School Nurse

Supervision of LVNs &

Health Clerks

ACSA Every Child Counts Symposium

January 2015

Susan Chaides, MEd, RN, CPNP

2015 Los Angeles County Office of Education

California Ed Code 49400

The governing board of any school

district shall give diligent care to

the health and physical

development of students, and may

employ properly certified

persons for the work.

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Diligent Care

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Handle health and medical needs of students

Fully support Free and Appropriate Public Education (FAPE)

Follow state & federal laws, including nursing licensure

School Nurse

Legally recognized school health authority

Authority to recognize qualifications & abilities of UAP*/LVN assigned to perform health care tasks in school

*UAP = Unlicensed Assistive Personnel

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Legal Considerations for

Nurses

Federal Regulations

State Laws & Regulations (Business &

Professions Code, Education Code)

Job Description

Nursing Standards

Complex Legal & Clinical Issues

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Goals of School Health

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Enhance Learning Achievement

Increase Health & Safety

Improve Quality of

Life

Prevention of Illness

Improve Attendance

Control Contagious

Diseases

CEC 49426

School Nurse Role

Immunization compliance

Assess, evaluate, interpret health &

developmental status

Design & implement health plan

Refer resources for services

Maintain communication (case

management)

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CEC 49426

School Nurse Role

Interpret medical & nursing findings &

make recommendations

Consult, conduct trainings, & serve as

resource to staff on health instruction

Assist parents/students to access

health care

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CEC 49426

School Nurse Role

Counsel students and parents – Assisting in utilizing health care services

– Counseling regarding health-related

attendance problems

– Helping understand & adjust to physical,

mental and social limitations

– Exploring attitudes, information & values

which affect health behavior

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Roles & Responsibilities of the

Credentialed School Nurse

Health Assessment

Case Management

Health Counseling

Health Education

Health Screenings

Health Care

Prevent/Control Communicable

Diseases

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Health Clerk Role A

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First aid- ill & Injured students

Specialized Physical Health Care Services

Maintain files, reports, referrals

Prepare reports

Communication Clerical duties

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LVN Role A

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Same duties as HC LVN job description

SPHCS Administer meds -

injections

Basic assessments Basic nursing care

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Performed Only by an RN

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Perform comprehensive

assessment

Validate assessment

data

Formalize nursing

diagnosis

Identify goals derived from nsg diagnosis

Determine nsg plan of care

Evaluate effectiveness of

nsg care provided

RN / LVN Relationship

2015 Los Angeles County Office of Education

LVN works under direction of RN (B&P Code 2859)

Prior to assigning SPHCS to LVN, RN must conduct assessment

Data collection done by RN, may be done by LVN (basic assessment – Title 16, § 2518)

LVN must report data to RN

RN / LVN Relationship

2015 Los Angeles County Office of Education

RN - analysis, synthesis & evaluation of data

Can only be done by RN

Cannot be delegated to LVN or UAP

LVN - not determine educational (health)

needs of patient Does not educate

patient/family

Contributes to development &

implementation of teaching plan related

to self-care for patient

RN / LVN Relationship

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RN must directly observe patient, analyze, synthesize, & evaluate data collected by him/herself and LVN

RN uses data to:

- Make nursing diagnosis

- Determine appropriate interventions

- Make appropriate assignments of tasks

RN / LVN Relationship

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LVN does not initiate, evaluate, or change patient’s treatment/nursing care plan (NCP = IHP)

LVN:

Participates in planning

Executes interventions as per treatment/NCP

Contributes to evaluation of interventions r/t treatment/NCP

RN / LVN Relationship

LVN can monitor patient

Only RN can manage patient

RN decides appropriateness of

assignment of tasks, based on

nursing judgment

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LVN

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• Health Office Staff

• Health Care Aide assigned to a particular student(s)

District Employee

• Contracted by District

• Provided by parent Agency LVN

Health Office Staff

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• School Nurse (RN) - credentialed

