Unlicensed Assistive Personnel NCSBN Workshop June 30, 2010

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 CitizensSTATE Total Population 5,618,250

5. Maryland Has 5.6 Million CitizensSTATE Total Population 5,618,250

6. 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

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 1970’s developed the Certified Medicine Aide to work in the licensed NH to administer medication: • oral • suppository • topical

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

10. 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)

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 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)

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 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.

39. 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

40. 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.

41. 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

42. 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

43. 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

44. If We Could Start OverCMTISSUES • 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 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)