HB 276-REGULATION OF NURSING  SB 283-REGULATION OF NURSING  CHAIRMAN STEVENS announced HB 276 and SB 283, companion bills, to be up for consideration. He said they would use the working draft of HB 276 for discussion. REPRESENTATIVE PEGGY WILSON, sponsor of HB 276, said: HB 276 is essentially a cleanup bill that brings the nursing statutes up to date with current nursing practice in three different ways. One, it gives licensed nurses the authority to delegate duties to other unlicensed personnel. Two, it increases the length of time available for a temporary nursing license from four to six months just for the criminal justice background checks. It takes a little longer now than it used to because of that. And three, it changes the wording regarding licensure by endorsement and brings the wording in statute into compliance with what's already being done in the division. I have the whole nursing board behind me, so… SENATOR TORGERSON asked if there was a definition of "assistive personnel" in section 5 where it says they can delegate to unlicensed assistive personnel. REPRESENTATIVE WILSON replied that meant unlicensed assistive personnel, like nurses aides or someone else that would be working with a patient or a client. SENATOR TORGERSON asked if that was defined in statute. He had no objection to the way it was written in the sponsor statement - unlicensed assistive personnel (UAPs) such as aides and technicians - MS. LYNN HARTZ, a nurse practitioner and member of the Board of Nursing, responded: Whether there is a definition in statute that determines who is an unlicensed assistive personnel - no, because by definition unlicensed assistive personnel is someone who doesn't have a certificate or a license to practice and has been historically and currently. Perhaps I could back up a little bit, if I may. I had some testimony that might help explain this as far as giving licensed nurses the authority to delegate nursing duties to other personnel. This came about when the Board of Nursing was drafting regulations on delegation last year and we were told at that time that nurses did not have the authority to delegate to assistive personnel whom in general we call UAPs (someone without a license or certificate in this state). Therefore, the Board could not write regulations about delegation. The Board had always assumed that nurses had this authority to delegate to unlicensed assistants and it even published a position statement on that with our statutes and regs in 1993. So that's why we view it as a cleanup section because it's giving the Board of Nursing and nurses the authority we thought we already had. An example of delegation might be a nurse asking a nurses aide to run a urine test on a patient. The nurse's aide has no legal scope of practice. Hence the term unlicensed assistive personnel. The legal source of the authority to do the nursing task, in this case a urine test, is the licensed nurse, because the nurse does have a legal scope of practice in the state. So the nurse transfers or delegates that authority to the unlicensed person, in this case to do a urine specimen. Without the ability for the nurse to delegate nursing tasks, the unlicensed assistants have no authority to act. Therefore, without this legislation the UAPs who are called patient care technicians at Providence Hospital have no legal basis to continue to perform nursing tasks that are delegated. At the municipality of Anchorage, UAPs are called family service aides. It seems to be that since they are unlicensed and certificated, different employment agencies give them different terminology. So, at Anchorage Health Department, they are called family service aides. They would not be able to perform nursing tasks delegated by public health nurses. We do have unlicensed assistive personnel defined, but it's a part of the position statement written in 1993, which the Board of Nursing was told it didn't have the authority to write, because we didn't have statutory authority to delegate to unlicensed assistive personnel. SENATOR TORGERSON said he would feel better if somewhere it said "supervised". "Right now you can go out and get somebody off the street and give them a job. That's the part that I don't like." MS. HARTZ said the safety component is under the regulations promulgated by the Board. There would be supervision by registered and licensed nurses. SENATOR AUSTERMAN said he understood that those regulations hadn't been adopted yet. MS. HARTZ replied, "Just because we don't have the statutory authority to write regulations." CHAIRMAN STEVENS said, "But you have the regulations." MS. HARTZ responded, "We have some proposed regulations that we've been working on, yes, that deal with supervision, yes." CHAIRMAN STEVENS asked, "Are they ready to be adopted as regulations now, then?" MS. HARTZ replied, "No. I would say we still want to work on them some more." SENATOR TORGERSON said he didn't care what they had, he thought it should be in the bill. "Supervised delegation" would be one fix for defining the level of personnel you can do this to. "Right now it's wide open." CHAIRMAN STEVENS asked about the concept of section 5 going into affect once the regulations are promulgated. REPRESENTATIVE WILSON replied that's the main reason for the bill. The nurses have the regulations, but there is nothing in statute saying they could adopt them. SENATOR AUSTERMAN said the Board currently has the authority to write regulations. MS. HARTZ replied, "Not regarding delegation of authority and yet it's being done daily currently in public health hospitals, clinics." SENATOR DAVIS asked if the unlicensed personnel were certified to work in a hospital. Someone indicated they aren't. She asked if they could cover the issue by limiting the authority to people who are employed by the facility. SENATOR AUSTERMAN said that a hospital could use a janitor in that instance. MS. HARTZ responded that it was professionally inappropriate for an RN to delegate in an inappropriate or unsafe manner. They have been telling people while they are in this gray area of practice to please go by appendix D in the back of the statutes, which deals completely with delegation and licenses to personnel. They would like to refine that and that is what she meant when she said they didn't have those regulations ready to go. CHAIRMAN STEVENS asked if this practice has already been going on, why do they need it in statute. MS. HARTZ replied that was a good question and the Nursing Board was under the misapprehension that nurses had that authority all along and that's why that appendix was written in 1993. The