63-80 of the South Carolina Code of Laws), and based on an understanding of pharmacotherapeutics, provide the full range of services associated with the safe “administration of medications.” The use of unlicensed school personnel to “assist” students with medications should be limited to situations where the RN or LPN working full-time at the school is absent or not available.

Following training by the RN assigned to the school or the RN supervising the clinical practice of the LPN assigned to the school, trained unlicensed school personnel may assist students with regularly scheduled medications during school-sponsored functions if the RN or LPN on staff full-time at the school is absent or not available. Assisting with medications includes the acts of reminding a student of the time to take a medication; opening the container that is properly labeled; and/or assisting the individual to place the medication in the mouth or properly apply the medication. Assisting with medications does not include injectable medications, insulin in anyform, instillation of medications into the eye or ear, or insertion of rectal or vaginal medications.

School-sponsored functions may include those conducted during regular school hours on schoolgrounds, before- and after-school activities conducted by the school on school property, transit to or from school or school-sponsored activities when the vehicles are owned or leased by the school district, and any school-sponsored activity in which the student is a participant. Examples of school-sponsored activities are field trips, interscholastic sporting events, and fine arts events in which the student is a participant. The RN will determine on a case-by-case basis whether trained unlicensed school personnel may assist a specific student with regularly scheduled medications at school-sponsored functions outside of regular school hours if the RN ~~or LPN is~~ absent or not available. A licensed healthcare prescriber or a RN must be available via telecommunications to answer questions that the trained unlicensed school employee may have when assisting students with medications in the absence of the RN ~~or LPN assigned to the school.~~

The skills taught to unlicensed school personnel by the RN or LPN may be used only at school or school-sponsored functions and are not transferable to other settings. Once trained, the unlicensed school employees may not delegate the tasks to others or supervise others in performing the tasks. Because of risks for anaphylaxis and/or other serious untoward reactions, an unlicensed person must never assist students with the initial dose of a routinely scheduled medication.

When implementing When implementing the guidelines included in this Board of Nursing Advisory it is critical that school districts involve RNs in the planning process. A RN or LPN cannot legally be required by school officials to delegate the practice of nursing, nor to delegate nursing tasks to unlicensed school personnel where, in the nurse's judgment, the safety of the student would be endangered.

A school principal/administrator cannot by law require a school nurse to delegate the practice of nursing in any way that is contrary to the requirements of the laws and regulations governing nursing practice, nor can a school principal/administrator who is not licensed to practice nursing legally delegate nursing tasks.

C. Selection of Unlicensed Persons to Assist Students

Note: In schools where there is a RN or LPN on staff full-time to provide health services for students, the RN assigned to the school or the RN supervising the clinical practice of the LPN assigned to the school in collaboration with the LPN may select, train, determine the competency of, and evaluate unlicensed school personnel for assisting students with medications in situations where the RN or LPN on staff at the school is absent or not available. Unlicensed school personnel may be trained to assist students with regularly scheduled medications only if there is a RN or LPN employed at the school full-time to provide health services for students.

1. The RN assigned to a school or the LPN in consultation with his/her RN supervisor should work with the school’s principal/administrator to identify staff members or faculty who agree to assist students with medications if the RN ~~or LPN is absent or not available.~~

2. Training may be offered to all staff or faculty members who volunteer. However, the RN will recommend to the school’s principal/administrator only those trainees who complete the training and pass the outlined competency requirements for assignment to assist students with medications.

3. The school principal, with written authorization from a student’s parent(s) or legal guardian(s), may assign one or more of the individuals recommended by the RN the duties of assisting students with medications.

4. Parents or guardians should be made aware of and understand the difference between administration of medications and assisting with medications.

D. Training & Determining Competency

Note: In schools where there is a RN ~~or LPN on staff full-time to provide health services for students, the RN assigned to the school~~ or the RN supervising the clinical practice of the LPN assigned to the school in collaboration with the LPN may select, train, determine the competency of, and evaluate unlicensed school personnel for assisting students with medications in situations where the RN or LPN on staff at the school is absent or not available. Unlicensed school personnel may be trained to assist students with regularly scheduled medications only if there is a RN or LPN employed at the school full-time to provide health services for students.

1. A RN must provide the initial training and competency determination of unlicensed school employees. The RN may delegate training updates that do not include procedural changes and periodic re-evaluation of an unlicensed school employee’s competency to a LPN only after the RN has determined and documented that the LPN is competent to perform the tasks. The RN should develop a checklist for the LPN to use during training

updates and the reevaluation process. Training updates that include procedural changes shall be treated as an initial training, and therefore, must be first provided by a RN.

2. Unlicensed school personnel may be trained to assist students with medications in the absence of the RN ~~or LPN on staff full-time at the school to provide health services for students, if the school district has:~~

a written policy that authorizes the training of unlicensed school personnel by a RN or LPN under the direction of a RN and provides for error reporting and error tracking, and
written procedures outlining task specific trainings and quality assurance measures including competency determination, post-emergency evaluation, error reporting, and error tracking.

3. Training for unlicensed persons may include the skills necessary for assisting students with medications to be given by oral (including feeding tubes), topical, nasal, and sublingual routes, and medications that are inhaled (e.g., asthma inhalers). Unlicensed school personnel may not be trained to give routinely scheduled injectable medications, instill drops into the eye or ear, insert medications rectally or vaginally, or to give any form of insulin. See Advisory # 49 for exceptions related to training unlicensed school personnel to administer medications that may be needed for medical emergencies.

SeeAdvisory # 50 for guidance regarding training unlicensed school personnel for select tasks such as gastric tube feedings.

4. The instructional plan must include:

Step by step instructions and rationale for the tasks;
Return demonstration of the tasks to evaluate competency and to assure accuracy and safety;
Observation of the unlicensed school employee performing the tasks to evaluate competency and to assure accuracy and safety;
An evaluation of knowledge related to the tasks to measure understanding of pertinent concepts;
Provision of written instructions as a reference;
A plan for seeking advice and/or emergency assistance from qualified licensed healthcare personnel;
A plan for ongoing evaluation of student outcomes by a RN;
Documentation of instruction provided and a plan for training updates at least annually; and
Documentation of initial competency and periodic re-evaluation of competency at least annually.

5. Upon completion of all training sessions, the trainees must be advised that the skills taught are to be used only for meeting the needs of the students for which they have been assigned to assist with medications at school or school-sponsored functions and are not transferable to other settings. The trained unlicensed school district employees cannot delegate the tasks to others or supervise others in performing the tasks. Because of risks for anaphylaxis and/or other untoward reactions, an unlicensed person must never assist students with the initial dose of a routinely scheduled medication.

6. If a portion of the training involves course content for which the RN or LPN is certified to teach to unlicensed persons (e.g., cardiopulmonary resuscitation instruction), and the RN or LPN provides the training according to the specifications of the certifying body, then that portion of the training is transferable to other settings, and the RN or LPN will provide the trainee with the appropriate certificate.

E. Evaluation

1. The RN shall maintain a training file on each school employee trained.

2. The RN shall ensure that the competencies of unlicensed school employees trained to assist students with medications are re-evaluated at least annually and that training updates of procedural changes are offered in a timely manner.

