1 Unlicensed Assistive Personnel NCSBN Workshop June 30, 2010.
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1
Unlicensed Assistive Personnel
NCSBN Workshop
June 30, 2010
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RN Delegation to CMA/CMT in
Group Home Setting
Barbara Newman RN, MS
Director of Nursing Practice
Maryland Board of Nursing
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Maryland Demographics
• Population – 5.6 Million
• Environment – Mountain-Sea
• Coal mining – Watermen
• Hospital (68) 10, 880 beds
• NH (240) 30,0000 beds
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Maryland Has 5.6 Million CitizensSTATE Total Population 5,618,250
Age Number of Citizens
% of Total
Population
0-4 years 370,404 6.6%
5-9 years 359,958 6.4%
10-14 years 376,713 6.7%
15-19 years 410,914 7.3%
Over 19 4,100261 73%
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Maryland Has 5.6 Million CitizensSTATE Total Population 5,618,250
Age Number of Citizens
% of Total Population
Under 19 1,517,98911 27%
20-44 849,722 34.6%
45-64 1,491,441 26.6%
65-84 578,722 10.3%
Over 85 85,337 1.5%
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Maryland Demographics (Cont.)
• AL (1300+providers) 20,000 beds
• DDA (220+providers) 10,000 beds
• School (24 Counties) 850,000 Students
• Corrections (24 Counties) 140,000/month
• Prisons (25) 23,000 average census
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MBON LICENSURE
• RN = 65,600
• LPN = 13, 600
• Advance Practice = 4,500
• CNA = 104,000
• CMT = 62,000
• CMA = 3,900
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Structured Care Facilities
In Mid 1970’s developed the Certified
Medicine Aide to work in the licensed NH to
administer medication:
• oral
• suppository
• topical
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Structured Care Community Care
1980’s and 1990’s – Mental Health Facility – group home– Developmental Disabilities facility – group
home– Congregate housing – Assisted Living
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Community Based Setting
• In Mid 1980’s movement of DD clients from State Hospitals to 3 bedroom single dwelling homes in local communities
• In Mid 1990s movement of Congregate housing adult clients to AL settings
(3 bedroom homes to 150 beds)
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Community based settings (Cont)
• In Mid 1980s CNAs in school health settings (no longer one RN per school in all Counties).
• In Mid 1990s shift from correctional officers administering medications to nursing staff.
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Structured Care to Community Based Setting
• Increase in population served
• Increase in sites that serve the population
• Available licensed staff did not keep pace
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Who May Administer Medication?
• RN
• LPN
• Certified Medicine Aide (CMA)
• Certified Medicine Technician (CMT)
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Certified Medicine Aide (CMA)
• Created mid 1970’s for the licensed NH• Must be a CNA/GNA• Must have worked for 1 year FT in NH• Trained specifically for the NH• Client chronic/stable/complex care with acute
illness• Licensed nurse (RN/LPN) on unit with CMA 24/7
(BON certified CNA/GNA/CMA 1999)
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CMA (Cont)
• Administers medication by the following routes:– Oral– Suppositories– Topicals– Eye/ear/nose/gtts– Nebulizer
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CMA (Cont)
• In the N.H. setting the CMA does not administer:
• GT feeding• IM/Subq/Intradermal• IVs
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CMA (Cont)
• Training Program 60+ hours in length
• 30 hours Theory
• 30 hours Clinical
• Clinical in NH with RN Instructor
• Taught in BON approved Community Colleges
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Certified Medication Technician (CMT)
• Created mid 1980s for community based settings
• Registered with BON 1999
• Certified by BON 2005 • Math/Reading
• Taking meds for self
• Throwing med in trash etc.
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CMT (Cont)
• CNA not required
• Works in Community based setting
• Group Homes (AL, DD, JS)
• Schools
• Supervised work settings
• Corrections
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CMT (Cont)
• Client chronic/stable/predictable
• RN not required 24/7
• RN makes supervisory visit 14 to 45 days
when medications are delegated
• RN supervisory visits for other delegated nursing tasks is determined by the RN specific to the client needs
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CMT (Cont)
• Training program length 20 hours • Must pass math/reading exams as prerequisite
• Theory
• Simulated med pass
• Med pass with client with RN Trainer present
• Taught by RN, CM/DN approved by the BON• Administers medication to client who is
chronic/stable/predictable
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CMT (Cont)
Administer medications by the following routes:
• oral
• eye/ear/nose drops
• topical patches/creams
• GT feedings
• Suppositories
• Subcutaneous injections
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CMT (Cont)
Does not administer:
• IM
• Intradermal
• IV
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CMA and CMT
• perform delegated nursing function of medication administration• Requires RN to assess the client and determine:
• is the client chronic/stable/predictable• is task of medication administration
routine-performed the same way?• is environment conducive to the delegation?• is the CMA/CMT competent to perform the
administration of medication?
