Bringing Delegation into Practice: The How To’s A L A S KA D I V I S I

Bringing Delegation into Practice: The How To’s A L A S KA D I V I S I O N O F P U B L I C H E A LT H S C H O O L N U R S I N G / S C H O O L H E A LT H S E RV I C E S P R O G R A M OCTOBER 2015

Objectives Describe how approved delegation parameters can protect the school nurse’s practice and meet the health needs of students. Describe how the Medication Delegation Decision Tree is applied in practice. Differentiate the appropriate level of training needed for various scenarios in the school setting. Section of Women’s, Children’s & Family Health

Delegation Defined The act of transferring to a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains accountability for the delegation. National Council of State Boards of Nursing 2005 The ability of the nurse to transfer the responsibility of a nursing task to an unlicensed person while the nurse continues to be accountable for the outcomes. American Nurses Association 2007 Section of Women’s, Children’s & Family Health

Delegation Defined Delegation in school nursing is a complex process in which the authority to perform a selected nursing task is transferred to a competent unlicensed individual (UAP) in a specific situation. National Association of School Nurses The assignment of the performance of a nursing activity to a non-nurse. Accountability remains with the registered nurses; state laws and regulations and school regulations must be followed; and standards of school nursing practice must be upheld. ANA & NASN SN Scope & Standards of Practice Section of Women’s, Children’s & Family Health

The need for delegation R E AL IT The need for delegation of nursing tasks in the school setting is greater today than ever before more school nurse responsibilities limited number of qualified school nurses unfunded mandates budgetary concerns staffing patterns where school nurses cover multiple schools Federal and state requirements (e.g. IDEA, Section 504 and the American Disabilities Act) requiring school health services for complex student health needs Section of Women’s, Children’s & Family Health

Delegation Literature Delegation is a core nursing competency requiring critical thinking and nursing judgment that must be taught and practiced. (NCSBN, ANA, NASN School Nurse) Appropriately implemented delegation: Ensures safe efficient delivery of nursing tasks Frees the school nurse to attend to more complex student health care needs Enhances skill development for assistive personnel Promotes cost containment for schools Literature provides support for the contribution unlicensed assistive personnel make in schools when there is adequate training and supervision. Section of Women’s, Children’s & Family Health

How Do I Delegate Safely & Successfully? Five Rights of Delegation 1. Right Task 2. Right Person 3. Right Direction/Communication 4. Right Supervision 5. Right Circumstance Section of Women’s, Children’s & Family Health

How Do I Delegate Safely & Successfully? RIGHT TASK Within nurse’s scope of practice? Reasonably routine and predictable? Based on written medical orders? Repeated frequently? Performed according to established steps? Does not involve assessment, interpretation, decision-making? Section of Women’s, Children’s & Family Health

How Do I Delegate Safely & Successfully? RIGHT PERSON Who is immediately available to the student? Who is willing and competent to do the task at the required time? Section of Women’s, Children’s & Family Health

How Do I Delegate Safely & Successfully? RIGHT DIRECTION/COMMUNICATION How much training will be required? How many tasks will the unlicensed staff need to learn? What other duties does she/he have? Section of Women’s, Children’s & Family Health

How Do I Delegate Safely & Successfully? RIGHT SUPERVISION How much initial training is needed? What type of ongoing supervision will be needed? Onsite Periodic Episodic Section of Women’s, Children’s & Family Health

How Do I Delegate Safely & Successfully? RIGHT CIRCUMSTANCE Is the student particularly vulnerable? Is the environment safe for UAP to perform the delegated task as planned? Section of Women’s, Children’s & Family Health

How Do I Delegate Safely & Successfully? Requires school nurses to work with school administrators to develop and implement proper delegation polices and guidelines. Requires school nurses to develop comprehensive training and supervision protocol for UAP. Depends on the school nurse developing dynamic relationships with family members, administrators, the educational team and UAPs. Section of Women’s, Children’s & Family Health