3. The RN may delegate training updates that do not include procedural changes and periodic re-evaluations of an unlicensed person’s competency to a LPN, only after the RN has determined and documented that the LPN is competent to perform the tasks. The RN should develop a checklist for the LPN to use during the training update and reevaluation process.

4. Following an absence of the licensed nurse during which a trained unlicensed school employee has assisted students with medications, the full-time RN or LPN assigned to the school shall perform a post-procedural review. The RN or LPN should document the results of the procedural review in the school employee’s training file. If the results of the post-procedural review indicate that the expected quality of care was not met, the RN must intervene by providing additional instruction or advising the school principal/administrator to rescind the assignment.

5. A licensed healthcare prescriber or a RN must be available via telecommunications to answer questions that the trained unlicensed school employee may have when assisting students with medications in the absence of the RN ~~or LPN assigned to the school.~~

6. A plan for the trained unlicensed school employee to follow for emergency situations must be outlined.

SC #50

A. Definitions

1. Medical Emergency: A medical emergency is defined as a sudden, urgent, unforeseen occurrence requiring immediate action in order to prevent disability or death. Medications and treatments scheduled for provision according to a routine schedule are not considered medical emergencies.

C. Selection of Unlicensed Persons to Assist Students in the Event of a Medical Emergency

1. The RN assigned to a school or the LPN in consultation with his/her RN supervisor should work with the school’s administrator or his/her designee to identify staff members or faculty who voluntarily agree to assist a student in the event that a medical emergency related to the student’s documented medical diagnosis occurs when a licensed nurse is not readily available.

3. The school administrator or his/her designee, with written authorization from a student’s parent(s) or legal guardian(s), may assign one or more of the individuals recommended by the RN the duties of providing specific nursing services for a student in the event of a medical emergency.

4. With the recommendation and approval of the RN assigned to the school, an unlicensed school employee may be trained to provide specific nursing services required in the event of medical emergencies for more than one student.

VA section K.

This section shall not prevent the administration of drugs by a person who has satisfactorily completed a training program for this purpose approved by the Board of Nursing and who administers such drugs in accordance with a physician's instructions pertaining to dosage, frequency, and manner of administration, and in accordance with regulations promulgated by the Board of Pharmacy relating to security and record keeping, when the drugs administered would be normally self-administered by (i) a resident of a facility licensed or certified by the State Mental Health, Mental Retardation and Substance Abuse Services Board; (ii) a resident of any assisted living facility which is licensed by the Department of Social Services; (iii) a resident of the Virginia Rehabilitation Center for the Blind and Vision Impaired; (iv) a resident of a facility approved by the Board or Department of Juvenile Justice for the placement of children in need of services or delinquent or alleged delinquent youth; (v) a program participant of an adult day-care center licensed by the Department of Social Services; or (vi) a resident of any facility authorized or operated by a state or local government whose primary purpose is not to provide health care services.

K (Contingent effective date - see Editor's note) This section shall not prevent the administration of drugs by a person who has satisfactorily completed a training program for this purpose approved by the Board of Nursing and who administers such drugs in accordance with a physician's instructions pertaining to dosage, frequency, and manner of administration, and in accordance with regulations promulgated by the Board of Pharmacy relating to security and record keeping, when the drugs administered would be normally self-administered by (i) a resident of a facility licensed or certified by the Department of Mental Health, Mental Retardation and Substance Abuse Services; (ii) a resident of the Virginia Rehabilitation Center for the Blind and Vision Impaired; (iii) a resident of a facility approved by the Board or Department of Juvenile Justice for the placement of children in need of services or delinquent or alleged delinquent youth; (iv) a program participant of an adult day-care center licensed by the Department of Social Services; or (v) a resident of any facility authorized or operated by a state or local government whose primary purpose is not to provide health care services.

L. (Contingent effective date - see Editor's note) Medication aides registered by the Board of Nursing pursuant to Article 7 (§ 54.1-3041 et seq.) of Chapter 30 may administer drugs that would otherwise be self-administered to residents of any assisted living facility licensed by the Department of Social Services. A registered medication aide shall administer drugs pursuant to this section in accordance with the prescriber's instructions pertaining to dosage, frequency, and manner of administration; in accordance with regulations promulgated by the Board of Pharmacy relating to security and recordkeeping; in accordance with the assisted living facility's Medication Management Plan; and in accordance with such other regulations governing their practice promulgated by the Board of Nursing.

M. In addition, this section shall not prevent the administration of drugs by a person who administers such drugs in accordance with a physician's instructions pertaining to dosage, frequency, and manner of administration and with written authorization of a parent, and in accordance with school board regulations relating to training, security and record keeping, when the drugs administered would be normally self-administered by a student of a Virginia public school. Training for such persons shall be accomplished through a program approved by the local school boards, in consultation with the local departments of health.

ROLES OF NURSES IN THE SUPERVISION AND DELEGATION OF

NURSING ACTS TO UNLICENSED PERSONNEL

In accordance with KRS 314.021(2), nurses are held responsible and accountable for their decisions regarding the supervision and delegation of nursing acts to unlicensed personnel who provide nursing assistance, based upon the nurse's educational preparation and experience in nursing.

In a supervising capacity, the registered nurse should provide direction and assistance to those supervised, observe and monitor the activities of those supervised, and evaluate the effectiveness of acts performed under supervision.

Only those nursing acts commensurate with the educational preparation and demonstrated ability of the person who will perform the act may be delegated to others. Therefore, the nurse should assure that the individual performing the act has the necessary educational preparation and validation of competence in order to perform the act in a safe manner.

Acts which require substantial specialized nursing knowledge, judgment and skill should be performed only by registered nurses. Acts which require nursing knowledge and skill in implementing a plan of care should not be delegated to an unlicensed person. Unlicensed personnel who provide nursing assistance may contribute to the implementation of the plan of nursing care in situations where the delegation of the task does not jeopardize the patient's welfare. Some tasks that require nursing judgment may be delegated only after the nursing judgment is made. Such tasks may include, but are not limited to:

a) Collection, documentation, and reporting of data (e.g., vital signs, oxygen saturation using pulse oximeter equipment, height, weight, intake and output, and blood glucose testing when sample is obtained from a capillary site).

b) Assisting patients to perform self-care tasks, including assistance with a patient's self-administered medication. Such assistance does not include the preparation of syringes for injection.

c) Performing tasks of a routine nature that do not require simultaneous nursing judgment. For example, simple non-sterile dressing changes, external catheter care, tap water enema administration, and colostomy appliance changes on mature stoma sites with sustained skin integrity.

d) Selected ambulation, positioning, turning, activities of daily living, or exercise programs.

e) Providing and maintaining a safe, comfortable environment.

f) Selected nutritional activities, such as feeding and meal preparation. This does not include the administration of nasogastric tube feedings by unlicensed personnel, but may include the administration of feedings via a gastrostomy tube when the tube is in a mature stoma site with sustained skin integrity, and when it is delegated by and performed under the supervision of a nurse.

g) Socialization activities.

h) Transportation of patient/client.

5. As stated in KRS 314.011(6)(c) and (10)(c), the administration of medication is the practice of nursing. The administration of medication to patients in health care facilities is both the responsibility of nurses and an integral part of the nursing care rendered to patients. Medication may also be administered to patients in health care facilities by physicians or other health care professionals who have statutory authority to administer medications. In Kentucky, unlicensed personnel known as medication aides or similar titles, may function by administering oral and topical medication in long-term care facilities only through delegation by and under the supervision of a registered nurse or licensed practical nurse. Unlicensed personnel who function as medication aides must have successfully completed the state approved course for administration of medication as defined in the administrative regulations issued by the Cabinet for Health and Family Services, Office of the Inspector General.

