NURSE PRACTICE ACT
PROFESSIONAL ORGANIZATIONS - RESOURCES TO SUPPORT STANDARDIZED PROCEDURES
-American Nurses Association Scope and Standards of Practice -Specialty professional organizations also have scope and standards of care -Offer position statements on complex or high risk issues -Provide resources and continuing education
BRN & NURSE PRACTICE ACT
-BRN - contained within the California Business and Professions Code -CA Code of Regulations - CCR Title 22 Patient Classification Systems/Nurse-Patient Ratios -CCR Title 16 Standards of competent performance -Defines nursing practice -Defines advanced practice and public health nurse roles *http://www.rn.ca.gov/pdfs/regulations/npr-b-53.pdf*
RN LICENSURE & NURSE PRACTICE ACT
-Boundaries for practice are defined in the NPA of each state; defines how nursing is regulated in that jurisdiction -Remember that nursing licensure is a *privilege* and not a right -Since the mandatory NPA was passed in N. Carolina in 1903, nursing has been legislated, directed, and controlled to some extent
ENFORCEMENT PROGRAM
-Complaint intake: Pt care Fraud Criminal conviction Sexual misconduct Mental illness Substance abuse -Investigation -Legal Action -Probation Monitoring
STANDARDIZED PROCEDURES DEFINED
-Developed by organized health system -Must be in writing, signed, and dated -Must clearly state specific functions to be performed -Clearly state requirements to be followed -Specify experience, education, or training required -Describe initial and ongoing competency validation process -Maintain written record of those authorized to perform -Specify scope of supervision required and immediate reporting/communication requirements -State limitations on settings -Provide for periodic review
INTERIM PERMIT
-Eligible after graduation -Not renewable; in effect from 6 months of the date issued or until NCLEX-RN exam resulted, at which time the interim permit is null and void -Use "I.P." designation -Practice under direct supervision of RN: Must be present at all times care is rendered RN may delegate nursing duties taught in nursing school that the permittee is capable of performing
ABANDONMENT DEFINED BY CA BRN
-Having first accepted the patient assignment, thus establishing a nurse-patient relationship, and then -Severed that nurse-patient relationship without giving reasonable notice to the appropriate person (e.g., supervisor) RNs must exercise critical judgment regarding ability if fatigued to provide safe patient care when declining or accepting requests to work overtime; Refusal to work additional hours or shifts would not be considered patient abandonment by the BRN. (BRN has no jurisdiction over employment and contract issues)
KNOW YOUR STATE NPA & RESOURCES/SUPPORT TO REVIEW AND INTERPRET
"NURSES WHO ARE AWARE OF THEIR RIGHTS AND DUTIES IN LEGAL MATTERS ARE BETTER ABLE TO PROTECT THEMSELVES FROM LIABILITY AND LOSS OF LICENSURE."
CA TITLE 22 NURSE-PATIENT RATIOS IN A NUT-SHELL
-Hospitals to provide staffing by licensed nurses, within scope of licensure in accordance with nurse-to-patient ratios. Licensed nurse = registered nurse, licensed vocational nurse and, in psychiatric units only, a licensed psychiatric technician -Hospital shall NOT assign a licensed nurse to a nursing unit or clinical area unless hospital determines that nurse has demonstrated current competence in providing care in that area, AND received sufficient orientation to provide competent care -Licensed nurse-to-patient ratios represent max # of patients assigned to one licensed nurse. "Assigned" means the licensed nurse has responsibility for the provision of care to a particular pt within scope of practice
PROGRAM COSTS AND TIME REQUIREMENTS
-How much does it cost to participate in the BRN's Diversion Program? Nurses pay $25.00 per month to help defray the cost of the Program when the RN is accepted. In addition, participants must pay for any costs related to their rehabilitation plan; drug testing, treatment, psychiatric or medical evaluations, and nurse support group attendance. -How long will RN be in the Diversion Program? The average length of time is 2 to 4 years for RNs to successfully complete the program
LVN PRACTICE SCOPE
-Monitor patients' health; VS -Administer non-IV medications -Administer basic nursing care; Drsg. Changes & catheter insertions-GU or IV -Provide basic comfort; ADLs -Discuss health care w/patients, listen to concerns -Report patients' status to RNs/MDs -Keep records on patients' health -Experienced LVNs oversee and direct other LVNs & UAPs
CONTINUING EDUCATION
-Must be completed with a board approved provider (concurrent enrollment programs [CEP], American Nurses Credentialing Center [ANCC], other BRN providers) -Must be relevant to practice of nursing -Enhance knowledge at level above basic nursing licensure requirements -Cannot repeat corse with similar content in same renewal cycle -Must maintain proof of completion of CE for at least 4 years - always be prepared for audit
BRN
-Nine Board Members: 4 public, 5 nurses (2 direct care, 1 APRN, 1 administrator, 1 educator) -Seven appointed by Governor; 2 by legislature -Serve 4 year terms (not more than 2 terms) -Set RN educational standards -Approve CA nursing programs -Issue and review licenses and certifications -Investigate complaints and take disciplinary action against nursing license -Manage diversion program -Maintain online license verification
USING THE "RN" TITLE
-No person shall engage in the practice of nursing, as defined in Section 2725, without holding a license which is in an active status -Every licensee may be known as a registered nurse and may place the letters "R.N." after his or her name
STANDARDS OF RN PRACTICE
-Nurse Practice Act -American Nurses Association (ANA) Scope and Standards of Practice -ANA Code of Ethics -Professional Specialty Organizations -Evidence Based Practice Sources
DIVERSION: NURSES WHO ARE INELIGIBLE
-Previously been disciplined by the Board for chemical dependency or mental illness, -Been terminated previously from this program or other state's diversion program for non-compliance -Sold drugs -Caused patient harm or death.