How Do I Delegate Safely & Successfully? Requires school nurses to follow their scope and standards of practice. Requires school nurses to follow Alaska Board of Nursing delegation regulations. Requires school nurses to follow school district policies and procedures. School nurse accountability is for the quality of nursing care given to the student. Section of Women’s, Children’s & Family Health

Alaska Board of Nursing Regulations 12 AAC 44.950 – 12 AAC 44.975 http:// commerce.alaska.gov/dnn/cbpl/ProfessionalLicensing/BoardofNursing.as px Section of Women’s, Children’s & Family Health

Alaska Delegation Regulations 12 AAC 44.950. STANDARDS FOR DELEGATION OF NURSING DUTIES TO OTHER PERSONS Duty must be within scope of practice of delegating nurse Nurse must assess patient Patient’s medical condition must be stable/predictable UAP is competent to perform duty and person accepts delegation and accountability Duty does not require nursing judgment or complex nursing skills UAP receives written instructions Nurse will provide direction and supervision, including evaluation Delegation specific to UAP and student Nurse remains responsible for quality of nursing care Section of Women’s, Children’s & Family Health

Alaska Delegation Regulations 12 AAC 44.955. DELEGATION OF ROUTINE NURSING DUTIES Occur frequently Do not involve nursing knowledge or judgment Do not involve complex nursing skills Have standard procedure and predictable results Present minimal potential risk Section of Women’s, Children’s & Family Health

Alaska Delegation Regulations 12 AAC 44.960. DELEGATION OF SPECIALIZED NURSING DUTIES Duties that require more training and skill than routine duties: Changing simple dressings Assisting student with self-medication Obtaining blood glucose levels Suctioning oral pharynx Giving tracheostomy care (stable patients) Removing urinary catheters Adding fluid to gastrostomy tube feedings Develop a delegation plan. Evaluate onsite at least once every 90 days. Keep a record of the evaluations conducted. Section of Women’s, Children’s & Family Health

Alaska Delegation Regulations 12 AAC 44.965. DELEGATION OF THE ADMINISTRATION OF MEDICATION The administration of medication is a specialized nursing task that may be delegated to a school setting provider. The person must successfully complete a training course approved by the BON. Routinely scheduled oral, topical, transdermal, nasal, inhalation, optic, otic, vaginal, rectal medications may be delegated with written instructions PRN medications, other than controlled substances, may be delegated if the nurse assesses the student to determine if assessment is required before each dose. Injectables, PRN controlled substances, and medications given via gastrostomy tube are not delegable by a registered nurse Section of Women’s, Children’s & Family Health

Alaska Delegation Regulations 12 AAC 44.966. DELEGATION OF THE ADMINISTRATION OF INJECTABLE MEDICATION Injectable medications may be delegated only by an advanced nurse practitioner to a certified medical assistant Section of Women’s, Children’s & Family Health

Alaska Delegation Regulations 12 AAC 44.970. NURSING DUTIES THAT MAY NOT BE DELEGATED Nursing duties that require nursing knowledge or judgment or complex nursing skills may not be delegated. Section of Women’s, Children’s & Family Health

Alaska Delegation Regulations 12 AAC 44.975. EXCLUSIONS The provisions of nursing delegation regulations do not apply when nursing duties have not been delegated including when a person is acting under other legal authority (e.g., PARENTS) Section of Women’s, Children’s & Family Health

Alaska Delegation Regulations RECAP School nurses MAY delegate: Routine nursing duties such as taking vital signs and personal care tasks. Specialized nursing duties such as assisting a student with self-medication, obtaining blood glucose levels, oral pharynx suctioning, trach care, and G-tube feedings. Specialized nursing duty of routine oral, topical, transdermal*, nasal, inhalation, optic, otic, vaginal*, and rectal* medications. *routine administration of these medications in the school setting is rare Section of Women’s, Children’s & Family Health