The following acts related to the administration of medications should not be delegated to unlicensed personnel:

a) Conversion or calculation of drug dosage;

b) Administration of medications via any injectable route;²

c) Administration of medication via tubes inserted in any body cavity, except for: 1) the administration of a “Fleet” enema (Fleet Bisacodyl or Fleet Phospho-Soda, and 2) the administration of medications via a gastrostomy tube for students in a school setting, when performed under the delegation and supervision of a nurse and in accordance with established facility policy and procedure;

d) Administration of antineoplastic drugs.

Dialysis technicians may administer only those medications listed in 201 KAR 20:470 Dialysis technician credentialing requirements and training program standards

6. The performance of nursing acts by the patient for self-care or by the patient's family members (e.g., self-administration of medications, administration of medications by family members) does not constitute "nursing assistance" or the delegation of nursing acts to unlicensed personnel for compensation.

Patient and family education is a part of nursing practice. As a part of preparing a patient for self-care, nurses may teach and supervise the performance of acts by patients and family members who have demonstrated a willingness and an ability to perform the acts.

7. In the utilization of unlicensed personnel to provide nursing assistance, nurses should follow written approved policies and procedures of the health care facility/agency which are consistent with KRS Chapter 314.

8. The Board of Nursing must assure the public that nursing assistance is provided in a

manner which assures that safe and effective care is provided for the citizens of the Commonwealth.

KY AOS #30 School Health Nursing Services

The Board has received multiple inquiries on the role, utilization, and scope of practice for the advanced registered nurse practitioner (ARNP) designated nurse practitioner or clinical specialist, registered nurse, and licensed practical nurse who provide school health-nursing services.

The primary mission of the Kentucky Board of Nursing is to ensure public protection and, in this capacity, the Board is concerned with the appropriate utilization of both licensed and unlicensed personnel who provide healthcare to students and in this role issues guidelines regarding the delivery of care in educational settings to ensure the health and safety of students.

As stated in the American Nurses' Association "Scope and Standards of School Nursing Practice" (2001) and the "Scope and Standards of College Health Nursing Practice" (1997)

The purpose of school nursing is to enhance the educational process by the modification or removal of health-related barriers to learning and by promotion of an optimal level of wellness.

Effective July 15, 2002, KRS 156.501 established provisions for the Department of Education to provide leadership and assistance to local school districts relating to student health services. The Department, working in cooperation with the Department of Public Health, is required to establish standardized protocols and guidelines for health procedures to be performed by health professionals and school personnel. The protocols and guidelines shall include, in part, the delegation of nursing functions consistent with administrative regulations promulgated by the Kentucky Board of Nursing. (Ref: 201 KAR 20:400 Delegation of nursing tasks). The statute created a registered nurse school consultant position within the Department of Education.

Effective July 15, 2002, KRS 156.502 established a definition of “health services” and established provisions for who shall provide health services in schools. Persons who provide health services include: physicians, advanced registered nurse practitioners (ARNP), registered nurses, and licensed practical nurses. In addition, school employees who are delegated responsibility to perform health services by a physician, ARNP, or registered nurse may perform only select services in specific situations.

Advisory Opinion

After review of the statutes governing nursing practice, curricula of prelicensure and continuing education nursing programs, standards of nursing practice, and study of the issues and concerns regarding school health nursing practice, the Kentucky Board of Nursing issued this advisory opinion statement.

I. Advanced Registered Nursing Practice

It is within the scope of the advanced registered nurse practitioner (ARNP), designated nurse practitioner or clinical nurse specialist, to provide primary healthcare services to students in accordance with 201 KAR 20:057 Scope and standards of practice of ARNPs. The ARNP may also perform acts within the scope of registered nursing practice.

II. Registered Nursing Practice

It is within the scope of registered nursing practice for a registered nurse, qualified by education, experience, and current clinical competence to provide school health services/acts including but not limited to the following:

A. Utilize substantial, specialized nursing knowledge, judgment and skill in providing primary healthcare to students including "... initial assessment, management of minor illness and/or referral to other health professionals, monitoring of chronic diseases, health supervision, counseling, promotion of healthy life-styles, disease prevention, and the coordination of services when specialized care is required." (National Association of School Nurses, Resolution--Primary Health Care, June 1981.)

B. Serve as a health advocate of students, and a consultant to educational staff.

C. Serve in family resource and youth services centers as defined in KRS 156.497.

D. Provide health teaching with a focus on disease prevention, health promotion, and health restoration.

E. Monitor the quality of the healthcare services provided for students.

2 For additional information please refer to the Advisory Opinion Statement #27 entitled "Components of

F. Provide direct clinical services for students with special needs and/or teach and verify competency, supervise and delegate [as defined in KRS 314.011(2)] the performance of select acts to unlicensed school personnel in accordance with the administrative regulation 201 KAR 20:400 governing delegation of nursing tasks to unlicensed persons.

G. Participate in the development of policies and procedures to guide nursing practice in school settings, and to address expanding school health services to students, families and communities.

H. Delegate select health services to a school employee in accordance with KRS 156.502 and 201 KAR 20:400.

III. Licensed Practical Nursing Practice 2

KRS 314.011(10) defines licensed practical nursing practice. By definition, licensed practical nurses practice under the direction of a registered nurse, physician, or dentist and are not licensed for independent nursing practice. The Board recognizes the participation of the licensed practical nurse in school nursing practice when the LPN is qualified by education, experience and current clinical competency and practices under the direction and delegation of a designated registered nurse, physician, or when applicable, a dentist. The licensed practical nurse performs acts within the scope of licensed practical nursing practice as defined in KRS 314.011 (10); however, under KRS 156.502 (2) the LPN does not delegate the performance of health services to school employees.

Delegatory Decisions

A registered nurse who makes delegatory decisions regarding the performance of acts/tasks by others is governed by 201 KAR 20:400 Delegation of nursing tasks (An informational copy of the regulation may be purchased from the Board office or downloaded from the KBN website at http://kbn.ky.gov). In summary, delegation should occur only if, in the professional opinion of the delegating nurse, the act may be properly and safely performed by the person to whom the act is delegated.

Determining Scope of Practice

KRS 314.021(2) holds all nurses individually responsible and accountable for the individual's acts based upon the nurse's education and experience. Each nurse must exercise professional and prudent judgment in determining whether the performance of a given act is within the scope of practice for which the nurse is both licensed and clinically competent to perform. In addition to this advisory opinion statement, the Kentucky Board of Nursing has published "Scope of Practice Determination Guidelines" which contains a decision tree chart providing guidance to nurses in determining whether a selected act is within an individual nurse's scope of practice now or in the future. A copy of the guidelines may be purchased from the Board office or downloaded from the KBN website at http://kbn.ky.us.

Educational Preparation

Nurses are responsible for having documented evidence of adequate educational and experiential preparation to provide school nursing in a safe, effective manner. Such educational preparation should be acquired in an approved prelicensure education program or via successful completion of an applicable continuing education program(s). Post registered nurse licensure programs are available which offer curricula preparing nurses for school nursing practice.

