Legislature(2001 - 2002)
05/11/2002 10:52 AM Senate FIN
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* first hearing in first committee of referral
+ teleconferenced
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+ teleconferenced
= bill was previously heard/scheduled
SENATE CS FOR CS FOR HOUSE BILL NO. 276(L&C)
"An Act relating to temporary permits and licenses by
endorsement issued by the Board of Nursing; and relating to
the delegation of nursing duties."
This was the first hearing for this bill in the Senate Finance
Committee.
REPRESENTATIVE PEGGY WILSON, the sponsor of the bill, informed the
Committee that this legislation would update State statutes to
align with current nursing practices by: allowing nurses to
delegate nursing duties to other personnel; increasing the
temporary licensing application time period from four months to six
months to allow sufficient time for the required criminal
background check; and provide for changes in statute language to
comply with current Division of Occupational Licensing practices.
Senator Green informed the Committee that some employers discuss
with prospective nursing applicants the expectation that the nurses
would delegate certain responsibilities to Certified Nursing
Assistants (CNAs). She noted that "great pressure" has been exerted
on nurses to delegate duties even when the nurses are not
comfortable in doing so. She asked Representative Wilson whether
this bill would supplant a Registered Nurse's (RN) ability to
decide whether or not to delegate certain duties.
Representative Wilson responded that the language in this bill
"definitely does not" undermine an RN's ability to make those
decisions. She explained that there are strict rules and
regulations for nurses, and nurses are very careful not to delegate
a duty to an unqualified individual as this could jeopardize the
nurse's license.
Co-Chair Donley voiced concern that current State statutes are
vague regarding medical staffing in the State's medical facilities,
and he noted that other states "have more specific and clear
statutes regarding the proper amount" of medical personnel,
especially nurses. He asserted that hospital staffing level
requirements in the State are "dangerously low," and he questioned
whether this legislation would result in a further "strain on
nurses" who, he asserted are being asked to assume a wider range of
responsibilities. He furthered that nurses are constantly being
asked to update their skills and increase their knowledge about
newly introduced medications.
Co-Chair Donley stressed that the increasing complexities of the
nursing profession intensify his concern regarding delegation of
duties. He stated that the Committee should be cognizant "of any
endangerment to the levels of service" provided to patients because
of the delegation of nurses' duties "as the staffing is already
under a lot of strain because of those cross-training things that
are being forced on nurses now."
Senator Olson advised that this legislation does not propose to
delegate complicated medicating duties or other high-skill
responsibilities to unlicensed staffers, but rather allows
qualified personnel to delegate some "lesser duties that tie up
personnel" to subordinates. He stated that this would allow a nurse
to determine what, if any, responsibilities could be delegated
which would allow the nurse to address more critical needs. He
exampled that this legislation would provide a nurse in a clinic
the authority to delegate such "lesser duties" as monitoring blood
pressure rates to a subordinate in order for the nurse to more
thoroughly concentrate on someone in critical condition who needs
to be admitted to a hospital.
Co-Chair Donley contented that, in addition to the pressure placed
upon a nurse to delegate duties when concentrating on a critical
patient, there are circumstances where a nurse might be under
"tremendous pressure from the hospital," specifically a for-profit
facility, "to delegate more and more of their duties." He stated
that he has witnessed situations where "nurses are being asked to
do things that they don't really feel is in the best interest of
patients, and yet the economic pressure is on them." He stressed
that nurses could be placed in a "tough situation" and ultimately
the license of the nurse, not the facility, is at stake.
Representative Wilson explained that during a recent review of
nursing statutes and regulations, nurses found that several long-
established practices, including the delegation of certain nursing
responsibilities, are not defined in current statute. She stated
that this legislation was prompted by the Department of Law's
suggestion that delegation authority should be addressed in State
statute. She stressed that the Board of Nursing would define the
parameters regarding which duties could be delegated.
Co-Chair Donley asked whether individuals who draw blood are
required to be licensed, for it appears that delegation of this
duty has become an established practice.
Representative Wilson voiced that she does not support the
delegation of this responsibility; however, a hospital might
establish this practice. She stated that the person who is
administering the procedure should have practical experience to
know what they are doing. She asserted that the majority of nurses
would not delegate this responsibility.
