NEW YORK NURSE: November 2010

Annual Report from the New York State Board for Nursing

By Barbara Zittel, RN, PhD, Executive Secretary

According to the New York State Education Department, 272,116 individuals were licensed and registered to practice professional nursing in New York as of Jan. 1, 2010. This continues to reflect an upward trend. The Department issued 14,143 new RN licenses in 2009. While this represents 300 fewer licenses issued than in 2008, we need to wait an additional year before determining if this is the initiation of a trend or normal, random fluctuations.

New York State has slightly more than 15,300 nurse practitioners (NPs) practicing in over 16 specialties. Almost 800 new master’s prepared NPs were added in 2009. As of Jan. 1, 2010, there were 69,902 licensed practical nurses (LPNs), a decrease of over 1,600 from 2009. While 4,009 new LPN licenses were issued during this time frame, this is only 100 more than in 2008.

Discipline categories

Among the 47 licensed professions, the State Board for Nursing has the highest caseload of disciplinary and moral character charges. In 2009, 1,397 cases were opened against RNs, 92 against NPs, and 784 against LPNs. Negligence/incompetence remains the most frequent category for all titles. For RNs and LPNs, “conviction of a crime” increased more in 2009 than any other category.
One finds a significant difference when comparing disciplinary cases opened against RNs and LPNs, using a common metric. On average, in each year between 2001 and 2009, for each 1,000 nurses, there were 11 disciplinary/moral character cases against LPNs, compared to 4 cases against RNs.

To help understand this discrepancy, the board will start using a new data collection instrument called “Taxonomy of Error, Root Cause Analysis and Practice-responsibility” (TERCAP). The instrument was developed by regulators nationwide, under the National Council of State Boards for Nursing, led by Patricia Benner, RN, PhD, of the Carnegie Foundation for the Advancement of Teaching. It attempts to address the nuances of nursing practice breakdowns. By using this nurse-developed instrument, the Board hopes to have a comprehensive analysis of errors from which to recommend changes in areas such as environment, education, or management.

Practice guideline changes

In 2009, the board office handled over 17,459 telephone calls and 5,054 e-mails. The majority were related to scope of practice. Answers to nursing issues are posted on our website under “Practice Alerts and Guidelines.” Major guidelines added this year include:

Medical assistants – It has come to the attention of the Office of the Professions that a significant number of physicians’ offices are utilizing medical assistants or other unlicensed persons to assist in the care of patients. Section 6530 (11) of Education Law states that “permitting, aiding or abetting an unlicensed person to perform activities requiring a license” constitutes unprofessional conduct. Medical tasks may only be delegated to persons authorized by law to perform that task — for instance, medication administration, starting IVs, taking an X-ray, and making a diagnosis.

The fact that an unlicensed person may be “competent” to perform a task does not confer legal authorization to engage in an activity restricted to licensed persons. Licensed professionals, including physicians, who knowingly delegate a medical task to a person who is not legally authorized are guilty of professional misconduct.

The state boards for nursing and medicine developed a list of tasks that can and cannot be performed by “medical assistants” or other unlicensed persons. The lists include tasks frequently mentioned by practitioners in queries to board offices. It is not an exhaustive list. Practitioners may be called upon to make judgments about whether certain tasks, not mentioned in the list, may be delegated.

Practitioners with authority to order or delegate medical tasks should be guided by the principle that tasks requiring an exercise of medical judgment and assessment, or tasks specifically restricted to licensed professionals, may not be delegated to medical assistants or unauthorized persons.

Such tasks must be performed by licensed persons who, by their education and licensure, are presumed to possess the level of professional judgment and assessment skills to ensure safe practice. Tasks that can be performed by medical assistants or unlicensed persons include secretarial work, such as assembling charts or assisting with billing; measuring vital signs; performing ECGs; drawing blood work; and assisting an authorized practitioner, under their direct and personal supervision, to carry out a specific task, as a “second set of hands.”