The Board recognizes the value and necessity of prelicensure education in community health nursing for nurses who provide school health services; community health nursing curriculum is included in baccalaureate degree registered nursing education programs. Post registered nurse licensure programs are available which offer curricula preparing school nurse practitioners.

KRS 314.011(13) defines "nursing assistance" as:

… The performance of delegated nursing acts by unlicensed nursing personnel for compensation under supervision of a nurse.

KRS 314.021(2) states:

All individuals licensed under provisions of this chapter shall be responsible and accountable for making decisions that are based upon the individuals' educational preparation and experience in nursing.

KRS 314.011(2) defines "delegation" as:

... Directing a competent person to perform a selected nursing activity or task in a selected situation under the nurse's supervision and pursuant to administrative regulations promulgated by the board in accordance with the provisions of KRS Chapter 13A.

GUIDELINE FOR REGISTERED NURSE DELEGATION TO UAP’S

I. Introduction

The purpose of this delegation guideline is to ensure that nursing care services have a consistent standard of practice upon which the public and profession may rely, to safeguard the authority of the registered nurse delegator to make independent professional decisions regarding the delegation of a nursing task, and to protect the safety of consumers.

A licensed registered nurse may delegate specific nursing care tasks to unlicensed assistive personnel (UAPs) who meet certain requirements. Before delegating a task, the registered nurse delegator must determine that specific criteria described in this guideline are met. The registered nurse delegator and the UAP are accountable for their own individual actions in the delegation process.

This guideline addresses delegation of specific tasks. It in no way replaces general legal and ethical responsibilities of providers, including but not limited to emergency response procedures, crisis intervention, and consumer participation in service plan development. This guideline does not apply to tasks that do not require delegation, such as assistance with bathing, dressing, or other activities of daily living. The registered nurse retains overall accountability for the nursing care of the consumer, including nursing assessment, evaluation, and assuring documentation is completed. No person may coerce the registered nurse delegator into compromising consumer safety by requiring the nurse to delegate if the registered nurse delegator determines it is inappropriate to do so.

All the steps of the delegation procedure may be done by one delegating nurse, or may be shared by several nurses.

II The Delegation Procedure

Step 1: Use the Delegation Decision Tree to determine whether delegation of particular task is appropriate. If not, do not delegate. If task is generally appropriate for delegation, continue.

Step 2: The RN should delegate only in accordance with her/his education, training and experience. If necessary, the RN should seek consultation from a knowledgeable RN.

Step 3: Assess the consumer and situation including the environment and available resources to ensure that there are no unique factors that could make outcomes of the delegated task unpredictable.

Step 4: Assess the UAP’s willingness and potential ability to perform the task with this consumer. The registered nurse delegator shall:

Consider the psychomotor and cognitive skills required to perform the nursing task.

Verify that the UAP is willing to perform the task in the absence of direct or immediate nurse supervision and to accept responsibility for her/his own actions.

Analyze the complexity of the nursing task and determine the required training or additional training needed by the UAP to competently accomplish the task.

Assess the level of interaction required, considering language or cultural diversity that may affect communication or the ability to accomplish the task to be delegated, as well as methods to facilitate the interaction.

Step 5: Provide training for the UAP. Upon discretion, the RN may also require a demonstration of competence by the UAP.

Step 6. Provide clear and specific instructions to the UAP including when and how to contact the delegating nurse or back-up nurses.

Step 7: Implement and Evaluate Delegation

The registered nurse delegator must ensure that the performance of the UAP is supervised and evaluated.

The method of supervision is at the discretion of the registered nurse delegator.

Step 8: Document the delegation according to agency policies.

Note: The documentation of the tasks to be delegated will depend upon the complexity of the tasks, the setting and the agency practice guidelines and or protocols.

III Procedure for Implementing Changes in Delegated Tasks

A. If a delegated task is changed or added, the registered nurse delegator must review the criteria and process for delegation prior to delegating the new or revised task to the UAP.

B. The registered nurse delegator maintains the authority to decide if the new or altered medication, treatment, or procedure can be delegated immediately.

C. Each UAP must receive clear instructions on the action to take when delegated tasks are altered.

IV Rescinding Delegation.

A. The registered nurse delegator may rescind delegation of the nursing task whenever the nurse believes that consumer safety is being compromised or for other reasons according to the judgment of the nurse.

B. In the event delegation is rescinded, the registered nurse delegator initiates and participates in developing an alternative plan to ensure continuity for the provision of the task.

C. Document the rescinding of the delegation.

DEFINITIONS

"Coercion" means to force or compel another, by authority, to do something that he/she would not otherwise choose to do.

"Complex task" means that a nursing task may become more complicated because of the interrelationship between the following criteria:

The consumer's condition
The setting
The nursing care task and involved risks, and
The skill level required to perform the task.

The registered nurse delegator must identify the need for and facilitate procurement of additional training of the UAP prior to delegation in these situations. The registered nurse delegator may decide the task is not delegatable because it is too complex.

“Consumer” means the individual recipient of the tasks. In community settings, “consumer” is the preferred word instead of “patient.”

“Guidelines” are systematically developed statements to assist practitioner and consumer decisions about appropriate health care for a specific clinical condition.

"Outcome" means the end result or consequence of an action after following an established plan of care.

"Procedure" means a series of steps by which a desired result is obtained, a particular course of action or way of doing something.

"Protocol" means an explicit, detailed written plan specifying the procedures to be followed in providing care for a particular condition.

"Registered nurse delegation" means the registered nurse transfers the performance of selected nursing tasks to competent UAPs in selected situations. The registered nurse delegating the task retains the responsibility and accountability for the nursing care of the consumer.

"Supervision" means the provision of guidance and evaluation by a registered nurse delegator for the accomplishment of a nursing task or activity as outlined in this guideline including the initial direction of the task or activity, periodic inspection of the actual act of accomplishing the task or activity, and the authority to require corrective action.

a. “Direct supervision means immediate availability to continually coordinate, direct and inspect at first hand the practice of another” (Wisconsin Administrative Code N6.

b. “General supervision means regularly to coordinate, direct and inspect the practice of another” (Wisconsin Administrative Code N6).

"Stable and predictable condition" means a situation in which the consumer's clinical and behavioral status is known through the registered nurse delegator's assessment to be non-fluctuating and consistent, including a terminally ill consumer whose deteriorating condition is predictable. The registered nurse delegator determines that the consumer does not require their frequent presence and evaluation.

"UAP" means unlicensed assistive personnel. It includes certified nurse assistants, personal care workers, daily living assistants, supportive home care workers, adult family home owners and staff, unlicensed workers in community-based residential facilities, assisted living facilities. UAP can be broadly interpreted to include any person paid to provide supports in community. Nurses’ training of family members to perform tasks is training, not delegation.

VERMONT STATE BOARD OF NURSING THE ROLE OF THE NURSE IN DELEGATING NURSING INTERVENTIONSPOSITION STATEMENT

Licensed nurses have the authority to delegate nursing intervention that may be performed by others.

Assistive Personnel:

Individuals who are trained to function in an assistive role to the licensed nurse in the provision of patient care activities as delegated by the licensed nurse. This term includes but is not limited to licensed nursing assistants and unlicensed personnel.