Senator Olson, [a medical doctor] stated that his experience has
been primarily in clinics rather than for-profit hospitals, and
that there is a misconception that the "higher licensed" person
should perform a procedure such as drawing blood; however, he
contended that, even though he has a "higher" level of training,
most nurses "and even nurses aides" are more highly skilled in that
procedure than he is. He stressed that there should be "a balance
to make sure that you have the most skilled person" performing the
procedure. He continued that some procedures do not require a
licensed individual and with today's staffing situations,
"sometimes it is not practical."
Co-Chair Donley clarified that his concern involves "delegating
down" rather than to another as equal or higher qualified
individual. He asked whether this legislation would allow a
hospital administration to exert pressure on nurses to delegate
duties, "such as the drawing of blood and other invasive
procedures," to lower level personnel.
Representative Wilson responded that this bill would not change any
practice that is currently established, but rather would
incorporate established practices into State statute. She stated
that this incorporation and clear identification of which
established practices nurses could delegate would serve to protect
nurses.
Senator Olson asked whether Bush Alaska's health aides would be
affected by this legislation.
Representative Wilson reiterated that this legislation would not
incur any changes to established practices.
Senator Olson clarified that health aide's positions would not be
affected.
Representative Wilson concurred.
Senator Olson, addressing Co-Chair Donley's concerns regarding who
administers invasive procedures, stated that oftentimes in rural
Alaska, someone gets injured, and unlicensed, but trained, medical
staffers might have to administer invasive procedures "as the first
line of health care."
Co-Chair Donley stated that statute exemptions address rural health
care situations, and stressed that his primary concern pertains to
large, for-profit medical facilities that might exert "incredible
pressures" on health care professionals in order to reduce the cost
of care. He stated that this legislation might give those entities
more opportunity to exert pressure on the nursing staff to delegate
duties to staff who might not properly trained in a procedure.
Co-Chair Donley explained that current statute requires a minimum
of one person on duty who is specifically trained for the
procedures administered in the department; and that other nurses
assigned to that department would report to the trained individual.
He furthered that if the trained individual becomes unavailable
during a shift, that person is required to delegate duties to other
untrained individuals. He stated that it is unfair to nurses to
have this onus placed on them; especially if they do not agree with
the hospital directives. He stated that a balance must be reached
whereby nurses could not be forced to delegate a duty "that they do
not necessarily agree with."
Representative Wilson stated that nurses could refuse to delegate a
responsibility, and if a doctor overrules the nurse's decision not
delegate a duty that she deems unsafe or ill advised, the nurse
could "write the doctor up." She exampled that duties such as
watching a wound for redness could be delegated provided that the
person has received proper training. She reiterated that State
statutes would specify what could or could not be delegated "which
offers protection to the nurse and to the patient."
Co-Chair Donley asked for examples of what regulations are being
considered by the Board of Nursing, as he considers the bill's
language "wide open as far as delegation of authority."
Representative Wilson stated that current nursing regulations
specify that the Board would define unprofessional conduct to
include: "knowingly delegating a nursing care function, task, or
responsibility to another who is not licensed" when that delegation
is contrary to that specified in State statute, "or involves a
substantial risk or harm to a client, and failing to exercise
adequate supervision over other persons who are authorized to
practice only under the supervision of a licensed personnel." She
expressed that these regulations clearly define what could legally
be delegated; however, the corresponding language is not currently
included in State statute.
Representative Wilson explained that the Department of Law is
requesting that the language be placed in State statute to enable
the statute to conform to existing regulations. She summarized that
the nursing profession is "strongly and heavily regulated," and
that this legislation would match State statute to current
regulations, would not change what is currently common practice,
and would continue to hold nurses to levels of "high conduct."
Co-Chair Donley stressed that his concern lies more with "the for-
profit motive in health care" which exerts pressure on nurses, and
that protecting nurses from that pressure is important. He
continued that another concern is when duties are delegated it is
the nurse's license rather than a hospital or clinic's license that
is at risk. He asked whether "better insulations" could be provided
to address this concern.
