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Find answers to questions about the practice of nursing in Maine.
Questions Specific to:
Joint Advisory Opinions
Role of the Registered Professional Nurse in the Coordination and Oversight of Unlicensed Assistive Personnel (UAP) regarding Gastrostomy Tubes (G-Tubes)
The Maine State Board of Nursing issues this Position Statement to guide the practice of nursing. The Board's primary concern is the health and safety of consumers.
The purpose of this position statement is to provide guidelines/criteria that define the conditions under which the registered professional nurse (RN) may coordinate and oversee the task of
The RN must complete a thorough assessment of the consumer's nursing care needs, taking into consideration the consumer's overall medical condition. Assessment of the consumer's need related to the G-tube includes the condition of the G-tube (e.g., the maturity of the stoma site, patency, and sustained skin integrity) and designating the appropriate care giver. The RN is responsible for communication and consultation regarding provision of G-tube services.
All UAP providing G-tube care must be at a minimum Certified Residential Medication Aides (CRMA).
The RN is responsible to develop an instructional plan for the UAP and maintain documentation of instructional activities. Part of the instructional plan shall include a mechanism to evaluate competency.
Individual written plans that address the consumer's needs must be available for the UAP at the site at which care is rendered. Information must be updated as needed The plan must include contingency provisions to address unexpected G-tube occurrences.
Questions have been raised regarding the hiring and utilization of new graduates from nursing programs by health care facilities prior to the person's licensure. Technically, these individuals are unlicensed assistive personnel since they are not eligible to be classified as registered professional nurse (RN) applicants or licensed practical nurse (LPN) applicants. However, to differentiate them from certified nursing assistants and other unlicensed assistive personnel, it is recommended that these individuals be referred to as new graduates. These new graduates may not refer to themselves as RNs or LPNs and may not practice as RNs or LPNs.
32 MRSA Section 2102 2. H. and Chapter 6 Regulations Relating to Coordination and Oversight of Patient Care Services by Unlicensed Assistive Personnel allow a registered professional nurse to coordinate and oversee certain nursing tasks consistent with the standards set forth in the regulation.
The Board has considered the issue of the orientation of new graduates prior to licensure. Orientation and preparation for the role of a licensed nurse is an important aspect of a new nurse's career. It is recognized that orientation involves both didactic and clinical components. For purposes of orientation prior to licensure, the new graduate must be in a structured setting with a defined educational program for the orientation of new graduates. Conversely, if the employer does not meet this requirement, it is not appropriate to employ the new graduate until he or she is licensed.
The employers of new graduates should utilize the following criteria for orientation of a new graduate prior to licensure.
1. The new graduate shall have submitted an application for examination to NCLEX®.
2. The new graduate shall have submitted an application for licensure to the Board and have been declared eligible by the Board to take the examination prior to beginning orientation. Upon declaration of eligibility to test by the Board, the applicant is mailed an Authorization To Test (ATT) letter by the test service. The new graduate should provide a copy of the ATT to the employer to show evidence of having applied to the Board for licensure.
3. A registered professional nurse preceptor must be designated as the responsible individual to provide continuous, on-site supervision for the new graduate. However, a registered professional nurse may designate a licensed practical nurse to participate in the orientation for the graduate of a practical nursing program.
4. The new graduate may not engage in independent nursing responsibilities such as: delegating nursing functions to other nursing personnel, and independently passing medications or administering intravenous therapy. The new graduate should not be part of the facility's staffing pattern, i.e. does not carry a patient assignment.
5. New graduates are required to pass the NCLEX® examination within three months of starting orientation. If the individual is not licensed by the end of a three month orientation period or has failed the first attempt at the NCLEX® examination, the new graduate may function only as an unlicensed assistive personnel(UAP).
The Maine State Board of Nursing issues this Position Statement to guide the practice of dialysis nursing. The Board's primary concern is the health and safety of patients.
This Position Statement delineates nursing roles and responsibilities for the safe delivery of specialized health care in the dialysis setting. The Board supports the collaborative role of the registered professional nurse (R.N.) with members of a multidisciplinary team in the provision of care to individuals undergoing dialysis therapy for either acute or chronic renal failure. The Board believes that the overall accountability and responsibility for nursing care provided to patients and the coordination of patient care activities, including the provision of many specific dialysis-related assessments and interventions, rests with the registered professional nurse. Specifically, the registered professional nurse is responsible for pre-assessment, ongoing assessment and post assessment of the dialysis patient.
Unlicensed assistive personnel in dialysis settings are individuals who are trained to function in an assistive role in the provision of patient care activities. The registered professional nurse is responsible for continuous assessment of the patient's condition and care needs, and for recognizing the unlicensed assistive person's competencies and skills.