Overview:

The licensed nurse delegates tasks based on the needs and conditions of the patient, potential for ham, stability of the patient’s condition, complexity of the task, predictability of the outcomes, and the abilities of the staff to whom the task is delegated. Although a variety of tasks and services may be performed by assistive personnel, assessment, evaluations and nursing judgement cannot be delegated.

Tasks being performed by assistive personnel are delegated to be performed under specific circumstances and after proper assessment. These tasks are not transferable by assistive personnel to another care setting for another patient without proper assessment and redelegation.

VERMONT STATE BOARD OF NURSING THE ROLE OF THE NURSE IN THE DELEGATION OF INSULIN PUMPS

IN SCHOOL SETTINGS

POSITION STATEMENT

OVERVIEW:

Diabetes has been determined as a disability under the Diabetes Education Act and The Americans with Disabilities Act. Under these laws accommodations should be provided within the student’s usual school setting with as little disruption to the student’s routine as possible and allowing the student full participation in all school activities.

POSITION:

Appropriate diabetic care in the school setting is a responsibility of the school nurse.

Care of students with health care needs must be individualized and supervised by a Registered Nurse who is accountable for the care provided.

The delegation of procedures/treatments is a nursing decision based on the guidelines delineated in the Board of Nursing’s Position Statement on Delegation.

Delegation of care for children on insulin pumps should be confined to procedures that do not require nursing assessment, judgement, evaluation or complex skills.

Procedures that may be appropriate to delegate include inputting carbohydrate counts and blood sugar levels, and activation of the pump to infuse a pump-calculated insulin bolus, correction, or total dose.

Inserting a new infusion set, disconnecting and reconnecting tubing, filling and priming a pump are not appropriate to delegate since they involve complex skills.

The Registered Nurse is responsible for the coordination and oversight of assistive personnel and will:

Identify the task to be performed;
Provide education and training;
Evaluate the ability of the assistive personnel;
Evaluate the performance of the task;
Develop detailed protocol procedures;
Develop an individualized health care plan with parent involvement and input from the Medical Team; and
Provide for immediate accessibility to a health care provider to answer questions and provide direction if the school nurse is not on site.

JOINT STATEMENT OF THE VERMONT BOARDS OF PHARMACY, STATE BOARD OF NURSING AND THE DEPARTMENT OF EDUCATION REGARDING THE ADMINISTRATION OFMEDICATION ON SCHOOL FIELD TRIPS BY SCHOOL NURSESPOSITION STATEMENT

On December 6, 2000, duly appointed committees of the above boards met with representative of the Department of Education to discuss administration of student medication on school field trips. As a result of those discussions and in accord with the Nurse Practice Act the following statement was approved.

When it is necessary for a school nurse to delegate responsibility for administering students’ medications on field trips, the nurse should attempt to obtain a labeled container from the prescribing pharmacy for the dose needed. It is within the scope of the Nurse Practice Act for the nurse to delegate the administration of the medication to a responsible adult attending the field trip.

DEPARTMENT OF REGULATORY AGENCIES

Division of Registrations

Board of Nursing

3 CCR 716-1

CHAPTER XIII

RULES AND REGULATIONS REGARDING

THE DELEGATION OF NURSING TASKS

The professional nurse is responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she provides either directly or through the delegated care provided by others. Supervision of personnel associated with nursing tasks is included in the legal definition of the practice of professional nursing.

3. DEFINITIONS: For the purposes of these Chapter XIII rules, the following terms have the indicated meaning.

"Delegatee" means an individual receiving the Delegation who acts in a complementary role to the professional nurse, who has been trained appropriately for the task delegated, and whom the professional nurse authorizes to perform a task that the individual is not otherwise authorized to perform.

3.4 "Delegation" means the assignment to a competent individual the authority to perform in a selected situation a selected nursing task included in the practice of professional nursing as defined in section 12-38-103(10).

3.5 "Delegator" means the professional nurse making the Delegation; the Delegator must hold a current, active license.

3.10 “School” means any institution of primary or secondary education, including preschool and kindergarten.

7.0 DELEGATION OF THE ADMINISTRATION OF ORAL, TOPICAL AND INHALED MEDICATIONS IN SCHOOLS

7.1 A professional nurse employed or contracted by a School may delegate the administration of oral, topical (including eye and ear drops) and inhaled Medications to a specific Delegatee(s) for the population of a School, within a specific time frame not to exceed one school year.

7.2 A professional nurse employed by or contracted by a school district may delegate to one or more specific Delegatee(s) who have successfully completed appropriate training the administration of emergency medications, prepackaged in unit dose preparations, including but not limited to injectable epinephrine, where there is an emergency need for such treatment. The professional nurse must provide to the Delegatee a specific written protocol for each Client as determined in the IHP.

7.3 The Delegator shall not delegate the administration of Medications in Schools to any Client where the route of medication administration is not included in 7.1 or 7.2.

7.4 The Delegator shall not delegate the administration of Medications in Schools where the administration requires the Delegatee to exercise the judgment required of a professional nurse.

7.5 Medication administration must occur within the context of generally accepted standards, including authorization by an individual authorized by statute to prescribe; appropriate storage of Medications; administration procedures including the use of pharmacy or pharmaceutical company labeled Medications; and documentation.

7.6 Nothing in this Section 7 shall be construed to prohibit a professional nurse from delegating a specific nursing task to a specific Delegatee for a specific Client in the School setting, as otherwise provided for and governed by the provisions of this Chapter XIII.

8. DELEGATION OF INSULIN AND GLUCAGON ADMINISTRATION IN THE SCHOOL SETTING AND LICENSED CHILD CARE FACILITY

8.1 The injection of insulin or glucagon is a nursing task that may be delegated in accordance with the requirements of these Chapter XIII rules. The selection of the type of insulin and dosage levels shall not be delegated.

8.2 An IHP shall be developed for any Client receiving insulin in the School or Licensed Child Care Facility setting. Delegation of tasks for Clients with diabetes shall be confined to procedures that do not require nursing assessment, judgment, evaluation or complex skills.

A. By example, but not limited to the following list, the IHP may include:

i. Carbohydrate counting 5

ii. Glucose testing

iii. Activation or suspension of an insulin pump

iv. Usage of insulin pens

v. Medical orders

vi. Emergency protocols related to glucagon administration

8.3 Insulin injection by the Delegatee shall only occur when the Delegatee has followed the guidelines of the IHP.

A. Dosages of insulin may be injected by the Delegatee as designated in the IHP.

B. Non-routine, correction dosages of insulin may be given by the Delegatee only after:

i. Following the guidelines of the IHP; and

ii. Consulting with the Delegator, parent or guardian, as designated in the IHP, and verifying and confirming the type and dosage of insulin being injected.

C. Under Section 8.3, insulin injection by the Delegatee is limited to a specific Delegatee, for a specific Client and for a specific time.

8.4 When the Delegator determines that the Client is capable of self-administration, as documented in the IHP, the Delegator may delegate to the Delegatee as designated in the IHP the verification of insulin dosage via pump or injection.

8.5 When the Client is not capable of self-administration, routine daily meal boluses of insulin, based on carbohydrate counts and blood glucose levels, may be injected via the insulin pump by the Delegatee as designated in the IHP.