SFC 02 # 95, Side B 11:45 AM
Senator Green reminded the Committee that these concerns have been
addressed before; however, it was State agencies rather than for-
profit or non-profit entities that were requiring nurses to
delegate duties improperly.
Senator Green furthered that there have been situations in which
employment was contingent on an applicant's agreeing to delegate
authority to CNAs. She stated that hearings were conducted to
affirm that this practice would not be allowed. She stressed the
concern that this legislation might inadvertently undermine the
ability of a nurse to refuse to delegate a duty they were
instructed to delegate, and then not receive "the backup" they
might require.
Co-Chair Donley echoed Senator Green' concerns, and reiterated that
it is unfair for a supervisor's directives to place a nurse's
license in jeopardy.
Co-Chair Donley asked whether current State regulations hold upper
management accountable for exerting pressures on nurses that might
result in endangering the nurses' license.
Representative Wilson responded that doctors know what procedures a
nurse could or could not perform, in addition to what duties could
or could not be delegated. She told of a hearing process in the
event a doctor exerts pressure on a nurse to perform or delegate a
duty that might place the nurse's license in jeopardy or be unsafe
for a patient. She stressed that the procedures are "very clear and
known."
Co-Chair Donley asked whether there is a "medical whistle blower
statute."
Senator Olson interjected that the normal procedure for reporting
undue pressure placed on a subordinate, involves the employee
filing an incident report with a supervisor or a committee for
review. He continued that if the report is determined to have
merit, a letter of reprimand could be issued.
MARY WEYMILLER, Licensed Practical Nurse and Member, Board of
Nursing, testified via teleconference from Fairbanks and read a
letter from Lynne Hart, a Nurse Practitioner and a member of the
Board of Nursing [copy not provided] which spoke in support of this
legislation, specifically as it addresses the established practice
of nurses "delegating, or transferring their legal authority to
perform a specific nursing act to unlicensed assistants." She read:
that it "recently came to light" that the delegation practice is
not included in State statute as had incorrectly been assumed, and
that this omission has affected the Board of Nursing's ability to
modify regulations regarding safe delegation practices. The letter,
she continued, states that this legislation would correct both the
statute and the regulation issues; would not create new health care
worker positions as staffers are already in place, and "would
eliminate a gray area for nurses who currently are already
delegating to assistants as part of their job on a daily basis."
She read that Ms. Hart urges the Committee to support this
legislation.
Ms. Weymiller commented that current practice is that non-licensed
individuals are asked to assume additional duties after receiving
training in those procedures; however, she stressed, the practice
must be included in State statute to protect both the nurse and the
patient. She qualified that patient care could only be delegated
when a patient's condition is chronic and stable, and the non-
licensed staffer and the patient both agree to have the task
delegated. She noted that numerous safeguards and guidelines exist
to protect the licensed nurse, the person to whom the duties are
being delegated, and the patient. She "strongly urged the Committee
to pass this bill."
Senator Wilken offered a motion to "report Committee Substitute for
House Bill 276 from Committee with individual recommendations and
attached fiscal note."
Co-Chair Donley objected and expressed the hope that individuals in
the nursing profession are aware of the content of this bill and
support its intent. He furthered that were this legislation to be
enacted, its regulations should be quickly established and should
include safeguards to protect nurses from undue pressure to
delegate duties as well as including language that specifies that
management should be penalized for any directives that might result
in a nurse's license being placed in jeopardy.
Co-Chair Donley withdrew his objection.
Senator Olson asked whether, during this process, any abuse of
power incidents have been reported.
Representative Wilson stressed she has had "not one single letter
or phone call from anyone" in opposition to this legislation or any
reports of undue pressure to delegate duties.
Co-Chair Donley reiterated that during his conversations with
nurses, he has heard "horror stories" about the pressures exerted
on nurses to delegate authority. He noted that the lack of abuse of
power reports is not surprising as it is sometimes difficult to
record the specifics of an incident.
Senator Olson affirmed that nurses sometimes receive "threats of
retaliation" which could be a "real significant factor."
There being no further objections, SCS CS HB 276 (L&C) was REPORTED
from Committee with a previous zero fiscal note, dated February 15,
2002 from the Department of Community and Economic Development.
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