Certificated Staff

• RN – not credentialed

• LVN

• UAP – Health clerk, aide, CNA, MA

Classified Staff

Staff

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Credentialed School Nurse

• Licensed RN

• Bachelor’s degree

• Credential in School Nursing

• Many have master’s degree

• 5-6 years of education

Registered Nurse

• Licensed RN

• 2-4 years of education

Staff

Licensed Vocational

Nurse • Licensed LVN

• 12-14 months of training

• Entry level healthcare provider

Unlicensed Assistive

Personnel (UAP)

• Not licensed

• Health clerk/aide, CNA, MA

• Trained in CPR & first aid

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Continuum of Health Care

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UAP LVN SN,

RN

Medically Stable, Not

Complex

Medically Fragile,

Complex

Who Can Provide Mandate Credentialed

SN

RN LVN UAP

Minor First Aid Yes Yes Yes Yes

Assessment &

Mgmt of

Trauma

Yes Yes

Limited No

General Health

Assessment

Yes Yes Basic,

Vital signs

No

Vision Yes No No No

Hearing Yes No No No

Scoliosis Yes No No No

IHPs, ECPs Yes Yes, maybe No No

SPHCS – Train,

supervise

Yes No No No

SPHCS – Direct

Care

Yes Yes, if

supervised

by SN

Yes, if

supervised

by SN

Yes, if

supervised by

SN 2015 Los Angeles County Office of

Education

Who Can Provide Mandate Credentialed

SN

RN LVN UAP

Medication –

Train, supervise

Yes

(program)

No No No

Medication –

Administration

Yes Yes Yes, if

supervised

by SN

Yes, if

volunteer/

No

Special Ed , SST Yes No No No

Section 504

Assessments

Yes No No No

Maintain student

health records

Yes Yes Yes Yes

Health Education Yes Yes,

maybe

No No

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Who Can Provide Mandate Credentialed

SN

RN LVN UAP

Crisis Response Yes Yes (follow

written

plan)

Yes (follow

written plan)

Yes (follow

written plan)

Child Abuse Yes Yes Yes Yes

Communicable

Disease-Prevent

& Control

Yes

Yes,

Limited

Limited

No, Limited

CHDP & Oral

Health

Assessment

Yes, and

interpret

Yes

Yes

Yes

Case Mgmt Yes Yes, maybe No No

Referral &

Follow-up

Yes May assist

SN

May assist

SN

May assist

SN

Health

Counseling

Yes Yes No No

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Utilization of Qualified

Designated Personnel

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Or be assisted by qualified designated school personnel

Perform services under supervision of SN, PHN, or MD

Be assisted by credentialed SN or certified PHN

CEC 49423.5

Any student with exceptional needs who requires SPHCS

Utilization of Unlicensed

Assistive Personnel (UAP)

NPA does not give RN authority to

delegate nursing tasks & functions

which require substantial knowledge

and skills to unlicensed persons

Authority for UAPs to provide SPHCs

is conferred by Ed Code, not license of

nurse or physician

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Utilization of LVN

RN may delegate to LVN (permitted by

statute)

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Supervision

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Level of Care Required

• SN / RN

• LVN

• UAP

Level of Supervision

• Immediate

• Direct

• Indirect

Training of RN/LVN/UAP

• Initial training

• Return demonstration

• Observation

Level of Care Affected By:

Health Status

Staffing at Home

Complexity, # Procedures, Supervision

School Environment,

Schedule

Need for Immediate

Medical Support

Community Standard of

Care

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5 Factors Affecting

Decision to Assign

Potential for harm

Complexity of task

Problem solving & innovation necessary

Unpredictability of outcome

Level of interaction required

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1

2

3

4

5

Determining Assignment

of Tasks

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Task is considered routine for patient

Poses little potential hazard to patient

Involves little or no modification

Be performed with predictable outcomes

Does not involve ongoing assessment, interpretations, or decision making

Patients for whom UAPs

May Not Be Assigned

Patient is medically fragile,

condition is not chronic or stable

Patient who is usually stable is

experiencing an acute episode

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School Nurse Supervision

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UAP LVN SN,

RN

Medically Stable, Not

Complex

Medically Fragile,

Complex

Continuum of Health Care

School Nurse

Who Trains UAP/LVN?

