1. Scope of Practice and Telehealth Nursing: 2005/2006 Update Carol Rutenberg, RNC, MNSc AAACN 31 st Annual Conference

2. Outcome Objectives At the completion of this presentation, the participant will be able to: recognize regulatory telehealth nursing practice issues articulate issues related to state’s scope of practice identify problems relative to scope of practice in your state develop strategies to address areas of deviation from scope of practice in your clinical setting

3. Practice Standards

4. Standards Regulatory Organizational Policy Professional Accreditation

5. Standards REGULATORY Organizational Policy Professional Accreditation

6. Telenursing: A Challenge to Regulation Telenursing is defined as the practice of nursing over distance using telecommunications technology. National Council of State Boards of Nursing recognizes nursing practice provided by electronic means as the practice of nursing and, thus, asserts that it is regulated by the boards of nursing. National Council of State Boards of Nursing (1997)

7. Nurse Practice Act State LAW, so it can’t be “ignored” There are 50 of them (and they’re all different) Federal laws supersede state laws  Department of Defense (Military)  Veteran’s Administration  Indian Health Services

8. Legal Authority Board of nursing exists to protect the public Nurse Practice Act  Rules and Regulations Position Papers / Declaratory Rulings  FAQs  Correspondence / Minutes

9. Nurse Practice Issues Interstate Practice / Licensure Scope of Practice  (Recommendation of medications) Role of LPNs and UAPs

10. Interstate Compact for Mutual Recognition of Nurse Licensure www.ncsbn.org February, 2006

11. Interstate Practice Issues Permanent residents  88% (43/49) require licensure in their state Excluding  HI  KY  NH Silent  IN  PA  WI

12. Interstate Practice Issues Permanent residents  88% (43/49) require licensure in their state “Snow birds”  80% (39/49*) require licensure in their state Vacationers / Business travelers  59% (29/49*) require licensure in their state Established relationship (eg Drs. Office)  31% (15/49**) make an exception in this case * 3 silent** 4 silent

14. 20 States + NJ (pending)

15. Considering Interstate Compact: 7 “Soon” Colorado Florida Illinois Kentucky Massachusetts Minnesota Montana Unknown  Michigan? No Plans (21) (+ 21 = 58%)

16. State Attorney General Opinions/Interpretive Documents State Attorney General Opinions  Kansas  Maryland  Nebraska  Wisconsin Interpretive Documents  California http://nursingworld.org/gova/state/attgen99/index.htm retrieved 4-2-05

17. Canada: Locus of Accountability “Nurses engaged in telepractice are considered to be practising in the province/territory where they are located and currently registered, regardless of where the client is located.” CNA Position Statement, The role of the nurse in telepractice 2000

18. Recommendation of Meds 199920012005 RN OTC (w/out protocol) 7 to 91115 /49 OTC (with protocol) 323139 /49 Refill Prescriptions --- 29 /49 Prescription 262123 / 49 LPN/LVN OTC (w/out protocol) 5 /49 OTC (with protocol) 151322 /49 Refill Prescriptions 20 /49 Prescription 11915 /49

19. Recommendation of Meds 199920012005 RN OTC (w/out protocol) 14-18%22%31% OTC (with protocol) 64%62%80% Refill Prescriptions --- 59% Prescription 52%42%47% LPN/LVN OTC (w/out protocol) 10% OTC (with protocol) 30%26%45% Refill Prescriptions 41% Prescription 22%18%31%

23. Policy on Telehealth Nursing: 16/49 (33%) Arkansas California Iowa Kentucky Massachusetts Minnesota Mississippi North Dakota New Hampshire Nevada Oklahoma South Carolina South Dakota Texas Wisconsin Wyoming

24. RNs, LPN/LVNs, and UAPs  Independent scope of practice  Nursing process  Not licensed to assess independently (so can they do telephone triage?)  Works under supervision of RN or MD 47% (23/49) yes  1 independently (Massachusetts)  22 under supervision 47% (23/49) no 6% ( 3/49) silent

25. Policy on LPNs and Telenursing: 11/49 (22%) Arkansas Massachusetts Minnesota Mississippi New Hampshire  Nevada New York Texas Vermont Wisconsin Wyoming

26. RNs, LPN/LVNs, and UAPs RN  Independent scope of practice  Nursing process LPN / LVN  Not licensed to assess independently (so can they do telephone triage?)  Works under supervision of RN or MD ________________________________________________________________________________________________________________________  uap Widely variable education/training Does triage under license of MD

27. Captain of the Ship Doctrine “Legal doctrine that, when applied to medical malpractice, holds doctor liable for the actions of others, such as nurses, attendants, and other staff.” (Bogart, p. 640) “Borrowed Servant” may apply in cases in which the UAP is an employee of the organization but under the control of the physician. Bogart, J. B. (ed.), (1998). Legal Nurse Consulting Principles & Practice. American Association of Legal Nurse Consultants.

28. Policy on UAPs and Telenursing: 20/49 (41%) Alaska Arkansas California Connecticut Idaho Kansas Kentucky Massachusetts Maine Minnesota Mississippi Montana North Carolina North Dakota New Jersey Nevada Rhode Island South Carolina West Virginia Wyoming

30. So Where Do I Go Now?

31. “…has legal action been taken against nurses re telephone nursing practice in your state?” Related to Interstate Practice  Kansas  Nevada Not related to Interstate Practice  Minnesota  Wisconsin

32. Act in the Patient’s Best Interest!

33. Nursing Process Plan Implement Assess Evaluate

34. USE THE NURSING PROCESS! Do a thorough assessment Diagnose urgency (clinical judgment) Develop the right plan (based on protocol, context, patient preference/critical thinking) Facilitate implementation of the plan Evaluate to be sure you know if the patient doesn’t get better

35. Nursing Process Plan Implement Assess Evaluate

36. So What Can You Do? Interact with your Board of Nursing about issues related to telephone triage. Join a professional organization & get involved. Stay informed of new developments (read, network, assume responsibility).

37. So What Can WE Do? Be certain our standards address these issues clearly Are there policy statements that we need to construct?  Re interstate practice and the Compact?  Re UAPs (specifically medical assistants) and their role in telephone triage?

38. carol@telephone-triage.com 501-767-4564 www.telephone-triage.com