Training of the unlicensed assistive person must be in accordance with a detailed curriculum with outcome measures identified to evaluate the trainee. Technological changes should be the basis for updating competency of registered professional nurses and unlicensed assistive personnel in providing dialysis care.
The Maine State Board of Nursing and Maine Association of School Nurses collaborated to provide guidelines for nursing practice in the educational setting.
Maine has experienced an increase in the number and complexity of students with health conditions coming to school due to the advances in medicine, health and science. Medically complex children requiring the skills of a professional registered nurse in nursing assessment, diagnosis and intervention during the school day have increased.
The registered nurse practicing as a school nurse is the coordinator/facilitator of nursing care in the school, and may not necessarily be the direct care provider, for children who are technology dependent. In coordinating or facilitating care, the registered nurse:
June 16, 1993
Schedule II Drug Prescriptive Authority by Nurse Practitioners and Certified Nurse-Midwives (NP and CNM)
To clarify the roles and responsibilities of physicians, nurse practitioners, and nurse midwives regarding the prescription of Schedule II drugs
The statutes and rules of health care regulatory agencies define the parameters of the scope of practice of the licensed practitioner. Respective boards provide the outside parameters of scope of practice beyond which practice may not be exceeded by their licensees.
32 MRSA Sec. 3270-A (BOLIM) provides the statutory framework for delegation of medical acts by physicians, and Chapter 3 of the BOLIM rules provides that Schedule II drug prescriptive authority may NOT be delegated to nurse practitioners or certified nurse midwives practicing under delegation. The rule provides for petition by the physician for an exemption on a case by case basis. The BOLIM, to date, has not looked at the issue of allowing the delegation of Schedule II prescriptive authority based solely on the basis that the nurse practitioner or nurse midwife, if practicing under the MSBON rules' scope of practice, could so prescribe.
32 MRSA Sec. 2102 2-A (MSBON) grants prescriptive authority to NPs and CNMs. Chapter 8 of the MSBON rules provides that Schedule II drugs may be prescribed by NPs and CNMs as part of their regular scope of practice.
Situation 1: The NP or CNM is practicing in "independent" practice according to the statute and rules of the MSBON. The Boards agree that this individual may prescribe Schedule II drugs.
Situation 2: The NP or CNM who chooses to practice under the delegation of a physician, in accordance with 32 MRSA 2205-B(3) may NOT prescribe Schedule II drugs because of the limitation of delegation placed upon the physician by the BOLIM. The BOLIM's rule provides for petition for an exception on a case by case basis.
Situation 3: NPs and CNMs who work under delegation at a health care institution as required by the rules governing membership or employment at the facility whose rules or bylaws prohibit Schedule II prescribing by other than fully licensed physicians or appropriate delegated licensed staff, the scope of practice may be made more restrictive, but not less. That institution may be a clinic, hospital, nursing home or other health care provider. When the NP or CNM accepts a contract, real or implied, to abide by the rules of the institution, the NP or CNM may NOT prescribe Schedule II substances.
In the instance where a NP or CNM works in multiple settings which include multiple categories, the NP or CNM may prescribe Schedule II drugs only when working in "independent" practice settings.
Signed by chairmen of both the MSBON and BOLIM December 11, 2001
1. To clarify the roles and responsibilities of physicians and nurses regarding telephone orders.
2. To insure public protection and assure quality of care.
Physicians, nurses and other health care providers rely on the professional skills and integrity of all participants in the health care delivery process.
Physicians are responsible to assure that the orders communicated are appropriate to the situation, and that orders are accurately relayed from the physician's office.
Nurses may accept physician orders via telephone from office personnel designated by the physician. In receiving orders from physician offices, nurses are responsible for recognizing the appropriateness of the order with respect to the plan of care, and for implementing the order or obtaining clarification.
Dated: February 1995
The registered professional nurse may not delegate nursing functions to prehospital personnel.
The registered professional nurse who delegates nursing functions to prehospital personnel will be in violation of 32 MRSA Sections 2102(C) and (D) and 2105-A (2) (D).
Prehospital personnel are not licensed by the Board of Emergency Medical Services to perform any skills in the hospital other than during their training and in completing the transfer of their patient to the hospital staff.
Prehospital personnel will be functioning in direct conflict with 32 MRSA Section 2106(3) (Law Regulating the Practice of Nursing) if they are employed by the hospital to perform nursing functions.
