Transcript Scope of Practice and Telehealth Nursing: 2005/2006 Update Carol Rutenberg, RNC, MNSc AAACN 31st Annual Conference.

Scope of Practice and
Telehealth Nursing:
2005/2006 Update
Carol Rutenberg, RNC, MNSc
AAACN 31st Annual Conference
Outcome Objectives
At the completion of this presentation, the participant
will be able to:
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recognize regulatory telehealth nursing practice
issues
articulate issues related to state’s scope of practice
identify problems relative to scope of practice in
your state
develop strategies to address areas of deviation
from scope of practice in your clinical setting
Practice
Standards
Standards
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Regulatory
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Organizational Policy
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Professional
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Accreditation
Standards
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REGULATORY
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Organizational Policy
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Professional
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Accreditation
Telenursing:
A Challenge to Regulation
Telenursing is defined as the practice of
nursing over distance using
telecommunications technology.
National Council of State Boards of
Nursing recognizes nursing practice
provided by electronic means as the
practice of nursing and, thus, asserts
that it is regulated by the boards of
nursing.
National Council of State
Boards of Nursing (1997)
Nurse Practice Act
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State LAW, so it can’t be “ignored”
There are 50 of them
(and they’re all different)
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Federal laws supersede state laws
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Department of Defense (Military)
Veteran’s Administration
Indian Health Services
Legal Authority
Board of nursing exists to protect the public
 Nurse Practice Act
 Rules and Regulations
 Position Papers / Declaratory Rulings
 FAQs
 Correspondence / Minutes
Nurse Practice Issues
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Interstate Practice / Licensure
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Scope of Practice
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(Recommendation of medications)
Role of LPNs and UAPs
Interstate Compact for Mutual
Recognition of Nurse Licensure
February, 2006
www.ncsbn.org
Interstate Practice Issues
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Permanent residents
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88% (43/49) require licensure in their state
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Excluding
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HI
KY
NH
Silent
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IN
PA
WI
Interstate Practice Issues
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Permanent residents
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“Snow birds”
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80% (39/49*) require licensure in their state
Vacationers / Business travelers
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88% (43/49) require licensure in their state
59% (29/49*) require licensure in their state
Established relationship (eg Drs. Office)
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31% (15/49**) make an exception in this case
* 3 silent
** 4 silent
20 States + NJ (pending)
Considering Interstate Compact:
7 (+ 21 = 58%)
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“Soon”
 Colorado
 Florida
 Illinois
 Kentucky
 Massachusetts
 Minnesota
 Montana
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Unknown
 Michigan?
No Plans (21)
State Attorney General
Opinions/Interpretive Documents
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State Attorney General Opinions
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Kansas
Maryland
Nebraska
Wisconsin
Interpretive Documents
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California
http://nursingworld.org/gova/state/attgen99/index.htm
retrieved 4-2-05
Canada:
Locus of Accountability
“Nurses engaged in telepractice
are considered to be practising
in the province/territory where
they are located and currently
registered, regardless of where
the client is located.”
CNA Position Statement, The role
of the nurse in telepractice 2000
Recommendation of Meds
1999
2001
2005
7 to 9
32
--26
11
31
--21
15/49
39/49
29/49
23/49
RN
OTC (w/out protocol)
OTC (with protocol)
Refill Prescriptions
Prescription
LPN/LVN
OTC (w/out protocol)
OTC (with protocol)
15
13
11
9
Refill Prescriptions
Prescription
5/49
22/49
20/49
15/49
Recommendation of Meds
1999
2001
2005
14-18%
64%
--52%
22%
62%
--42%
31%
80%
59%
47%
RN
OTC (w/out protocol)
OTC (with protocol)
Refill Prescriptions
Prescription
LPN/LVN
OTC (w/out protocol)
OTC (with protocol)
30%
26%
22%
18%
Refill Prescriptions
Prescription
10%
45%
41%
31%
Policy on Telehealth Nursing:
16/49 (33%)
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Arkansas
California
Iowa
Kentucky
Massachusetts
Minnesota
Mississippi
North Dakota
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New Hampshire
Nevada
Oklahoma
South Carolina
South Dakota
Texas
Wisconsin
Wyoming
RNs, LPN/LVNs, and UAPs
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Independent scope of practice
Nursing process
Not licensed to assess independently
 (so can they do telephone triage?)
Works under supervision of RN or MD
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47% (23/49) yes
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1 independently (Massachusetts)
22 under supervision
47% (23/49) no
6% ( 3/49) silent
Policy on LPNs and Telenursing:
11/49 (22%)
Arkansas
 Massachusetts
 Minnesota
 Mississippi
 New Hampshire
 Nevada
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 New
York
 Texas
 Vermont
 Wisconsin
 Wyoming
RNs, LPN/LVNs, and UAPs
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RN
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Independent scope of practice
Nursing process
LPN / LVN
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Not licensed to assess independently
 (so can they do telephone triage?)
Works under supervision of RN or MD
________________________________________________________________________________________________________________________
 uap
Widely variable education/training
Does triage under license of MD
Captain of the Ship Doctrine
“Legal doctrine that, when applied to medical
malpractice, holds doctor liable for the actions
of others, such as nurses, attendants, and
other staff.” (Bogart, p. 640)
“Borrowed Servant” may apply in cases in which the UAP is an
employee of the organization but under the control of the
physician.
Bogart, J. B. (ed.), (1998). Legal Nurse Consulting Principles &
Practice. American Association of Legal Nurse Consultants.
Policy on UAPs and Telenursing:
20/49 (41%)
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Alaska
Arkansas
California
Connecticut
Idaho
Kansas
Kentucky
Massachusetts
Maine
Minnesota
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Mississippi
Montana
North Carolina
North Dakota
New Jersey
Nevada
Rhode Island
South Carolina
West Virginia
Wyoming
Group Practice
Manager or Board
Medical
Director
Medical Staff
Office
Manager
Nursing
Director
Nursing Staff
(RNs & LPNs)
Medical
Assistants
Telephone
Triage Director
Nursing Assistants
Clerical
Personnel
Telephone
Triage Nurses
So Where Do I
Go Now?
“…has legal action been taken against nurses
re telephone nursing practice in your state?”
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Related to Interstate Practice
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Kansas
Nevada
Not related to Interstate Practice
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Minnesota
Wisconsin
Act in the Patient’s Best Interest!
Nursing Process
Assess
Plan
Implement
Evaluate
USE THE NURSING PROCESS!
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Do a thorough assessment
Diagnose urgency (clinical judgment)
Develop the right plan (based on protocol,
context, patient preference/critical thinking)
Facilitate implementation of the plan
Evaluate to be sure you know if the
patient doesn’t get better
Nursing Process
Assess
Evaluate
Plan
Implement
So What Can You Do?
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Interact with your Board of Nursing about issues
related to telephone triage.
Join a professional organization & get involved.
Stay informed of new developments (read,
network, assume responsibility).
So What Can WE Do?
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Be certain our standards address these issues
clearly
Are there policy statements that we need to
construct?
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Re interstate practice and the Compact?
Re UAPs (specifically medical assistants) and their
role in telephone triage?
[email protected]
501-767-4564
www.telephone-triage.com