Board submitted regulations to the Department of Law and were advised them and the Attorney General that that needed to be in statute. CHAIRMAN STEVENS asked if there's liability involved with administering any sort of tests, does the liability trail follow the delegation of authority and has anyone ever sued an institution for having an adverse reaction to a drug. MS. HARTZ replied that it is the nurse's responsibility. Her license would be at stake if something like that happened. The three categories of unlicensed assistive personnel are identified as follows: Those who nurses supervise and to whom they delegate some activities to, those who nurses teach, but do not supervise to those who are not directly or indirectly supervised or taught by nurses. SENATOR TORGERSON said he thought they should adopt the suggested language and that would clarify the whole thing. He suggested replacing section 5 with some of the language. SENATOR TORGERSON moved a conceptual amendment on page 60 where the unlicensed assisted personnel is defined. There were no objections and that amendment was adopted. MS. NANCY DAVIS, Chief, Public Health Nursing, supported HB 276, because it brings a number of protections to the public. The language is good in terms of licensure and it makes a lot of sense for them to look carefully at endorsement licensure and making sure that there are current competencies. They are also supportive of the delegation of nursing functions, because it's a critical element of nursing practice already. It's essential to rural health care, especially in this state, in that there aren't licensed practitioners in all the villages and there are a lot of health care that needs to occur through delegation. MS. PATRICIA SENNER, President, Alaska Nurses Association, supported SB 283. She said over the past 10 years there has been an increase in the number and type of ancillary unlicensed health care workers that RNs and LPNs delegate duties to and have oversite over the work they perform. It is imperative that we have regulations from the Board of Nursing covering delegation of nursing tasks. Nurses rarely hire or train the unlicensed personnel they are required to work with, yet their employers require them to make sure these persons perform the tasks delegated to them in a safe and accurate manner. Because these individuals are unlicensed, there is no regulatory body overseeing their training and competency. In terms of the definition of unlicensed assistive personnel, she said, there are family members who are hired under the Choice program who take care of the patient and in those cases, they would come under the authority of a registered nurse. It would be different than a family member doing this out of the goodness of their heart. She didn't know if there was wording saying the caregiver had to be employed. SENATOR TORGERSON was looking at the statute and said that it was silent on that issue. Maybe they needed to think about that. REPRESENTATIVE WILSON said the fact that it's not mentioned means that it would mean anyone, whether they were employed or not. SENATOR TORGERSON said: That's not what this says. Not to belabor it. It says, 'The term also includes, but is not limited to orderlies, assistants, attendants and technicians. For the purposes of this delegation criteria, unlicensed and assistive personnel do not include family members of the client immediate family or guardians. So we have to change that to say "may include" if we want to be inclusive. MS. REARDON asked why they need to go any further than the first sentence of that definition, which says: Unlicensed assistive personnel are individuals who are not authorized to perform nursing acts or tasks that are regulated by the Board of Nursing except pursuant to legal delegation by a nurse. SENATOR TORGERSON proposed amendment #2 to delete "do not" and insert "may". The Board is going to have to define it anyway because those regulations were wrong for what they were doing for delegation to people who were home and were family members. If they're delegating that now, that can't happen because they would be under the same law. CHAIRMAN STEVENS asked why the regulations do not include members of the client's immediate family. MS. REARDON replied that this language never became regulation, so it didn't go through the legal review process. "These are just an advisory opinion of the Board of Nursing." She said the reason it didn't include family members is because of the last sentence, which says: Family members and guardians have performed and continue to perform these activities without specific delegation. I suspect they were trying not to constrict what family members could do, since the rest of this advisory opinion puts constraints and guidelines and rules about the delegation. She thought they were trying to say for family members it could be a more flexible system. CHAIRMAN TORGERSON said they don't write laws or regulations by saying historically this is what happens. His conceptual amendment left the last sentence out. CHAIRMAN STEVENS asked if there were any objections to the conceptual amendment. TAPE 11, SIDE B  SENATOR DAVIS said they shouldn't put family members in there, because they could come back on the nurses. "How can they supervise them if they're doing it at home. The nurses are in the hospitals working…" SENATOR TORGERSON said he thought the family members were being paid, which is a big difference and he didn't think they were performing procedures. MS. SENNER said that was the point she was making. Family members are trained by nurses and other health care professionals to do all kinds of advanced care, giving I.V.s or someone comes home on a respirator and the family member takes care of the respirator. The issue only comes into play when they are hired, such as under the Choice program and then they do come under the authority of a nurse. She thought they should say: "Unlicensed assistive personnel or individuals who are hired to perform health care services." You would have the employment part in there, too. SENATOR TORGERSON said they could do that by regulation. His objective was to define the personnel and he thought they had done that by adopting the definitions. There is still clearly a role for the Board of Nursing to play and the regulatory process to implement this law. CHAIRMAN STEVENS said there were no further objections to amendment #2 and it was adopted. REPRESENTATIVE WILSON supported the amendments. SENATOR TORGERSON moved to pass SCSHB 276(L&C) from committee with individual recommendations. There were no objections and it was so ordered.