Nursing Practice in California

Hon. Tricia Hunter RN, MN

Board of Registered Nursing California State Assembly Office of Statewide Health Planning and

Development California Medical Assistance Commission Region 13 Disability Board OSHPD Advisory Committee

Who am I?

a re b o rn o u t o f le g is la tio n , re fle c tin g th e w ill o f th e p e o p le

STATUTES

Regulations: develop and grow through administrative efforts within the Executive

Branch

Protect the Public Purview of the State Individual Licensure versus Facility California Medical Practice Act

Licensing

Scope of Medical Practice

diagnose mental and physical conditions

use drugs in or upon human beings sever or penetrate tissues other methods in treatment of

disease, injury deformities or other physical or mental conditions.

The physician’s and surgeon’s certificate authorizes the holder to use drugs or devices in or upon human beings and to sever or penetrate the tissues of human beings and to use any and all other methods in the treatment of diseases, injuries, deformities, and other physical and mental conditions.

Business and Professions CodeSection 2051-2052

Any person who practices or attempts to practice, or who advertises or holds himself or herself out as practicing, any system or mode of treating the sick or afflicted in this state, or who diagnoses, treats, operates for, or prescribes for any ailment, blemish, deformity, disease, disfigurement, disorder, injury, or other physical or mental condition of any person, without having at the office so doing a valid, unrevoked, or unsuspended certificate as provided in this chapter, or without being authorized to perform such act pursuant to a certificate obtained in accordance with some other provision of law, is guilty of a misdemeanor

2051 – 2052 Continued….

Whenever the word “diagnose” or “diagnosis” are used in this chapter, they include any undertaking by any method, device, or procedure whatsoever, and whether gratuitous or not, to ascertain or establish whether a person is suffering from any physical or mental disorder. Such terms shall also include the taking of a person’s blood pressure and the use of mechanical devices or machines for the purpose of making a diagnosis and representing to such person any conclusion regarding his or her physical or mental condition. Machines or mechanical devices for measuring or ascertaining height or weight are excluded from this section.

Business and Professions Code Section 2038

Court Case

People v. Fowler, 32 Cal.App2dSupp.737 (1938); 21 Ops.CalAtty Gen.228

Constitutes the practice of medicine as penetration of tissues of a human being in the treatment of disease or injury, or for test or analysis purposes.

Legal Precedent Delegation

Court Case

Unless one engaging in the practice of medicine is licensed under the state Medical Practice Act or is otherwise authorized to engage in such acts he is liable for violation of STATUTES which, like section 2141, prohibit the unlicensed practice of medicine, and supervision by a duly licensed medical doctor.

Magit v. Board of Medical Examiners, 57 Cal 2d 74, 84 (1961)

Delegation is a legal term used to describe the transfer or responsibility for the performance of a task from one individual to another, while retaining accountability for the outcome.

Principles for Delegation, American Nurses Association, 2005

Delegation

STATUTORY DELEGATION

DELEGATION BY LICENSURE

STATUTORY AUTHORITY TO DELEGATE

DELEGATION

Glucagon, Epinephrine, Diastat

IEP Individual Education Plan

504

Statutory Delegation

Nurse Practice

Act

Independent license to practice Nursing.Nursing: Dynamic field Continually evolving

Sophisticated Patient Care Activities

SCOPE OF RN PRACTICEBPC Section 2725

LEGISLATIVE INTENT: RN

Clear legal authority for functions and

procedures in common acceptance and usage.

Recognize existenceof overlapping

functions nurse physician

Permit additional sharing of functionsWithin organized health care system.

Acute care, home health, clinics,physician offices, public & community

health services.

NPA Section 2725(a)

Practice of Nursing means functions that: help people cope with difficulties in

daily living» actual/potential health/illness

problems» treatment

require a substantial amount of scientific knowledge or technical skill

© Safety© Comfort© Personal Hygiene© Protection of Patients© Disease Prevention© Restorative Measures

RN ASSESSMENT FUNCTIONSDirect & Indirect

NPA Section 2725(b)(1)

Administration of medications and therapeutic agents to implement treatment, disease prevention or rehabilitative regime ordered by and within scope of practice of a licensed physician, dentist, podiatrist, or clinical psychologist.

RN ASSESSMENT FUNCTIONSDirect & Indirect

NPA Section 2725(b)(2)

© Skin tests

© Immunization techniques

© Withdrawal of blood from veins and arteries

RN FUNCTIONS

NPA Section 2725(b)(3)

Observations of signs and symptoms of illness, reactions to treatment, general behaviors, or general physical condition, and (A) determination of whether the signs, symptoms, reactions, behaviors, or general appearance exhibit abnormal characteristics, and (B) implementing, based on observed abnormality, of appropriate reporting, or referral, or standardized procedures, or the initiation of emergency procedures.