CA TITLE 22 → PT CLASSIFICATION SYSTEM → ACKNOWLEDGES NURSE WORK INTENSITY!
-Pt classification system; establish staffing requirements by unit, patient, and shift = predict nursing care requirements "GRASP" = EB, acuity, workload solutions (Grasp Reynolds Application and Study of PETO) -Evaluation amount of nursing care needed for each patient category; validate each unit/shift R/T trends/patterns of nursing care delivery -Address nursing care needed, R/T patient category, care delivery pattern; annual data, populations, skill mix, staff allocation, or patient care delivery model
CA TITLE 16 STANDARDS OF COMPETENCE AND PERFORMANCE
-RN considered to be competent when demonstrates ability to transfer scientific knowledge from social, biological, and physical sciences in applying the nurses process -Interim permittee (IP) requirements to practice under the direct supervision of an RN [IP # assigned post-graduation - residency programs know this is pending]
THE BRN PROTECTS CITIZENS BY:
-RN licensing -Monitoring of RN educational standards -RN continuing education oversight -Discipline of RNs -Regulatory agency → *role is to protect the public (consumer) - under CA dept of consumer affairs
BASIS FOR RN SCOPE AND LICENSURE
-RN scope and licensure is defined by *state law* -Each state has a NPA and a method for initial and continuing licensure -Requirements for licensure and scope vary slightly between states; multiple state licenses = mutual recognition model or endorsement process
RN PRACTICE SCOPE
-Record medical Hx and symptoms -Administer medications and treatments -Set up/revise POC -Assess patients and record -Consult w/MDs, & other HC professionals -Operate/monitor medical equipment -Help perform diagnostic tests and analyze results -Teach patients/families DZ mgmt. -DC Teaching
MAINTAINING LICENSURE
-Renewed after 2 birth years (last day of month following birth date) then every 2 years -Must complete 30 hours of board approved continuing education (exempt for first renewal and may apply ongoing college nursing units) -Must submit renewal form and fee (on time) -Must report any convictions or discipline by regulatory body -Must report changes in name or address to the BRN within 30 days of change
NURSE PRACTICE ACT
-The NPA is a legal instrument; defines functions of nursing and sets standards for licensure -Grants a nurse the authority to carry out those functions -Each state has its own NPA, but all must be consistent w/ provisions or statues established at the federal level
HISTORY OF NURSING REGULATION
1800s - Nightingale schools and publications 1896 - First nurse convention 1903 - North Carolina first state to enact Nurse Practice Act (NPA) 1911- America Nurses Association (ANA) was established 1923 - All others states have NPA Licensure regulations 1930s-1950s; nursing was narrowly defined 1970s - Advanced practice roles
ADVANCED PRACTICE NURSES (APNs)
Clinical Nurse Specialist Nurse Practitioner Certified Nurse Midwife Certified Nurse Anesthetist Must have stricter professional liability insurance due to their specialties = risk
CA DIVERSION PROGRAM
Alternative to traditional disciplinary process. Allows for treatment of RNs licensed and living in CA who: -Are mentally ill or display alcohol or drug abuse to the extent that their nursing practice may be affected -*Voluntarily* agree to enter the program and provide consent for appropriate medical or psychiatric evaluations
REVIEW
CA NPA Document: http://www.rn.ca.gov/pdfs/regulations/npr-i-15.pdf National Council of State Boards of Nursing [NCSBN] Licensure Brochure: https://www.ncsbn.org/Nursing_Licensure.pdf 2014 Survey of CA RNs PPT: http://www.rn.ca.gov/pdfs/forms/survey2014pp.pdf
MANDATORY REPORTING
California registered nurses have multiple reporting requirements for known or suspected abuse and/or neglect including: -Certain injuries - violence, physical abuse -Child abuse and neglect -Elder or dependent adult abuse/neglect Requirements http://www.rn.ca.gov/pdfs/regulations/npr-i-23.pdf
LICENSES IN CALIFORNIA
BRN oversees RNs licensed in CA including: -Certified Nurse Anesthetist (CRNA) -Certified Nurse Midwife (CNM) -Clinical Nurse Specialist (CNS) -Nurse Practitioner (NP) -Public Health Nurse (PHN)
DISCIPLINE/REVOCATION
