Legal and Ethical Considerations

1. Legal and Ethical Considerations Valarie Waldmeier, PhD, APRN, FNP-BC School of Nursing and Allied Health

2. Objectives • Discuss challenges nurses face when providing care in the school setting • Discuss La. Administrative Code and how to utilize it to guide clinical practice. • Discuss legal and ethical considerations pertinent to the school nurse

3. Who is the “School Nurse” • In Louisiana, there are registered nurses (RNs) and licensed practical nurses (LPNs). There is also the certified nursing assistant ("CNA"). Louisiana state law requires each city and parish school system to employ at least one "school nurse" certified by the State Board of Elementary and Secondary Education (BESE) at a ratio not to exceed 1,500:1. • This “School nurse” is a Registered Nurse. • 2012 – Escamilla, Poneck, & Cruz LLP per LA R.S 17:29 (A)

5. School Nurse • shall supervise the implementation of the school policies for the administration of medications in schools to insure the safety, health and welfare of the students. • The school nurse shall be responsible for the training of non-medical personnel who have been designated by each principal to administer medications in each school. The training shall be at least six hours.

6. RN Major Responsibilities

7. challenges in the school setting • Variance in paperwork to document care • Communicating with parents / legal guardians regarding a student receiving medication at school / care • Changes in medication Regimen • Required paperwork & signatures from PCP and parents • Amount of medication allowed at school • Disposal of medication • (ADHD)

8. challenges in the school setting • Delegation to licensed and unlicensed personnel • Code speaks to ensuring the RN has documented evidence of Training reflective of Noncomplex skills.

9. Code Location www.lsbn.state.la.us/NursingPractice.aspx Code Location is found at the LSBN website

10. LA. Administrative Code • The La. State Board of Nursing recognizes that assessment, planning, intervention, evaluation, teaching and supervision are the major responsibilities of the RN in the practice of nursing. • The code still speaks of Nursing diagnoses, goals, & expected outcomes. • The plan of care is to be documented, list priorities for nursing action, and nursing actions are consistent with stated plan. • There are 7 Standards

11. Standard 1 collecting and Recording Individual’s Health Status • Data must be “systematically and continuously collected...” • Look at your documents, do they address growth and development ? • Are you charting re-assessment? • Is there a place on your form to chart re-assessment?

12. Documentation is Key • Documentation includes, but is not limited to, written records that attest to the care provided to patients based on assessment data and the patient's response to the intervention.

13. Close the Loop in documentation • Make sure that your school documentation includes all the elements as outlined by the code; the RN is responsible. • ABD pain? Did you document auscultation in all 4 quads? • Did you administer an antipyretic? Acetaminophen? Did you recheck and chart the reduced fever or pain? • Must reassess within 45 minutes

14. Standard 2: Analysis of Health Status Data • Nursing Diagnoses, care goals, expected outcomes • Nursing Care Plans

15. Standard 3: Priorities and actions for Nursing care • Must be individualized and reflect prioritization • Based on scientific knowledge and nursing practice • How are you staying up to date on evidence based practice? • Journals, conferences?

16. Standard 3: Priorities and actions for Nursing care • Must have appropriate resources • Plan is developed with the individual, family, pertinent others, and to health personnel as appropriate. • DOCUMENTED Plan • Plan provides for continuity of care

17. Standard 4implementation of nursing care plan • How is the Nursing Care plan Evaluated? • Must be consistent • Interventions are implemented safely • Are your providers adequately trained? • Interventions are documented by written records, observation of nursing performance, report of nursing action by the individual and/or pertinent orders

18. Standard 5evaluation of nursing care plan • Evaluation is systematic and ongoing • What we do is cyclic; not linear • Use current data • Vital Signs, pain scale • Family participation is encouraged in the evaluation of the established goals • Student response is compared with observable outcomes

19. Standard 6continuous process of reassessment and modification • If you find you need to modify your care – it is okay… the code states “revise diagnoses, outcomes, and the plan of care, as needed’

20. Standard 7 professional performance • Every nurse must maintain professional performance and you must maintain current knowledge in nursing practice.