RN ASSESSMENT

RN assessment includes the interpretation, analysis and synthesis of patient response to illness, treatments, reactions, procedures, medications, including correlation of laboratory values and imaging reports regarding the patient condition and determining what nursing and medical action is needed for the patient. RN acts on nursing assessment information.

RN ASSESSMENT

Determine abnormal characteristics:

RN Functions

BPC Section 2725 (b)(4)(B)

signssymptomsreactionsbehaviorsgeneral

appearance

RN Functions Implementation of Care: based on observed abnormalities:

report; refer; implement standardized procedures

change treatment based on standardized procedures

initiation of emergency procedures

BPC Section 2755 (b)(4)(B)

Standardized Procedures Legal authority for RN practice to overlap the practice of medicine

Board of Licensed Vocational Nurses and Psychiatric Technicians

BUSINESS AND PROFESSIONS CODE SECTION 2859-2872.2

Licensed Vocational Nurses

LVN Role To assist the School Nurse: Same duties as health clerk

◦ First aid, records, communication, reports, clerical duties

Observations Administer medications, injections Basic nursing care Sample Job Description – Green Book

LVN / RN Relationship The RN must directly observe the patient,

assess, plan, implement and evaluate the data collected by him/herself and the LVN

RN uses data to:◦ Make a nursing diagnosis◦ Determine appropriate interventions◦ Make appropriate assignments of tasks and

activities

LVN contributes in planning, executes interventions as per treatment plan and the nursing care plan, and contributes to evaluation of interventions

The LVN can define the reaction to care but not make a conclusion

LVN Role

Who Can ProvideMandate Credential

ed SNRN LVN Health Clerk

Minor First Aid Yes Yes Yes YesAssessment & Mgmt of Trauma

Yes Yes Limited No

General Health Assessment

Yes Yes Basic,Vital signs

No

Vision Yes No No NoHearing Yes No No NoScoliosis Yes No No NoIHPs, ECPs Yes Yes,

maybeNo No

SPHCS – Train, supervise

Yes No No No

SPHCS – Direct Care

Yes Yes, if supervised by SN

Yes, if supervised by SN

Yes, limited if supervised by

SN

This amendment provided that any individual with exceptional needs who requires specialized physical health care services, during regular school day, may be assisted by a certain specified individuals, including designated school personnel.

(d) “Specialized physical health care services” as used in this section, include catheterization,gastric tube feeding, suctioning, or other services that require medically related training.

Requires 504 or ISHP

AB 1667 (Saldana) Chapter 414 amended Section 49423.5 of the Education Code

Medications and Unlicensed Staff

What are Medications? Medications:

◦substances used to prevent, diagnose, cure or relieve signs and symptoms of disease

Includes:◦Prescription◦Controlled

Substances◦Over the Counter◦Herbal◦Alternative◦Research

Controlled substances

Ritalin , Adderall, Focalyn

ONLY LICENSED PERSONNEL MAY GIVE CONTROLLED SUBSTANCES

Health and Safety Code 11154(a)

Administration is the act of measuring the dosage, per a doctor’s order, and giving it to a person to take or injecting the medication.

Assisting is watching someone take the medication from the container. Assist can mean taking off the lid for someone who finds this difficult. Assist is making sure they don’t take to much.

Assist versus Administer

Diastat

in the absence of a credentialed school nurse or other licensed nurse onsite at the school or charter school, a school district, county office of education, or charter school may elect to participate in a program, pursuant to this section, to allow nonmedical employees to volunteer to provide medical assistance to pupils with epilepsy suffering from seizures, upon request by a parent or guardian pursuant to subdivision

SB 161 Established

Federal law (Fair Labor Standards Act)

-defines a volunteer as an individual who provides services without any expectation of compensation, and without any coercion or intimidation.

Volunteer

A medication Administration volunteer is an unlicensed school employee who agrees, without any expectation of compensation and free from coercion, influence, or threat of retribution, to accept responsibility for giving mediation to student (s) pursuant to a physician’s order, A person is not a volunteer if his/her job description includes administering medications.

Unlicensed School Employee

The school or charter school shall distribute an electronic notice no more than twice per school year per child to all staff that states the following information in bold print: (A) A description of the volunteer request, stating that the request is for volunteers to administer an emergency antiseizure medication to a pupil experiencing a severe epileptic seizure, in the absence of a school nurse, and that this emergency antiseizure medication is an FDA approved, predosed, rectally administered gel that reduces the severity of epileptic seizures.

(B) A description of the training that the volunteer will receive pursuant to paragraph (1).

(C) A description of the voluntary … of the volunteer program, which includes the information described in paragraph (2).

(D) The volunteer rescission timelines described in paragraph (3). (5) The electronic notice described in paragraph (4) shall be the only means by which a school or charter school solicits volunteers.