Alaska Delegation Regulations RECAP School nurses may NOT delegate: Nursing assessment Individualized healthcare plan development and evaluation Health education or health counseling Receiving or transmitting healthcare provider orders Oral tracheal suctioning Medication management for unstable medical conditions NG tube feedings or medications G-tube feedings when newly placed, G-tube medications Injectable medications Non-herbal nutritional supplements PRN controlled substances Section of Women’s, Children’s & Family Health

Board of Nursing Medication Administration in the School Setting: Delegation Decision Tree approved and supported by the Alaska Board of Nursing April 2012 Section of Women’s, Children’s & Family Health

Medication Administration: Delegation Decision Tree Guidelines STEP 1 STEP 2 Step 3 Section of Women’s, Children’s & Family Health

Medication Administration: Delegation Decision Tree Guidelines STEP 2 Step 3 Section of Women’s, Children’s & Family Health

Medication Administration: Delegation Decision Tree Guidelines STEP 3 Section of Women’s, Children’s & Family Health

Medication Administration: Delegation Decision Tree Guidelines FINAL STEP (either path, whether school nurse or parent is delegating) Section of Women’s, Children’s & Family Health

Standardized Curricula AK Board of Nursing must approve training course in administration of medication that is used by registered nurse when delegating administration of medication. (12 AAC 44.965 (c). Section of Women’s, Children’s & Family Health

More Alaska Resources Medication Administration Training/Delegation Checklists: to assist in determining level of training needed in various situations, forms to include, evaluation and follow up required. Daily, frequent and/or emergency meds Field trips Extracurricular activities Section of Women’s, Children’s & Family Health

More Alaska Resources Department of Education & Early Development eLearning module: State of Alaska Medication Administration: Training for Unlicensed School Staff Register here: http://education.alaska.gov/ELearning/ Section of Women’s, Children’s & Family Health

Scenario Practice What process will you use to plan for the situation? What resources will assist you in your planning? What are the steps you will take? Is/are the medication(s) delegable by a school nurse? Is the delegation nurse-directed or parent-directed? What forms will need to be used? What other safety measures will need to be put in place? How often will you need to re-evaluate the trained staff person’s competency and further training needs? Section of Women’s, Children’s & Family Health

Scenario Practice: Scenario 1 Clem is a 13 year old seventh grader. She loves sports, and is planning on playing intramural basketball, which starts in two weeks. Intramurals at her middle school are held after school starting at 3:30, at which time the nurse is no longer in the building. Clem has diabetes. During the day, she is becoming more and more independent, but still has some pretty severe spikes and drops in her blood sugar. She uses an insulin pen, and checks her blood sugars independently. She’s pretty good at counting carbs, but not always right on her calculations, especially when her blood sugar is dropping and her brain is “fuzzy.” Mom and Dad both work and are not available to help until they pick Clem up after practice at 5:30 pm, but usually quick to answer their cell phones as long as they are in an area that has service. Glucagon is available in the nurse’s office, but that gets locked when the office closes at 3:30. The school secretary is there until 4:00pm. Section of Women’s, Children’s & Family Health

Scenario Practice: Scenario 2 There are 5 students in the school building with a history of allergies causing anaphylaxis that require immediate emergency Epinephrine administration in case of exposure and anaphylactic response. This elementary school is in a rural area and all parents work in the nearest city about 45 minutes from the school but the school has their cell numbers in case of emergency. Local EMS is staffed by volunteers and may take up to 20 min to respond. The school employs a half-time school nurse who works halftime at another school a distance away. This school has a rather high rate of staff turnover due to its remote location. Classes enjoy lots of hands-on nature activities and field trips are planned accordingly. Section of Women’s, Children’s & Family Health