For example, an authorized practitioner, after positioning a limb, asks the medical assistant to maintain the limb in the position while a bandage is applied or sutures removed. The assistant could not independently position the patient.
Tasks that cannot be performed by medical assistants or unlicensed persons include triage; administering medications; administering contrast dyes or injections; placing or removing sutures; taking or independently positioning patients for x-rays; applying casts; and first-assisting in surgical procedures.

Unlicensed assistive personnel and waived tests – The board received numerous inquiries on the role of unlicensed assistive personnel (UAPs) in performing waived tests in acute care settings – bedside tests such as glucose monitoring, which have been performed by UAPs for many years. With the passage of the bill licensing clinical laboratory technicians, such practice was restricted for several years.

A resolution was reached by the Department of Health (DOH) that waived tests may be performed by UAPs in acute care settings if the facility has obtained a permit from DOH for a limited service laboratory. The hospital’s clinical laboratory director must also be in charge of the laboratory. The clinical laboratory director, not nursing management, must ensure personnel are trained and equipment is appropriate and tested.

Prefilling medication boxes in homecare settings – In December 2009, the Governor signed into law Chapter 503, permitting RNs and LPNs functioning under RN supervision to prefill medication boxes for up to a 15-day supply.

As mandated by the law, a guideline of “best practice” was developed by the state boards for nursing and pharmacy. Highlights include:

This provision applies only to individuals receiving home care services ordered by an authorized practitioner, such as a physician or NP.
It applies to prefilling prescription medications dispensed by a pharmacist and over-the-counter drugs, vitamins, food supplements, ordered by an authorized practitioner.
There must be a patient-specific order for each medication.
No more than a 15-day supply of medication can be prefilled. This is not to imply that 15 days is a universal standard. Any supply up to 15 days should only be as appropriate.
An RN, in accordance with professional judgment, must assess the appropriateness of a patient for medication prefills, given the number of medications to be prefilled and the related complexity of labeling. Prefilling medications may not be a safe alternative for some patients. A non self-directing patient must have a self-directing caregiver able and appropriate to assist with administration of medications.
RNs must determine a method of proper identification for medication, which could be a log, picture, chart, or other means. Of particular concern is correctly identifying medication that must be taken at several, specific times of the day, with or without certain foods or liquids, or with specific instructions. Identification must be clear enough for a patient or caregiver to easily respond to a determination to “hold” or discontinue one of several drugs packaged together.
To determine appropriateness of a medication or container, an RN should consider whether a medication requires special packaging or storage so that it is not placed in an inappropriate container. An example of this would be nitroglycerin, which must be stored in glass containers only.
A household environment should be considered, whether controlled substances should be stored with non-controlled substances or be securely locked.
In a group or adult home, an RN must determine the best method of storage, taking into consideration variables such as labeling and the inadvertent or intentional use by others.
An RN must consider how to handle best medications administered as only “prn,” the introduction of new medications, and whether prefilling is appropriate.
The patient or caregiver must be instructed on procedures should an incident occur with the medication box, such as spillage.

After an initial assessment of the patient by an RN and under the supervision of an RN, an LPN may be permitted to prefill medication boxes, provided:

The RN and LPN consider the previously cited “best practice.”
The first prefill procedure for a patient must be performed by an RN.
An RN must provide written documentation of the competence of the LPN as specified in the employing agency’s policy.
No less than every 60 days, an RN must reassess medications’ effectiveness and the degree the patient remains self-directed.

Volunteer liability: good news

Effective July 1, 2010, Chapter 56, Part B of the Laws of 2010, provides immunity for training, drills and response activities for all affiliated volunteers. This includes Medical Reserve Corps and Citizen Corps volunteers who are specifically referenced in a county’s Emergency Management Plan, have clearly defined roles, and are activated by the county chief executive or designee. This is in addition to the defense and indemnification provided by a county through Public Officer’s Law 18.

Information on these issues is available on our web site:www.op.nysed.gov/prof/nurse/.