21. Code Interpretation Sometimes we all need further explanation of the Code

22. Legal and ethical Issues • Dr. Anita Fields requested clarification of delegation by school nurses of certain specific nursing procedures to the classroom teacher for the severely and profoundly handicapped child. • July 25, 1985

23. Response • The response came directly from the code.

24. Response #1 • “ Registered Nurse may delegate non-complex tasks to unlicensed nursing personnel, provided, however that the registered nurse has evaluated both the patient's condition and the competency of the unlicensed person, and provided that these evaluations show that the criteria for delegations are met. .. the expertise of a registered nurse is necessary for the determination of whether a task is complex or non-complex in a specific situation.”

25. response#2 Invasive nursing procedures may be delegated to classroom teachers if the procedures can be defined as non-complex tasks. A noncomplex task can safely be performed according to exact directions, with no need to alter the standard procedure and results are predictable. Suctioning a tracheostomy is complex.

26. Delegation to other nursing personnel • Tracheostomy suctioning is complex in some situations and can be non-complex in other situations, depending upon the patient's/ client's condition. • [In life threatening situations (life threatening) the rules of the board do not apply] • A Registered Nurse may delegate non-complex tasks to unlicensed personnel, provided, however that the RN has evaluated both the patient’s condition and the competency of the unlicensed person.

27. legal and ethical considerations pertinent to the school nurse • With regard to delegation, the code is pretty clear. • “The RN retains the accountability for the total nursing care of the individual. The RN is responsible for an accountable to each consumer of nursing care for the quality of nursing care he or she receives, regardless of whether the care is provided solely the RN or by the RN in conjunction with other licensed or unlicensed assistive personnel.”

29. Delegation parameters • (a). The person has been adequately trained for the task. • (b). The person has demonstrated that the task has been learned. • (c). The person can perform the task safely in the given nursing situation. • (d). The patient's status is safe for the person to carry out the task. • (e). Appropriate supervision is available during the task implementation. • (f). The task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all.

30. Delegation • The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e., when the following three conditions prevail at the same time in a given situation: • (a). nursing care ordered and directed by R.N./M.D. requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and • (b). change in the patient's clinical conditions is predictable; and • (c). medical and nursing orders are not subject to continuous change or complex modification

31. Not up for delegation • (a). administration of investigational drugs; • (b). administration of cancer therapeutic drugs; • (c). administration of medications by IV push, other than those defined by health agency protocol for emergency situations; • (d). administration of blood and blood products; • (e). administration of total parenteral nutrition solutions; • (f). accessing the implanted device:

32. Medication Administration • Registered nurses employed in the public school system are authorized to execute health care regimens prescribed by physicians licensed in adjacent states, pursuant to R.S. 17:436(B)(3)(a) and R.S. 17:436.1(B)(1)(a).

33. Medication Administration • it is the responsibility of the registered nurse to ascertain the competency of the persons to whom (s)he delegates the administration of medication. • R.S. 37:1021 et seq., provides for medication administration to certain persons with developmental disabilities; R.S. 17:436.1 provides for medication administration in the public school system.

34. Medications • All medications including both prescription and non-prescription. • All medications shall be stored in a secured locked area or locked drawer with limited access except by authorized personnel

35. Medication administration • Only oral, inhalant, topical ointment for diaper rash, and emergency medications shall be administered at school by unlicensed personnel. • E. Each student shall be observed by a school employee for a period of 45 minutes following the administration of medication. This observation may occur during instruction time. • F. School medication orders shall be limited to medications which cannot be administered before or after school hours.

36. Take Away for nursing practice • Document up to date training of licensed and unlicensed personnel • Teachers • LPN • CNA • Make sure your practices are current • Monitor the LSBN and Department of Education’s Resource Handbook for School Nurses and School Administrators • When in doubt, ask the LSBN to give you an Declatory Statement of Practice.

37. References • In 1985 – Dr. Anita Fields of MSU http://www.lsbn.state.la.us/Portals/1/Documents/Opinions/npop85.11.pdf • In 1990 – Delegation to an LPN was presented at the BON http://www.lsbn.state.la.us/Portals/1/Documents/Opinions/npop85.11.pdf • http://www.lsbn.state.la.us/Portals/1/Documents/Opinions/npop83.01.pdf • https://www.louisianabelieves.com/docs/default-source/public-school/2014-school-nursing-handbook.pdf?sfvrsn=6 • http://www.lsbn.state.la.us/ • http://www.charterschooltools.org/tools/LouisianaSchoolHeathIssues.pdf 2012 – Medical issues facing Louisiana’s public schools: What are school nurses, teachers, and administrators to do?