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.