Nurse is found to be in violation of the Nursing Practice Act - final decision can be to: -Revoke or suspend the license -Accept surrender of the license -Place the nurse's license on probation -Cite & fine
DELIGATING TO UAP
Potential Risks: -Liability for negligence -Issues for task delegation - Job description, knowledge base, demonstrated skills -Responsibility for pt outcomes COST - UAP can free professional nurses from tasks and assignments that can be completed by less well-trained personnel at a lower cost Increases the scope of liability for the RN RN may be liable if they were negligent in the supervision of those employees at the time they committed the negligent acts. Liability based on a supervisor's failure to determine which patient needs could safely be assigned to a subordinate or for failing to closely monitor a subordinate who requires such supervision. In assigning tasks to UAP, then the RN must be aware of the UAP job description, knowledge base, and demonstrated skills of each person. UAP training is not federally monitored through standards and community standards are also not established. What are the job descriptions for UAPs in the area you are doing your clinical precepting, did you observe the role of your preceptor nurse in terms of delegation. IDEAL: UAPs may complete tasks, measure VS, I & O and other indicators, but RN who analyzes the data for comprehensive assessment ND and the plan of care. RN is responsible for pt assessment, diagnosis, care planning and evaluation. UAP may perform simple nursing interventions related to hygiene, nutrition, elimination or activity but the RN remains responsible for patient outcomes. Not independent thinking tasks.
DELEGATION
RNs must know limit of scope for health care partners May not delegate to UAP (or supervise) the following: -Administration of medication -Venipuncture or intravenous therapy -Parenteral or tube feedings -Invasive procedures including inserting nasogastric tubes, inserting catheters, or tracheal suctioning -Assessment of patient condition -Educating patients and their families concerning the patient's health care problems, including post-discharge care
RN SCOPE
Recognizes the existence of overlapping functions between physicians and registered nurses Includes but is not limited to: -Assessment and interpretation of clinical findings -Disease prevention and restorative measures -Administration of medications (with valid order) -Skin tests, immunizations -Withdrawal of blood -Implementation of standardized procedures
INITIAL LICENSURE - RN
Submit application including live scan Pay fees - RN, IP Eligibility letter for testing Pass National Council Licensure Examination (NCLEX-RN) May repeat if not passed (45 day provision)
SUPERVISION
The Board of Registered Nursing may discipline RNs working in a supervisory capacity for authorizing untrained persons or LVNs to perform tasks which they (the RN) knew or should have known lacked the competency to safely perform.
BRN MISSION STATEMENT
The Board of Registered Nursing protects the health and safety of consumers by promoting quality registered nursing care in the State of California. Accomplish this through: -Licensing registered nurses. -Approving nursing education programs. -Establishing and upholding competency standards. -Intervening with discipline and rehabilitation. -*Serving as the final authority in the interpretation and enforcement of the Nursing Practice Act*
STANDARDIZED PROCEDURES
Used when nurses are expected to perform duties that are not common within the standards of practice for nursing (usually medical practice).(e.g. conscious sedation, intubations)
ABANDONMENT
What is a patient abandonment? Know your Capabilities! http://www.rn.ca.gov/pdfs/regulations/npr-b-01.pdf
COMPETENCY CASE SCENARIO
You are working on a medical surgical floor and the physician writes orders to administer midazolam (Versed) and fentanyl as sedation for a bedside biopsy procedure. Should you administer these medications? What should I do? -Resource RN, Lead → Supervisor, -Agency policy and procedures -BRN position statements http://www.rn.ca.gov/pdfs/regulations/npr-b-06.pdf -Professional organization position statements https://www.ena.org/SiteCollectionDocuments/Position%20Statements/Archived/Procedural_Sedation_Consensus_Statement.pdf