Scenario Practice: Scenario 3 Sixth grade (11-12 year olds), end of school camping trip is scheduled for 3 days. Location: 30-45 minutes away via boat from any EMS. Phone service is available, but unsure of cell phone service. Camping facilities include in-door plumbing, bunk house style sleeping facilities). Adult assigned to each building. Kitchen fully equipped for home cooked meals served in the dining room; three meals with snacks in between. Sack lunches for the hiking day. Variety of activities might include: hiking around the island, playing on the beach, arts/crafts, games, etc. Adults include teachers, parents, and other adult volunteers. Camp site coordinator (not employed by school) is a registered nurse with school nurse and ER experience. Four students may need specialized care (asthma, anaphylaxis, prescription medications) Section of Women’s, Children’s & Family Health

Scenario Practice: Scenario 4 Jimmy is 6 years old and diagnosed with ADHD. His parents don’t believe in the use of Ritalin or other prescribed medications, and prefer to handle things “naturally.” After a visit to his family naturopathic doctor, he comes to school with some homeopathic drops in his backpack, which his mom told him to take to the office, since they only have a nurse on Friday. The office calls you and you are able to head over to assess the situation. The drops contain several herbs which were compounded specifically for him by his local natural foods store. The drops are labeled for him, and specify the dose he is to take orally and identify the different components. A folded piece of paper from the mom requesting that this preparation be given at school has directions stapled to it to give 2 drop of tincture to Jimmy at lunch every day signed by the naturopath. Section of Women’s, Children’s & Family Health

Scenario Practice: Scenario 5 Fred is in second grader at Rural Elementary School and has a seizure disorder. He has a Seizure Care Plan in place that requires PRN rectal diazepam for control of his seizures. The school has a nurse who is part-time, once a week. Fred has had only two seizures at school in the past year, but they often follow stressful situations or activities. Diazepam was used for the first, but not the second event. The class has several field trips planned with one coming up in a week. The mother works and cannot attend the trip with the class but can be reached by telephone in case of emergency and requests that someone be prepared to give Fred’s diazepam, if needed. Section of Women’s, Children’s & Family Health

Scenario Practice: Scenario 6 Charlene and Diane are in 2nd and 3rd grade respectively and have signed up to participate in the school sponsored cross country ski program. They both have asthma and have current Asthma Action Plans in place with PRN albuterol inhalers locked up in the nurse’s office. Neither have permission to self-administer their asthma medicine but both do know when they need their inhalers and respond well to treatment. The ski program lasts 2 months, is from 3:00-4:00pm on Monday and Wednesday afternoon, and they go from the school on a 3-5 mile ski route then are picked up by the parent at a secondary location. The responsible staff carries a cell phone but the cell reception is sketchy while they are on the route. Section of Women’s, Children’s & Family Health

Scenario Practice: Scenario 7 The local Charter School, New Beginnings, is a growing school that has attracted many families with its “can-do” attitude. The school has 445 students but only a part time nurse, once a week. There are 7 students who need meds during the day. 4 students take Ritalin at school, 2 for inhalers before PE/Recess, and 1 for a long term cardiac problem. On occasion, students have brought in antibiotics and other short term medications. The teachers and staff are fairly experienced and are dedicated to student achievement and working as a team. The school secretary is the glue holding the school together but is quite busy with multiple assignments and cannot possibly take on another task. Section of Women’s, Children’s & Family Health

Scenario Practice: Scenario 8 You are a nurse at the Last Frontier Elementary School as well as the middle school. Once a month you also must travel to an outlying school with 30 students. You have arranged your workload to prioritize the elementary school in the mornings leaving for the middle school at 12:30 pm. Your travel day is flexible. In the elementary school two 1st grade students, Alicia and Stephanie, have Type 1 diabetes. Stephanie’s blood sugars are well controlled. Alicia has frequently documented blood glucose in the 50-60 mg/dL range but she responds well to treatment. Neither students are able to count their carbs and both have insulin pumps. Several field trips are planned for spring and both Alicia and Stephanie’s parents work full-time and cannot attend these functions. Section of Women’s, Children’s & Family Health

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