Scope of Practice and Telehealth Nursing: 2005/2006 Update

Carol Rutenberg, RNC, MNScAAACN 31st Annual Conference

Outcome Objectives

At the completion of this presentation, the participant will be able to:

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

Regulatory

Organizational Policy

Professional

Accreditation

Standards

REGULATORY

Organizational Policy

Professional

Accreditation

Telenursing:A Challenge to RegulationTelenursing 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 State LAW, so it can’t be “ignored” There are 50 of them

(and they’re all different) Federal laws supersede state laws

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 Interstate Practice / Licensure

Scope of Practice (Recommendation of medications)

Role of LPNs and UAPs

Interstate Compact for Mutual Recognition of Nurse Licensure www.ncsbn.orgFebruary, 2006

Interstate Practice Issues Permanent residents

88% (43/49) require licensure in their state Excluding

HI KY NH

Silent IN PA WI

Interstate Practice Issues Permanent residents

88% (43/49) require licensure in their state “Snow birds”

80% (39/49*) require licensure in their state Vacationers / Business travelers

59% (29/49*) require licensure in their state Established relationship (eg Drs. Office)

31% (15/49**) make an exception in this case

* 3 silent ** 4 silent

20 States + NJ (pending)

Considering Interstate Compact: 7

“Soon” Colorado Florida Illinois Kentucky Massachusetts Minnesota Montana

Unknown Michigan?

No Plans (21)

(+ 21 = 58%)

State Attorney General Opinions/Interpretive Documents State Attorney General Opinions

Kansas Maryland Nebraska Wisconsin

Interpretive Documents California

http://nursingworld.org/gova/state/attgen99/index.htmretrieved 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

RN OTC (w/out protocol)

7 to 9 11 15/49

OTC (with protocol) 32 31 39/49

Refill Prescriptions --- --- 29/49

Prescription 26 21 23/49

LPN/LVN OTC (w/out protocol)

5/49

OTC (with protocol) 15 13 22/49

Refill Prescriptions 20/49

Prescription 11 9 15/49

Recommendation of Meds1999 2001 2005

RN OTC (w/out protocol) 14-18% 22% 31% OTC (with protocol) 64% 62% 80% Refill Prescriptions --- --- 59% Prescription 52% 42% 47%

LPN/LVN OTC (w/out protocol) 10% OTC (with protocol) 30% 26% 45% Refill Prescriptions 41% Prescription 22% 18% 31%

Policy on Telehealth Nursing: 16/49 (33%)

Arkansas California Iowa Kentucky Massachusetts Minnesota Mississippi North Dakota

New Hampshire Nevada Oklahoma South Carolina South Dakota Texas Wisconsin Wyoming

RNs, LPN/LVNs, and UAPs

Independent scope of practice Nursing process

Not licensed to assess independently (so can they do telephone triage?)

Works under supervision of RN or MD 47% (23/49) yes

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

HampshireNevada

New York Texas Vermont Wisconsin Wyoming

RNs, LPN/LVNs, and UAPs

RN Independent scope of practice Nursing process

LPN / LVN

Not licensed to assess independently (so can they do telephone triage?)

Works under supervision of RN or MD________________________________________________________________________________________________________________________

uap

Widely variable education/trainingDoes 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%)

Alaska Arkansas California Connecticut Idaho Kansas Kentucky Massachusetts Maine Minnesota

Mississippi Montana North Carolina North Dakota New Jersey Nevada Rhode Island South Carolina West Virginia Wyoming

Group Practice Manager or Board

Medical Director

Nursing Director

Office Manager

Nursing Staff (RNs & LPNs)

Nursing Assistants

Medical Staff

Medical Assistants

Telephone Triage Director

Telephone Triage Nurses

Clerical Personnel

So Where Do I Go Now?

“…has legal action been taken against nurses re telephone nursing practice in your state?”

Related to Interstate Practice Kansas Nevada

Not related to Interstate Practice Minnesota Wisconsin

Act in the Patient’s Best Interest!

Nursing Process

Plan

Implement

Assess

Evaluate

USE THE NURSING PROCESS! 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

Plan

Implement

Assess

Evaluate

So What Can You Do?

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?

Be certain our standards address these issues clearly

Are there policy statements that we need to construct? Re interstate practice and the Compact? Re UAPs (specifically medical assistants) and

their role in telephone triage?

carol@telephone-triage.com

501-767-4564

www.telephone-triage.com