9. DELEGATION OF ADMINISTRATION OF ORAL, TOPICAL AND INHALED MEDICATIONS IN LICENSED CHILD CARE FACILITIES

9.1 A professional nurse employed or contracted by a Licensed Child Care Facility may delegate the administration of oral, topical (including eye and ear drops), and inhaled Medications to a specific Delegatee(s) for the population of the facility, within a specific time frame not to exceed one year.

9.2 A professional nurse employed or contracted by a Licensed Child Care Facility may delegate to one or more specific Delegatee(s) who have successfully completed appropriate training in the administration of emergency Medications, prepackaged in unit dose preparations, including but not limited to injectable epinephrine, where there is an emergency need for such treatment. The professional nurse must provide to the Delegatee a specific written protocol for each Client as determined in the IHP.

9.3 The Delegator shall not delegate the administration of Medication in child care facilities to any Client where the route of medication administration is not included in 9.1 and 9.2.

9.4 The Delegator shall not delegate the administration of Medications in Licensed Child Care Facilities where the administration requires the Delegatee to exercise the judgment required of a professional nurse.

9.5 Medication administration must occur within the context of generally accepted standards, including authorization by an individual authorized by statute to prescribe; appropriate storage of Medications; administration procedures including the use of pharmacy or pharmaceutical company labeled Medications; and documentation. 6

9.6 Nothing in this Section 9 shall be construed to prohibit a professional nurse from delegating a specific nursing task to a specific Delegatee for a specific Client in the Licensed Child Care Facility setting, as otherwise provided for and governed by the provisions of this Chapter XIII.

10. EXCLUSIONS FROM THE CHAPTER XIII RULE INCLUDE:

10.1 Any person registered, certified, licensed, or otherwise legally authorized in this state under any other law engaging in the practice for which such person is registered, certified, licensed, or authorized.

10.2 Any person performing a task legally authorized by any person registered, certified, or licensed in this state under any other law to delegate the task.

10.3 The professional nurse who teaches the Child Care Medication Administration course required by the Colorado Department of Human Services shall not be considered to be delegating as defined by this Chapter XIII.

10.4 Any child care provider as defined in section 26-6-102(1.7) C.R.S. acting in compliance with section 26-6-119 C.R.S., and any rules enacted pursuant to that section. Such child care provider must:

A. Have successfully completed a medication administration instructional program that is approved by the Colorado Department of Human Services;

B. Have daily physical contact with the parent or guardian of the Client to whom medications are administered;

C. Administer only routine medications and only in compliance with rules promulgated by the state Board of Human Services;

D. In emergency situations requiring the administration of unit dose epinephrine, comply with any protocols written by the prescribing health care professional; and

E. Administer a nebulized inhaled medication only in compliance with protocols written by the prescribing health care professional that identify the need for such administration.

Part C Information Compiled

This is a compilation of selections from the other states’ rules and advisory opinions that could POSSSIBLY be used in Wyoming. This was NEVER submitted to the State Board of Nursing. This is an example of one of the directions that could be taken with WSNA as a sponsor.

3/11/08 DRAFT #3

Proposal for Wyoming as an addition to Chapter IX, State Board of Nursing Rules

GUIDELINES FOR REGISTERED NURSES IN THE DELEGATION OF NURSING TASKS

TO UNLICENSED ASSISTIVE PERSONNEL IN THE SCHOOL SETTING

DEFINITIONS

Medical Emergency: A medical emergency is defined as a sudden, urgent, unforeseen occurrence in the school setting requiring immediate action in order to prevent disability or death. Medications and treatments scheduled for provision according to a routine schedule are not considered medical emergencies.

“School” means any institution of primary or secondary education, including preschool and kindergarten.

"Stable and predictable condition" means a situation in which the consumer's clinical and behavioral status is known through the registered nurse delegator's assessment to be non-fluctuating and consistent, including a terminally ill consumer whose deteriorating condition is predictable. The registered nurse delegator determines that the student does not require their frequent presence and evaluation.

Unlicensed Assistive Personnel (UAP): Unlicensed school personnel are employees of a school district who are not currently licensed to practice nursing by the Wyoming Board of Nursing.

Introduction and history

The primary mission of the Wyoming Board of Nursing is to ensure public protection and, in this capacity, the Board is concerned with the appropriate utilization of both licensed and unlicensed personnel who provide healthcare to students and, in this role, issues guidelines regarding the delivery of care in school settings to ensure the health and safety of students. The Board of Nursing must assure the public that nursing tasks are provided in schools in a manner which assures that safe and effective care is provided for the citizens of the state of Wyoming.

As stated in the American Nurses' Association "Scope and Standards of School Nursing Practice" (2001) and the "Scope and Standards of College Health Nursing Practice" (1997)1: The purpose of school nursing is to enhance the educational process by the modification or removal of health-related barriers to learning and by promotion of an optimal level of wellness.

The Board of Nursing recognizes that in school districts where the school nurse is responsible for more than one school it is difficult, at best, to insure the safe and legal administration of medication, provision of quality nursing services, and assessment and planning for the healthcare needs of individual students in order to support their education in the least restrictive environment. The Board is aware that, increasingly, students with chronic health conditions and who may be medically fragile attend school. The Board also recognizes the often complex health care needs of students in regular as well as special education classrooms. It is because of the frequent need for specialized nursing tasks for students during regular school hours that the Board recommends that school districts in Wyoming make it a priority to employ at least one registered school nurse. In view of the ongoing and growing need for provision of preventive, as well as restorative, maintenance, and emergency healthcare to students and staff, assistance to parents in the healthcare of their children, and development of coordinated school health programs, it is increasingly difficult for school districts to adequately support the academic achievement of all students. The presence of a school nurse in each school is a reasonable expectation for the safe provision of quality school health services for students and staff.

Provisions to provide leadership and assistance to local school districts relating to student health services have been previously established in Wyoming by the Attorney General and states that the school administrator is responsible for delegation of health care services in the school setting. School administrators are not educationally prepared to assume the role of practicing nursing and thus, the need for these guidelines.

This section establishes standardized protocols and guidelines for health procedures to be performed by registered nurses and school personnel. The guidelines reflect the delegation of nursing functions consistent with Sections 1-7 of this chapter, are specialized to the school setting and safeguards the authority of the registered nurse delegator to make independent professional decisions regarding the delegation of a nursing task and the authority to require corrective action.

This section establishes a definition of “nursing tasks” and establishes provisions for whom shall provide nursing tasks in schools. Persons who provide nursing tasks include: registered nurses and school employees, herein known as Unlicensed Assistive Personnel (UAP), who are delegated the responsibility to perform nursing tasks by a registered nurse. UAPs may perform only nursing tasks in specific situations.

Determining Scope of Practice in School Nursing

Registered Nursing Practice in School Nursing

Registered Nurses are responsible for having documented evidence of adequate educational and experiential preparation to provide school nursing in a safe, effective manner.

a. Utilize substantial, specialized nursing knowledge, judgment and skill in providing primary healthcare to students including "... initial assessment, management of minor illness and/or referral to other health professionals, monitoring of chronic diseases, health supervision, counseling, promotion of healthy life-styles, disease prevention, and the coordination of services when specialized care is required." (National Association of School Nurses, Resolution--Primary Health Care, June 1981.)

b. Serve as a health advocate of students, and a consultant to educational staff.

c. Provide health teaching with a focus on disease prevention, health promotion, and health restoration.

d. Monitor the quality of the healthcare services provided for students.

e. Provide direct clinical services for students with special needs and/or teach and verify competency, supervise and delegate the performance of select acts to unlicensed assistive personnel under specific requirements as outlined in this section.

f. Participate in the development of policies and procedures to guide nursing practice in school settings, and to address expanding school health services to students, families and communities.