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Community Based Settings
• fewer resources
• fewer supports
• complaints regarding quality of nursing
assessment/oversight/competency in delegation
• BON developed training program for the
RN
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Community Based Setting
Client is usually not in setting for health care:• School Health – education
• Detention Center/Prisons-incarceration
• DD-promote community/home like care
psychosocial model
• AL – maintenance of independence/supervision of nutritional intake/medication
• Juvenile Service - incarceration
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Community based setting
• RN not familiar/comfortable with:
• working in a system without a defined nursing system with clear
boundaries
• being the only RN or licensed health care person in the facility/agency
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Registered Nurse, Case Manager/Delegating Nurse (RN, CM/DN)
• Required training for a RN working in AL, JS, Sch. Hlth., Corrections, DDA
• Approximately 16 hours in length• Developed by BON with Community• Implemented 1999• 2nd Revision 2005• Beginning 3rd revisions 2010• Taught in 11 BON approved educational facilities
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Registered Nurse, Case Manager/Delegating Nurse (RN, CM/DN) Cont
• Training is specific to practice setting:
• Assisted Living
• Developmental Disabilities
• School Health/Juvenile Services
• Corrections
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Registered Nurse, Case Manager/Delegating Nurse (RN, CM/DN) Cont
• Content of the training program: 1. History of setting
• Description of aggregate client population
• Regulations governing the setting
• Nurse Practice Act
• Other regs
• Commission on Correctional Standards
• Maryland State Department of Education
• Juvenile Service
• Assisted Living • Developmental Disabilities
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Content of the Training Program• Overview of Role and Responsibilities of the RN, CM/DN:
• For specific setting such as:
• Corrections
• Maryland State Department of Education • Assisted Living
• Developmental Disabilities
• Juvenile Service
• Documentation
• Reporting requirements
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Content of the Training Program (Cont)
• How to teach the CMT:
• Prerequisite to CMT Training (math/
reading exam)
• Training Program Content
• Evaluation of CMT Competency
• Required Clinical Update
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Content of the Training Program (Cont)
• Case Manager – Principles
• Planning
• Coordination
• Resource utilization
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Content of the Training Program (Cont)
• Principles of Delegation • Standards of Delegation (COMAR 10.27.09) • Delegation of Nursing Functions
(COMAR 10.27.11) • CMA Regulations (COMAR 10.39.03) • Regulations Governing the CMT (COMAR 10.39.04) • Code of Ethics for the CNA/CMT (COMAR 10.39.07)
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Content of the Training Program (Cont)
• Legal/Ethical Issues
• Code of Ethics
• Client Advocacy
• Legal constraints
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Content of the Training Program (Cont)
Communication
• Is the effective foundation to delegation/supervision
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Content of the Training Program (Cont)
• Adult Learning Principles for teaching CMT Training Program
• Pedagogy/Andogagy
• Core goals/needs of adult learner
• Cultural diversity
• Engaging student in learning
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What have we learnedCMT ISSUES
• Difficulty with reading and math• No ownership of their certification• Poor historians• Poor compliance with renewal process –
everyone else is responsible• Believe it is just another training necessary
for the job.
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What have we learnedCMT ISSUES (Cont)
• The CMT • Requires remediation during the site visit by RN, CM/DN • Does not always document administration
consistently
• Does not always notify RN of new medications
• Does not always notify RN of changes in patient
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What have we learnedRN ISSUES
• Some difficulty with working in isolation (JS, DDA, AL setting) • Other RNs absent
• Other staff with health background absent • Feels as if they are a “lone voice in
wilderness” • Negotiating skills limited • Case management skills limited • Does not consistently determine competency of people they are delegating to.
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What have we learnedRN ISSUES
• Time management/multitasking in community based setting some times difficult.
• Leadership skill and coordinating with house manager sometime difficult
• RN, CM/DN voices need for peer support group
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What would we do differentlyRN ISSUES
• Strengthen knowledge & skill in interviewing (The RN instruction and supervision is based in part upon CMT reporting)
• Strengthen knowledge and skill set in: • Coordination with unlicensed people who serve
as managers of the home• Directing the care workers to do the delegated tasks
• Determining competency of the CMT/CNA • Encourage/partner with association to create peer
support group
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What has been successfulRN ISSUES(Cont)
• Strengthen ties with other state agencies– DDA – 4 Regional RNS– AL-OHCQ (new regs)– School Health - MSDE– Corrections - MCCS
• Reasonable expectations of RN in isolated setting
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If We Could Start OverCMT ISSUES
• Require CMT to be CNA • CNA functions need to be the basis for the
CMT • Require CMT training in Community College • Require CMT Clinical Update to be done by
Community College
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If All Could Start OverRN ISSUES
• Require all RNs to take a RN, CM/DN refresher Course every 2 years
• Do not permit the RN in the setting to teach the CMT Training Program
• Require the RN to have at least two (2) years of RN experience
• Strengthen negotiation/coordination/interviewing skills
• Limit role to delegating and supervising (not training the CMT)
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