SB 161 Volunteer Defined

Now that there is a law authorizing RN to train volunteer school personnel to administer Diastat and the student has a physician order to administer Diastat; the RN can train the school volunteer.

   Thanks for the question   Janette Wackerly, MBA, RN Supervising Nursing Education Consultant

Training

FDA APPROVED DRUGS

The Court concluded that California law does permit trained, unlicensed school personnel to administer prescription medications, including insulin, in accordance with written statements of individual students “treating physicians” with parental consent and that the person who act under the authority do not violate the Nurse Practice Act.

Ca Supreme Court Decision

Education Code Section 49423

“Any pupil who is required to take, during the regular school day, medication prescribed for him or her by a physician an surgeon…may be assisted by the school nurses or other designed school personnel…

…..”medications are administered only in accordance with medical orders and parental consent.”

Crux of the Supreme Court Decision (1)

Section 601 defines “other designated school personal” who are thus authorized to act as “including any individual employed by the local school agency who: Has consented to administer the medication to the publi or otherwise asist the pupil in the administration of the medication

Crux of the Supreme Court Decision (2)

The Court determined that the words “assist” means able to administer.

The court implied the sections talking about legally able or licensed were additions not requirements.

As allowed by law… The Supreme Court says section 604 and 605 discussing assist allows unlicensed school personal under the law.

Interpretation

The Supreme Court concluded the Medical-orders exception does permit a layperson to carry out a physician’s medical orders for a patient, even orders that would otherwise fall within the definition of nursing practice, without thereby vilolating the rule against unauthorized practice.

Medical Order Exception

This chapter does not prohibit: … The performance by any person of such duties as required in the physical care of a patient and/or carrying out medical orders prescribed by a licensed physician; provided such person shall not in any way assume to practice as a professional, registered, graduate or trained nurse.

Medical Orders Exception (NPA)

The Supreme Court ruling leaves to each student’s physician, with parental consent, the question whether insulin may safely and appropriately be administered by unlicensed school personnel and further states no law, except for controlled substances, prohibits unlicensed persons in schools from administering prescription medications, generally, or insulin in particular, in caring out the medical orders of licensed physicians.

Physician Order

The legal advisory issues by the Department of Education states:

……eighth category of authorized persons, permitting insulin to be administered by a “voluntary school employee who is unlicensed but who has been adequately trained to administer insulin pursuant to the student’s treating physician’s orders as required by the Section 504 Plan or the IEP.

Legal Advisory 2007

The school district shall obtain both a written statement from the physician…◦ Detailing the name of the medication◦ Method◦ Amount◦ Time schedules by which the medication is to be

taken ◦ A written statement from the parent, foster parent

or guardian of the public indicating the desire the school district assist the pupil in the matters set forth in the statement of the physician

School District Requirements

Unresolved Issues………..

Supervision is the Active process of directing, guiding and influencing the outcome of an individuals performance of a task. In the context of healthcare, including the administration of medication, there are three types of supervision: immediate, direct and indirect.

When dealing with licensing in California a licensed act is delegated and a task is assigned.

Supervision

Immediate Supervision: The supervisor is physically present while a procedure is being performed or medication is being administered.

Direct: The supervisor is present in the same building as the person being supervised and is available for consultation and/or assistance.

Indirect: The supervisor is available to eh qualifed designated school personnel, either in person or through electronic means to provide necessary guidance, consultation and referral to appropraite care and services as needed.

Section 3051.12 (D) Code of Regulation Title 5 Education

Now that there is a law authorizing RN to train volunteer school personnel to administer Diastat and the student has a physician order to administer Diastat; the RN can train the school volunteer.

   Thanks for the question   Janette Wackerly, MBA, RN Supervising Nursing Education Consultant

Training

The courts have always held up licensed acts cannot be delegated unless there is statutory authority.

This Supreme Court Decision argues there is statutory authority in the Education Code.

The Supreme Court Decision also argues medical exception.

Physician Orders

Most RNs are aware of their responsibility to supervise care provided by subordinates and to use judgment in delegating functions to them; …... incidents usually fall into one of three categories:

delegation of tasks beyond the competence of a worker, delegation of functions outside the legal scope of

practice of a worker, or failure to assume responsibility when a worker

questions the appropriateness of care to be provided. Consider your own performance in respect to these categories as they are discussed here.

Supervision Defined by BRN

(a) It is the intent of the Legislature that the governing board of each school district and each county superintendent of schools maintain fundamental school health services at a level that is adequate to accomplish all of the following: (1) Preserve pupils' ability to learn. (2) Fulfill existing state requirements and policies regarding pupils' health. (3) Contain health care costs through preventive programs and education.

(b) The Legislature finds and declares that the provision of these services may be in jeopardy due to the current caseloads in the public schools, and that failure to maintain adequate health services and standards will result in pupils' poorer health and ability to learn.

Section 49427 Education Code

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