Delegation of nursing tasks by the Registered Nurse in the School Setting

The goal of these guidelines is to ensure that Wyoming students can remain in schools in the least restrictive environment (LRE), receive a free and appropriate public education (FAPE), meet the requirements in the Individuals with Disabilities Education Act (IDEA) and the Americans with Disabilities Act (ADA) and have access at all times to the nursing tasks and the support required for them to be successful in an educational setting in Wyoming.

Delegation to unlicensed assistive personnel occurs only when the RN is absent or unavailable and should not be construed as a replacement or substitution for care provided by a RN in Wyoming schools.

The registered nurse, as the school nurse, retains overall accountability for the nursing care of the students, including nursing assessment, evaluation, and assuring documentation is completed. No person may coerce the registered nurse into compromising student safety by requiring the registered nurse to delegate if the registered nurse determines it is inappropriate to do so.

Each registered nurse must exercise professional and prudent judgment in determining whether the performance of a given act is within the scope of practice for which the nurse is both licensed and clinically competent to perform.

In the school nurse’s absence, a registered nurse may delegate specific nursing tasks to unlicensed assistive personnel (UAPs) who meet certain requirements. Before delegating a task, the registered nurse must determine that specific criteria described in this guideline are met. The registered nurse and the UAP are accountable for their own individual actions in the delegation process.

The RN assigned to a school works with the school’s administrator or his/her designee to identify UAPs (staff members or faculty) who agree to provide select nursing tasks for students. The RN will recommend only those trainees who complete the training and pass the outlined competency requirements to the school administrator or his/her designee for assignment to provide specific nursing tasks for a specific student.

To determine if training of unlicensed assistive personnel is appropriate the RN shall review the student’s status including:

-whether the student’s condition is stable and predictable;

-the nature and complexity of the nursing task;

-the risk to the student if the task is performed inappropriately or incorrectly;

-whether the student outcome anticipated is stable and predictable

The Registered Nurse is responsible for the coordination and oversight of unlicensed assistive personnel and will:

a. Identify the task to be performed;

b. Select, determine competency of and evaluate unlicensed assistive personnel in the provision of select nursing tasks required in order for a student to attend school.

c. Provide education and training for unlicensed assistive personnel:

1. A RN must provide the initial training and competency determination of unlicensed assistive personnel. A RN may train and determine competency of unlicensed assistive personnel to provide select nursing tasks, if the school district has:

a written policy that authorizes the training of unlicensed assistive personnel by a registered nurse.
written procedures outlining specific trainings for nursing tasks and quality assurance measures including competency determination, post-emergency evaluation, error reporting, and error tracking.
Training updates that include procedural changes shall be treated as an initial training and, therefore, must first be provided by the RN

2. The instructional plan must include:

a. Step by step instructions and rationale for the task;

b. Return demonstration of the task by the UAP to evaluate competency and to assure accuracy and safety;

c. Observation of the unlicensed assistive personnel performing the task to evaluate competency and to assure accuracy and safety;

d. An evaluation of knowledge of the UAP related to the task to measure understanding of pertinent concepts;

e. Provision of written instructions and student IHP for the UAP as a reference;

f. A plan for seeking emergency assistance from qualified medical personnel;

g. A plan for ongoing evaluation of student outcomes by a RN;

3. Upon completion of all training sessions, the registered nurse providing the training must advise trainees that the skills taught are to be used only for meeting the needs of the specific student(s) for which they have been assigned to provide care while at school or school related functions and are not transferable to other settings outside of the school district. The unlicensed school employees trained cannot delegate the tasks to others or supervise others in performing the tasks.

4.. The frequency of direct observation and evaluation of the unlicensed assistive personnel shall be determined by the RN based upon the school setting, the student’s status, the complexity of the nursing task, the risk to the student, and the proximity of the RN.

5.. The registered nurse assigned to the school shall evaluate the student on a regular basis to determine progress toward goals of care. If the outcomes of the evaluation do not meet the expected quality of care, the RN must intervene. The RN may need to provide additional instruction to the unlicensed person or recommend that the administrator or his/her designee rescind the assignment.

6. Provide for immediate telephone accessibility to the registered nurse to answer questions and provide direction if the school nurse is not on site.

7. Outline a plan for backup assistance if the RN is not available.

8. Outline a plan for intervening in an emergency situation if the RN is not available.

9. Evaluation Component

10. The RN shall maintain a training file on each UAP trained which includes:

a. Documentation of initial, updates and follow-up training of UAP.

b. Assessment of the competencies of unlicensed assistive personnel

c. Meeting and observations of unlicensed assistive personnel.

Some Nursing tasks that require nursing judgment may be delegated only after the nursing judgment is made. Such tasks may include, but are not limited to:

a) Collection, documentation, and reporting of data (e.g., vital signs, oxygen saturation using pulse oximeter equipment, height, weight, and blood glucose testing when sample is obtained from a capillary site).

b) Assisting patients to perform self-care tasks, including assistance with a patient's self-administered medication. Such assistance does not include the preparation of syringes for injection.

c). Performing tasks of a routine nature that do not require simultaneous nursing judgment. For example, simple non-sterile dressing changes, external catheter care, and colostomy appliance changes on mature stoma sites with sustained skin integrity.

d) Tasks for meeting students’ needs for personal hygiene

e) Intermittent urethral or suprapubic catherization (elimination).

f) Selected ambulation, positioning, turning, activities of daily living, or exercise programs that have been developed by the physical therapist, occupational therapist or the RN.

g) Selected nutritional activities, such as feeding and meal preparation. This does not include the administration of nasogastric tube feedings by unlicensed personnel, but may include the administration of feedings via a gastrostomy tube when the tube is in a mature stoma site with sustained skin integrity, and when it is delegated by and performed under the supervision of a registered nurse.

h) Socialization activities.

i) Transportation of student.

j) The administration of medications via a gastrostomy tube for students in a school setting, when performed under the delegation and supervision of a registered nurse and in accordance with established school district policy and procedure;

k) Administering a nebulized inhaled medication only in compliance with protocols written by the prescribing health care professional that identify the need for such administration.

Nothing in this shall be construed to prohibit a registered nurse from delegating a specific nursing task to a specific unlicensed assistive personnel for a specific client in the school setting when the registered nurse is absent or unavailable for provision of needed nursing care during school or school sponsored activities.

The registered nurse shall not delegate any nursing task in schools where the nursing task requires the UAP to exercise the judgment required of a professional nurse.

This guideline in no way replaces general legal and ethical responsibilities of providers, including but not limited to emergency response procedures, crisis intervention, and consumer participation in service plan development.

This guideline does not apply to tasks that do not require delegation, such as assistance with hygiene, dressing, or other activities of daily living.

All the steps of the delegation procedure may be done by one delegating nurse, or may be shared by several nurses.

The nursing tasks delegated by the RN to UAPs may be used only at school or school related functions and are not transferable to other settings. The trained unlicensed assistive personnel may not delegate the tasks to others or supervise others in performing the tasks.

