School Nurse Supervision of LVNs & Health Clerks

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1 School Nurse Supervision of LVNs & Health Clerks ACSA Every Child Counts Symposium January 2015 Susan Chaides, MEd, RN, CPNP

2 California Ed Code The governing board of any school district shall give diligent care to the health and physical development of students, and may employ properly certified persons for the work.

3 Diligent Care Handle health and medical needs of students Fully support Free and Appropriate Public Education (FAPE) Follow state & federal laws, including nursing licensure

4 School Nurse Legally recognized school health authority Authority to recognize qualifications & abilities of UAP*/LVN assigned to perform health care tasks in school *UAP = Unlicensed Assistive Personnel

5 Legal Considerations for Federal Regulations Nurses State Laws & Regulations (Business & Professions Code, Education Code) Job Description Nursing Standards Complex Legal & Clinical Issues

6 Goals of School Health Enhance Learning Achievement Increase Health & Safety Improve Attendance Improve Quality of Life Prevention of Illness Control Contagious Diseases

7 CEC School Nurse Role Immunization compliance Assess, evaluate, interpret health & developmental status Design & implement health plan Refer resources for services Maintain communication (case management)

8 CEC School Nurse Role Interpret medical & nursing findings & make recommendations Consult, conduct trainings, & serve as resource to staff on health instruction Assist parents/students to access health care

9 CEC School Nurse Role Counsel students and parents Assisting in utilizing health care services Counseling regarding health-related attendance problems Helping understand & adjust to physical, mental and social limitations Exploring attitudes, information & values which affect health behavior

10 Roles & Responsibilities of the Credentialed School Nurse Health Assessment Case Management Health Counseling Health Education Health Screenings Health Care Prevent/Control Communicable Diseases

11 Assist School Nurse Health Clerk Role First aid- ill & Injured students Maintain files, reports, referrals Communication Specialized Physical Health Care Services Prepare reports Clerical duties

12 Assist School Nurse LVN Role Same duties as HC SPHCS Basic assessments LVN job description Administer meds - injections Basic nursing care

13 Performed Only by an RN Perform comprehensive assessment Identify goals derived from nsg diagnosis Validate assessment data Determine nsg plan of care Formalize nursing diagnosis Evaluate effectiveness of nsg care provided

14 RN / LVN Relationship Prior to assigning SPHCS to LVN, RN must conduct assessment LVN works under direction of RN (B&P Code 2859) Data collection done by RN, may be done by LVN (basic assessment Title 16, 2518) LVN must report data to RN

15 RN / LVN Relationship RN - analysis, synthesis & evaluation of data Can only be done by RN Cannot be delegated to LVN or UAP LVN - not determine educational (health) needs of patient Does not educate patient/family Contributes to development & implementation of teaching plan related to self-care for patient

16 RN / LVN Relationship RN must directly observe patient, analyze, synthesize, & evaluate data collected by him/herself and LVN RN uses data to: - Make nursing diagnosis - Determine appropriate interventions - Make appropriate assignments of tasks

17 RN / LVN Relationship LVN does not initiate, evaluate, or change patient s treatment/nursing care plan (NCP = IHP) LVN: Participates in planning Executes interventions as per treatment/ncp Contributes to evaluation of interventions r/t treatment/ncp

18 RN / LVN Relationship LVN can monitor patient Only RN can manage patient RN decides appropriateness of assignment of tasks, based on nursing judgment

19 LVN District Employee Health Office Staff Health Care Aide assigned to a particular student(s) Agency LVN Contracted by District Provided by parent

20 Health Office Staff Certificated Staff School Nurse (RN) - credentialed Classified Staff RN not credentialed LVN UAP Health clerk, aide, CNA, MA

21 Staff Credentialed School Nurse Licensed RN Bachelor s degree Credential in School Nursing Many have master s degree 5-6 years of education Registered Nurse Licensed RN 2-4 years of education

22 Staff Licensed Vocational Nurse Licensed LVN months of training Entry level healthcare provider Unlicensed Assistive Personnel (UAP) Not licensed Health clerk/aide, CNA, MA Trained in CPR & first aid

23 Continuum of Health Care Medically Stable, Not Complex UAP LVN SN, RN Medically Fragile, Complex

24 Mandate Who Can Provide Credentialed SN RN LVN UAP Minor First Aid Yes Yes Yes Yes Assessment & Mgmt of Trauma General Health Assessment Yes Yes Limited No Yes Yes Basic, Vital signs Vision Yes No No No Hearing Yes No No No Scoliosis Yes No No No IHPs, ECPs Yes Yes, maybe No No No SPHCS Train, supervise Yes No No No SPHCS Direct Care Yes Yes, if supervised by SN 2015 Los Angeles County Office of Education Yes, if supervised by SN Yes, if supervised by SN

25 2015 Los Angeles County Office of Education Mandate Medication Train, supervise Medication Administration Who Can Provide Credentialed SN Yes (program) RN LVN UAP No No No Yes Yes Yes, if supervised by SN Yes, if volunteer/ No Special Ed, SST Yes No No No Section 504 Assessments Maintain student health records Yes No No No Yes Yes Yes Yes Health Education Yes Yes, maybe No No

