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Unlicensed Assistive Personnel

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Structured Care to Community Based Setting Increase in population served Increase in sites that serve the ... administer medication: oral ... – PowerPoint PPT presentation

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Title: Unlicensed Assistive Personnel


1
  • Unlicensed Assistive Personnel
  • NCSBN Workshop
  • June 30, 2010

2
  • RN Delegation to CMA/CMT in
  • Group Home Setting
  • Barbara Newman RN, MS
  • Director of Nursing Practice
  • Maryland Board of Nursing

3
Maryland Demographics
  • Population 5.6 Million
  • Environment Mountain-Sea
  • Coal mining Watermen
  • Hospital (68) 10, 880 beds
  • NH (240) 30,0000 beds

4
Maryland Has 5.6 Million Citizens STATE 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
5
Maryland Has 5.6 Million Citizens STATE 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
6
Maryland Demographics (Cont.)
  • AL (1300providers) 20,000 beds
  • DDA (220providers) 10,000 beds
  • School (24 Counties) 850,000 Students
  • Corrections (24 Counties) 140,000/month
  • Prisons (25) 23,000 average census

7
MBON LICENSURE
  • RN 65,600
  • LPN 13, 600
  • Advance Practice 4,500
  • CNA 104,000
  • CMT 62,000
  • CMA 3,900

8
Structured Care Facilities
  • In Mid 1970s developed the Certified
  • Medicine Aide to work in the licensed NH to
  • administer medication
  • oral
  • suppository
  • topical

9
Structured Care ? Community Care
  • 1980s and 1990s
  • Mental Health Facility group home
  • Developmental Disabilities facility group home
  • Congregate housing Assisted Living

10
Community Based Setting
  • In Mid 1980s 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)

11
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.

12
Structured Care to Community Based Setting
  • Increase in population served
  • Increase in sites that serve the population
  • Available licensed staff did not keep pace

13
Who May Administer Medication?
  • RN
  • LPN
  • Certified Medicine Aide (CMA)
  • Certified Medicine Technician (CMT)

14
Certified Medicine Aide (CMA)
  • Created mid 1970s 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)

15
CMA (Cont)
  • Administers medication by the following routes
  • Oral
  • Suppositories
  • Topicals
  • Eye/ear/nose/gtts
  • Nebulizer

16
CMA (Cont)
  • In the N.H. setting the CMA does not administer
  • GT feeding IM/Subq/Intradermal
  • IVs

17
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

18
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.

19
CMT (Cont)
  • CNA not required
  • Works in Community based setting
  • Group Homes (AL, DD, JS)
  • Schools
  • Supervised work settings
  • Corrections

20
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

21
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

22
CMT (Cont)
  • Administer medications by the following routes
  • oral
  • eye/ear/nose drops
  • topical patches/creams
  • GT feedings
  • Suppositories
  • Subcutaneous injections

23
CMT (Cont)
  • Does not administer
  • IM
  • Intradermal
  • IV

24
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?

25
Community Based Settings
  • fewer resources
  • fewer supports
  • complaints regarding quality of nursing
  • assessment/oversight/competency in
    delegation
  • BON developed training program for the
  • RN

26
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

27
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

28
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

29
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

30
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

31
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

32
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

33
Content of the Training Program (Cont)
  • Case Manager Principles
  • Planning
  • Coordination
  • Resource utilization

34
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)

35
Content of the Training Program (Cont)
  • Legal/Ethical Issues
  • Code of Ethics
  • Client Advocacy
  • Legal constraints

36
Content of the Training Program (Cont)
  • Communication
  • Is the effective foundation to
    delegation/supervision

37
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

38
What have we learned CMT 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.

39
What have we learned CMT 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

40
What have we learned RN 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.

41
What have we learned RN 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

42
What would we do differently RN 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

43
What has been successful RN 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

44
If We Could Start Over CMT 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

45
If All Could Start Over RN 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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