School-sponsored functions may include those conducted during regular school hours on school grounds, before- and after-school activities conducted by the school on school property, transit to or from school or school-sponsored activities when the vehicles are owned or leased by the school district, and any school-sponsored activity in which the student is a participant. Examples of school-sponsored activities are field trips, interscholastic sporting events, and fine arts events in which the student is a participant. The RN will determine on a case-by-case basis whether trained unlicensed assistive personnel may assist a specific student with nursing tasks or regularly scheduled medications at school-sponsored functions outside of regular school hours if the RN is absent or not available.

A licensed RN must be available via telecommunications to answer questions that the trained unlicensed assistive personnel may have when assisting students with nursing tasks in the absence of the RN assigned to the school.

This section shall not prevent the administration of FDA approved medications by a person who has satisfactorily completed a district sponsored training program for this purpose and who administers such medications in accordance with a physician's instructions pertaining to dosage, frequency, and manner of administration, according to school board policy and in accordance with regulations promulgated by the Board of Pharmacy relating to security and record keeping, when the medications administered would be normally self-administered or given by parents/guardians at home.

The registered nurse may rescind delegation of the nursing task whenever the nurse believes that student safety is being compromised or for other reasons according to the judgment of the nurse. In the event delegation is rescinded, the registered nurse delegator initiates and participates in developing an alternative plan to ensure continuity for the provision of the task. Documentation of the process for the rescinding of the delegation is required.

In summary, delegation should occur by registered nurses in the school setting only if, in the professional opinion of the delegating nurse, the act may be properly and safely performed by the person to whom the act is delegated.

Special consideration: Diabetes

OVERVIEW:

Diabetic Care:

Appropriate diabetic care in the school setting is a responsibility of the registered nurse.

Care of students with health care needs must be individualized and supervised by a Registered Nurse who is accountable for the care provided.

The delegation of procedures/treatments is a nursing decision based on the guidelines delineated in the Board of Nursing’s Position Statement on Delegation.

The selection of the type of insulin and dosage levels shall not be delegated.

Delegation of tasks for Clients with diabetes shall be confined to procedures that do not require nursing assessment, judgment, evaluation or complex skills

Insulin:

The injection of insulin or glucagon is a nursing task that may be delegated in the absence of the registered nurse in order to assure immediate accessibility of care for the student with diabetes. Insulin injection by the UAP shall only occur when the UAP has followed the guidelines of the IHP.

By example, but not limited to the following list, the IHP may include:

i. Carbohydrate counting 5

ii. Glucose testing

iii. Activation or suspension of an insulin pump

iv. Usage of insulin pens. Insulin injection by the UAP is limited to a specific UAP, for a specific Client and for a specific time.

v. Medical orders

vi. Emergency protocols related to glucagon administration

vii. Dosages of insulin may be injected by the UAP as designated in the IHP.

Non-routine, correction dosages of insulin may be given by the UAP only after:

i. Following the guidelines of the IHP; and

ii. Consulting with the RN, parent or guardian, as designated in the IHP, and verifying and confirming the type and dosage of insulin being injected.

When the RN determines that the student is capable of self-administration, as documented in the IHP, the RN may delegate to the UAP, as designated in the IHP, the verification of insulin dosage via pump or injection.

When the student is not capable of self-administration, routine daily meal boluses of insulin, based on carbohydrate counts and blood glucose levels, may be injected via the insulin pump by the RN as designated in the IHP.

Insulin Pumps in School Settings:

Procedures that may be appropriate to delegate to UAPs include inputting carbohydrate counts and blood sugar levels, and activation of the pump to infuse a pump-calculated insulin bolus, correction, or total dose.

Inserting a new infusion set, disconnecting and reconnecting tubing, filling and priming a pump are not appropriate to delegate since they involve complex skills.

Delegation of Administration of Oral, Topical and Inhaled Medications In Schools

A registered nurse may delegate the administration of oral, topical (including eye and ear drops), and inhaled Medications to a specific UAP(s)

After delegation, UAPs may administer a nebulized inhaled medication only in compliance with orders written by the prescribing health care professional that identify the need for such administration.

Special Consideration: Emergency Medications in the School Setting

A registered nurse may delegate to one or more specific UAP(s) who have successfully completed appropriate training in the administration of emergency medications, prepackaged in unit dose preparations, including but not limited to injectable epinephrine, where there is an emergency need for such treatment. The registered nurse must provide to the UAP a specific written protocol for each student as determined in the IHP.

Medication administration must occur within the context of generally accepted district and state standards, including authorization by an individual authorized by statute to prescribe; appropriate storage of Medications; administration procedures including the use of pharmacy or pharmaceutical company labeled Medications; and documentation.

In emergency situations requiring the administration of unit dose epinephrine, RNs and UAPs comply with any protocols written by the prescribing health care professional

Special Consideration: Administration of Medication on School Field Trips

When it is necessary for a school nurse to delegate responsibility for administering students’ medications on field trips, the nurse should attempt to obtain a labeled container from the prescribing pharmacy for the dose needed. It is within the scope of school nurses for the registered nurse to delegate the administration of the medication to a responsible adult attending the field trip.

Part D Follow up after the Presentation to the State Board of Nursing

After the presentation, Mary Beth called Chris and invited the group to make a proposal by the 3/31/08 comment period for the proposed changes to the rules. With the short time frame to get a proposal to WSNA members, get consensus, Jan, Susan, Pam and Chris decided not to make a proposal. We knew it would be counterproductive to proceed without WSNA member consensus. Nothing has been presented on behalf of WSNA or school nursing as of this date.

Part E Where to go from this Point-WSNA membership needs to decide

At this point there are several ways that WSNA can proceed. Mary Beth offered input into the following list:

List of Options with SBON to address changing needs of student care in Schools

Option	Pros	Cons
#1 Do nothing: -let old Attorney General opinion stand -don’t offer possible revisions to BON rules for delegation	-Less work -accountability lies with principal -reactive, in that, it is assumed nothing will happen to a student	-doesn’t recognize that school nurses really do the work of delegating in schools -lawsuits for principals practicing nursing in other states -doesn’t acknowledge that the nurse will be included in any legal action taken if a child gets harmed -as needs of students expands, it is being assumed by schools that other more intensive tasks can be delegated
#2 Let old Attorney General opinion stand but add language that allows RNs to teach delegation of nursing tasks
#3 -Make proposal to BON regarding delegation to UAPs in schools via BON rules	- be more consistent with other states stance on delegation to UAPs in schools -the nurse controls the training and evaluation of student care in the selection of whom and what can be delegated. -more proactive to the changing needs of students	-lots of work to accomplish this-when this is done is dependent upon when the law is re-opened.
#4 Pursue changes in advisory opinions to include delegation to UAPs in school setting only	-don’t have to go through legal process -don’t have to wait until the law is re-opened -Katheryn Sessions originally asked for the old opinion and we could ask her to re-open the need for advice
#5 Pursue new attorney general’s opinion	-Would get an updated opinion with the changes in responsibilities of school nurses and increased acuity of students
#6 Pursue legislative money for school nurses and school nurse consultant

Part F Making your voice heard as a WSNA member!

WSNA needs to hear from you!

During the May 3, 29008 meeting, we will be discussing this and a possible structure for proceeding with plans for WSNA and the SBON.


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