Approved by Board of Nursing and Board of Emergency Medical Services
Dated: February 11, 1992
Delegation: Concepts and Decision-Making Process
To meet the public's increasing need for accessible, affordable, quality health care, providers of health care must maximize the utilization of every health care worker and ensure appropriate delegation of responsibilities and tasks. Nurses, who are uniquely qualified for promoting the health of the whole person by virtue of their education and experience, must be actively involved in making health care policies and decision; they must coordinate and supervise the delivery of nursing care, including the delegation of nursing tasks to others.
Issues related to delegation have become more complex in today's evolving health care environment, creating a need for practical guidelines to direct the process for making delegatory decisions. Accordingly, this paper expands and builds upon the National Council's 1987 and 1990 conceptual and historical papers on delegation by presenting a dynamic decision-making process and practical guidelines for delegation.
The purpose of this paper is to provide a resource for Boards of Nursing, health policy makers, and health care providers on delegation and the roles of licensed and unlicensed health care workers. The paper emphasizes and clarifies the responsibility of Boards of Nursing for the regulation of nursing, including nursing tasks performed by unlicensed health care workers, and the responsibility of licensed nurses to delegate nursing tasks in accord with their legal scopes of practice. It provides a decision-making tool which can be used in clinical and administrative settings to guide the process of delegation. This paper also describes the accountability of each person involved in the delegation process and potential liability if competent, safe care is not provided.
The following premises constitute the basis for the delegation decision-making process.
Accountability ..... Being responsible and answerable for actions or inactions of self or others in the context of delegation.
Regulatory Perspective: A Framework for Managerial Policies
Boards of Nursing have the legal responsibility to regulate nursing and provide guidance regarding delegation. Registered Nurses (RNs) may delegate certain nursing tasks to Licensed Practical Nurses/Vocational Nurses (LPN/VNs) and unlicensed assistive personnel (UAP). In some jurisdictions, LPN/VNs may also delegate certain tasks within their scope of practice to unlicensed assistive personnel. The licensed nurse has a responsibility to assure that the delegated task is performed in accord with established standards of practice, policies and procedures. The nurse who delegates retains accountability for the task delegated.
The regulatory system serves as a framework for managerial policies related to the employment and utilization of licensed nurses and unlicensed assistive personnel. The nurse who assesses the patient's needs and plans nursing care should determine the tasks to be delegated and is accountable for that delegation. It is inappropriate for employers or others to require nurses to delegate when, in the nurse's professional judgment, delegation is unsafe and not in the patient's best interest. In those instances, the nurse should act as the patient's advocate and take appropriate action to ensure provision of safe nursing care. If the nurse determines that delegation may not appropriately take place, but nevertheless delegates as directed, the nurse may be disciplined by the Board of Nursing.
Acceptable Use of the Authority to Delegate
The delegating nurse is responsible for an individualized assessment of the patient and situational circumstances, and for ascertaining the competence of the delegatee before delegating any task. The practice-pervasive functions of assessment, evaluation and nursing judgment must not be delegated. Supervision, monitoring, evaluation and follow-up by the nurse are crucial components of delegation. The delegatee is accountable for accepting the delegation and for his/her own actions in carrying out the task.
The decision to delegate should be consistent with the nursing process (appropriate assessment, planning, implementation and evaluation). This necessarily precludes a list of nursing tasks that can be routinely and uniformly delegated for all patients in all situations. Rather, the nursing process and decision to delegate must be based on careful analysis of the patient's needs and circumstances. Also critical to delegation decisions are the qualifications of the proposed delegatee, the nature of the nurse's delegation authority set forth in the law of the jurisdiction, and the nurse' personal competence in the area of nursing relevant to the task to be delegated.
Delegation Decision-Making Process
In delegating, the nurse must ensure appropriate assessment, planning, implementation and evaluation. The delegation decision-making process, which is continuous, is described by the following model:
C. Delegatee qualifications
Provided that this foundation is in place, the licensed nurse may enter the continuous process of delegation decision-making.
II. Assess the situation
If patient needs, circumstances, and available resources (including supervisor and delegatee) indicate patient safety will be maintained with delegated care, proceed to III.
III. Plan for the specific task(s) to be delegated
If the nature of the task, competence of the delegatee, and patient implications indicate patient safety will be maintained with delegated care, proceed to IV.
IV. Assure appropriate accountability
If delegator and delegatee accept the accountability for their respective roles in the delegated patient care, proceed to V.
V. Supervise performance of the task
VI. Evaluate the entire delegation process
VII. Reassess and adjust the overall plan of care as needed
The guidelines presented in this paper provide a decision-making process that facilitates the provision of quality care by appropriate persons in all health care settings. The National Council of State Boards of Nursing believes that this paper will assist all health care providers and health care facilities in discharging their shared responsibility to provide optimum health care that protects the public's health, safety and welfare.
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