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Elements of Training

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General principles of care

General written information about condition

Student specific training in assigned task

Written procedure

Demonstration & return demonstration

Identify potential emergencies & what to do (ECP)

Instruction in documentation

Training

Keep copies of everything given to

UAP

Document when training occurred

& outcome of training

If more than one return

demonstration is appropriate,

document

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School Nurse

Who Supervises the UAP/LVN?

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Effective Supervision

*Supervisor: a qualified SN, PHN, or MD who is qualified to perform the procedure. Supervisor shall have privilege to exercise judgment and specify level of supervision required, based on professional judgment & shall advise IEP team.

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Assess real/potential

harm

Consider patient safety

Competency of caregiver

Number & complexity of

tasks

Number of staff SN

supervises

Supervision

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Level & Frequency

Based on SN professional judgment

Health status of student

Complexity of task

Levels of Supervision

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• Supervisor physically present while procedure is being done Immediate

• Supervisor present in same building & available for consultation/ assistance

Direct

• Supervisor available in person or through electronic means to provide guidance, consultation, referral to services as needed

Indirect

Components of Supervision

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Document • Each instance

of supervision

Competency

• Trained personnel

Periodic • Observe the actual

procedure

Periodic

• Confer with the RN, LVN, UAP

Periodic

• Review documentation

Issues of Liability &

Documentation

Are health staff acting under

school nurse’s license?

NO!!!

UAP staff work under umbrella liability policy of school district

Not under school nurse’s license

LVN works under own license

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Issues of Liability &

Documentation

However, when school nurse “assigns” a

health care task:

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School nurse transfers responsibility for completing task to UAP/LVN

School nurse retains accountability for task being done appropriately

Documentation

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If UAP does something

inappropriate…

…And SN cannot demonstrate

(written documentation)

UAP was trained…

…And show (written documentation) UAP has successfully carried out procedure (supervision)

in the past…

…Then SN has put own license in jeopardy

Documentation Tools

Training Checklist

Health Care Contract

Emergency Care Plan

Procedure Checklist

Daily Logs

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Evaluation

Evaluation process for SPHCs in school

includes evaluation of:

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Qualified staff performance of standard healthcare procedures

Nursing interventions (outcomes)

Student’s goal achievement

Guidelines for Contracted Care

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Green Book – Section 2

• Guidelines for Contracted Care

• Sample Agreement

• Orientation Checklist

Site administrator

• Time, schedule, services to be provided

• Who is responsible for technical supervision

• How to contact supervisor

Guidelines for

Contracted Care

Agency nurse works under supervision

of agency supervisor

SN concerns about agency nursing care

should be reported to agency supervisor

All 911 calls should be communicated to

SN and site administrator

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Guidelines for

Contracted Care

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SN orient agency nurse to school site and safety practices

SN be available to interpret district policy

SN orient classroom teacher to guidelines

Agency LVN

Provided by Parent

Follow same procedures as when

District contracts with nursing agency

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Resources

The Green Book: Guidelines for Provision of

Specialized Physical Healthcare Services in

California Schools. CSNO

Children and Youth Assisted by Medical

Technology in Educational Settings: Guidelines for

Care, 2nd Ed. By S. Porter, M. Haynie, T. Bierle, T.

Caldwell, and J. Palfrey (Blue Book)

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Los Angeles County Office of

Education

Susan Chaides, Project Director III

chaides_susan@lacoe.edu

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“He who has health, has hope. And he

who has hope, has everything.”

~Arabic Proverb

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