1 Unlicensed Assistive Personnel NCSBN Workshop June 30, 2010.

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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)