26 Mandate Who Can Provide Credentialed SN Crisis Response Yes Yes (follow written plan) RN LVN UAP Yes (follow written plan) Yes (follow written plan) Child Abuse Yes Yes Yes Yes Communicable Disease-Prevent & Control CHDP & Oral Health Assessment Yes Yes, and interpret Yes, Limited Limited No, Limited Yes Yes Yes Case Mgmt Yes Yes, maybe No No Referral & Follow-up Health Counseling Yes May assist SN May assist SN May assist SN Yes Yes No No

27 Utilization of Qualified Designated Personnel CEC Any student with exceptional needs who requires SPHCS Be assisted by credentialed SN or certified PHN Or be assisted by qualified designated school personnel Perform services under supervision of SN, PHN, or MD

28 Utilization of Unlicensed Assistive Personnel (UAP) NPA does not give RN authority to delegate nursing tasks & functions which require substantial knowledge and skills to unlicensed persons Authority for UAPs to provide SPHCs is conferred by Ed Code, not license of nurse or physician

29 Utilization of LVN RN may delegate to LVN (permitted by statute)

30 Supervision Level of Care Required SN / RN LVN UAP Level of Supervision Immediate Direct Indirect Training of RN/LVN/UAP Initial training Return demonstration Observation

31 Level of Care Affected By: Community Standard of Care Health Status Staffing at Home Need for Immediate Medical Support School Environment, Schedule Complexity, # Procedures, Supervision

32 5 Factors Affecting Decision to Assign Potential for harm Complexity of task Problem solving & innovation necessary Unpredictability of outcome Level of interaction required

33 Determining Assignment of Tasks Task is considered routine for patient Poses little potential hazard to patient Involves little or no modification Be performed with predictable outcomes Does not involve ongoing assessment, interpretations, or decision making

34 Patients for whom UAPs May Not Be Assigned Patient is medically fragile, condition is not chronic or stable Patient who is usually stable is experiencing an acute episode

35 School Nurse Supervision Medically Stable, Not Complex UAP LVN SN, RN Medically Fragile, Complex Continuum of Health Care

36 Who Trains UAP/LVN? School Nurse

37 Elements of Training General principles of care General written information about condition Student specific training in assigned task Written procedure Demonstration & return demonstration Identify potential emergencies & what to do (ECP) Instruction in documentation

38 Training Keep copies of everything given to UAP Document when training occurred & outcome of training If more than one return demonstration is appropriate, document

39 Who Supervises the UAP/LVN? School Nurse

40 Effective Supervision *Supervisor: a qualified SN, PHN, or MD who is qualified to perform the procedure. Supervisor shall have privilege to exercise judgment and specify level of supervision required, based on professional judgment & shall advise IEP team. Assess real/potential harm Consider patient safety Competency of caregiver Number & complexity of tasks Number of staff SN supervises

41 Supervision Level & Frequency Based on SN professional judgment Health status of student Complexity of task

42 Levels of Supervision Immediate Supervisor physically present while procedure is being done Direct Indirect Supervisor present in same building & available for consultation/ assistance Supervisor available in person or through electronic means to provide guidance, consultation, referral to services as needed

43 Components of Supervision Competency Trained personnel Document Periodic Each instance of supervision Periodic Observe the actual procedure Periodic Confer with the RN, LVN, UAP Review documentation

44 Issues of Liability & Documentation Are health staff acting under school nurse s license? NO!!! UAP staff work under umbrella liability policy of school district Not under school nurse s license LVN works under own license

45 Issues of Liability & Documentation However, when school nurse assigns a health care task: School nurse transfers responsibility for completing task to UAP/LVN School nurse retains accountability for task being done appropriately

46 Documentation If UAP does something inappropriate And SN cannot demonstrate (written documentation) UAP was trained Then SN has put own license in jeopardy And show (written documentation) UAP has successfully carried out procedure (supervision) in the past

47 Documentation Tools Training Checklist Health Care Contract Emergency Care Plan Procedure Checklist Daily Logs

48 Evaluation Evaluation process for SPHCs in school includes evaluation of: Qualified staff performance of standard healthcare procedures Nursing interventions (outcomes) Student s goal achievement

49 Guidelines for Contracted Care Green Book Section 2 Guidelines for Contracted Care Sample Agreement Orientation Checklist Site administrator Time, schedule, services to be provided Who is responsible for technical supervision How to contact supervisor

50 Guidelines for Contracted Care Agency nurse works under supervision of agency supervisor SN concerns about agency nursing care should be reported to agency supervisor All 911 calls should be communicated to SN and site administrator

51 Guidelines for Contracted Care SN orient agency nurse to school site and safety practices SN be available to interpret district policy SN orient classroom teacher to guidelines

52 Agency LVN Provided by Parent Follow same procedures as when District contracts with nursing agency

53 Resources The Green Book: Guidelines for Provision of Specialized Physical Healthcare Services in California Schools. CSNO Children and Youth Assisted by Medical Technology in Educational Settings: Guidelines for Care, 2 nd Ed. By S. Porter, M. Haynie, T. Bierle, T. Caldwell, and J. Palfrey (Blue Book)

54 Los Angeles County Office of Education Susan Chaides, Project Director III

55 He who has health, has hope. And he who has hope, has everything. ~Arabic Proverb

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