School Nurse
Supervision of LVNs &
Health Clerks
ACSA Every Child Counts Symposium
January 2015
Susan Chaides, MEd, RN, CPNP
2015 Los Angeles County Office of Education
California Ed Code 49400
The governing board of any school
district shall give diligent care to
the health and physical
development of students, and may
employ properly certified
persons for the work.
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Diligent Care
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Handle health and medical needs of students
Fully support Free and Appropriate Public Education (FAPE)
Follow state & federal laws, including nursing licensure
School Nurse
Legally recognized school health authority
Authority to recognize qualifications & abilities of UAP*/LVN assigned to perform health care tasks in school
*UAP = Unlicensed Assistive Personnel
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Legal Considerations for
Nurses
Federal Regulations
State Laws & Regulations (Business &
Professions Code, Education Code)
Job Description
Nursing Standards
Complex Legal & Clinical Issues
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Goals of School Health
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Enhance Learning Achievement
Increase Health & Safety
Improve Quality of
Life
Prevention of Illness
Improve Attendance
Control Contagious
Diseases
CEC 49426
School Nurse Role
Immunization compliance
Assess, evaluate, interpret health &
developmental status
Design & implement health plan
Refer resources for services
Maintain communication (case
management)
2015 Los Angeles County Office of Education
CEC 49426
School Nurse Role
Interpret medical & nursing findings &
make recommendations
Consult, conduct trainings, & serve as
resource to staff on health instruction
Assist parents/students to access
health care
2015 Los Angeles County Office of Education
CEC 49426
School Nurse Role
Counsel students and parents – Assisting in utilizing health care services
– Counseling regarding health-related
attendance problems
– Helping understand & adjust to physical,
mental and social limitations
– Exploring attitudes, information & values
which affect health behavior
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Roles & Responsibilities of the
Credentialed School Nurse
Health Assessment
Case Management
Health Counseling
Health Education
Health Screenings
Health Care
Prevent/Control Communicable
Diseases
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Health Clerk Role A
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First aid- ill & Injured students
Specialized Physical Health Care Services
Maintain files, reports, referrals
Prepare reports
Communication Clerical duties
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LVN Role A
ssis
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ol N
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Same duties as HC LVN job description
SPHCS Administer meds -
injections
Basic assessments Basic nursing care
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Performed Only by an RN
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Perform comprehensive
assessment
Validate assessment
data
Formalize nursing
diagnosis
Identify goals derived from nsg diagnosis
Determine nsg plan of care
Evaluate effectiveness of
nsg care provided
RN / LVN Relationship
2015 Los Angeles County Office of Education
LVN works under direction of RN (B&P Code 2859)
Prior to assigning SPHCS to LVN, RN must conduct assessment
Data collection done by RN, may be done by LVN (basic assessment – Title 16, § 2518)
LVN must report data to RN
RN / LVN Relationship
2015 Los Angeles County Office of Education
RN - analysis, synthesis & evaluation of data
Can only be done by RN
Cannot be delegated to LVN or UAP
LVN - not determine educational (health)
needs of patient Does not educate
patient/family
Contributes to development &
implementation of teaching plan related
to self-care for patient
RN / LVN Relationship
2015 Los Angeles County Office of Education
RN must directly observe patient, analyze, synthesize, & evaluate data collected by him/herself and LVN
RN uses data to:
- Make nursing diagnosis
- Determine appropriate interventions
- Make appropriate assignments of tasks
RN / LVN Relationship
2015 Los Angeles County Office of Education
LVN does not initiate, evaluate, or change patient’s treatment/nursing care plan (NCP = IHP)
LVN:
Participates in planning
Executes interventions as per treatment/NCP
Contributes to evaluation of interventions r/t treatment/NCP
RN / LVN Relationship
LVN can monitor patient
Only RN can manage patient
RN decides appropriateness of
assignment of tasks, based on
nursing judgment
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LVN
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• Health Office Staff
• Health Care Aide assigned to a particular student(s)
District Employee
• Contracted by District
• Provided by parent Agency LVN
Health Office Staff
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• School Nurse (RN) - credentialed
Certificated Staff
• RN – not credentialed
• LVN
• UAP – Health clerk, aide, CNA, MA
Classified Staff
Staff
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Credentialed School Nurse
• Licensed RN
• Bachelor’s degree
• Credential in School Nursing
• Many have master’s degree
• 5-6 years of education
Registered Nurse
• Licensed RN
• 2-4 years of education
Staff
Licensed Vocational
Nurse • Licensed LVN
• 12-14 months of training
• Entry level healthcare provider
Unlicensed Assistive
Personnel (UAP)
• Not licensed
• Health clerk/aide, CNA, MA
• Trained in CPR & first aid
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Continuum of Health Care
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UAP LVN SN,
RN
Medically Stable, Not
Complex
Medically Fragile,
Complex
Who Can Provide Mandate Credentialed
SN
RN LVN UAP
Minor First Aid Yes Yes Yes Yes
Assessment &
Mgmt of
Trauma
Yes Yes
Limited No
General Health
Assessment
Yes Yes Basic,
Vital signs
No
Vision Yes No No No
Hearing Yes No No No
Scoliosis Yes No No No
IHPs, ECPs Yes Yes, maybe No No
SPHCS – Train,
supervise
Yes No No No
SPHCS – Direct
Care
Yes Yes, if
supervised
by SN
Yes, if
supervised
by SN
Yes, if
supervised by
SN 2015 Los Angeles County Office of
Education
Who Can Provide Mandate Credentialed
SN
RN LVN UAP
Medication –
Train, supervise
Yes
(program)
No No No
Medication –
Administration
Yes Yes Yes, if
supervised
by SN
Yes, if
volunteer/
No
Special Ed , SST Yes No No No
Section 504
Assessments
Yes No No No
Maintain student
health records
Yes Yes Yes Yes
Health Education Yes Yes,
maybe
No No
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Who Can Provide Mandate Credentialed
SN
RN LVN UAP
Crisis Response Yes Yes (follow
written
plan)
Yes (follow
written plan)
Yes (follow
written plan)
Child Abuse Yes Yes Yes Yes
Communicable
Disease-Prevent
& Control
Yes
Yes,
Limited
Limited
No, Limited
CHDP & Oral
Health
Assessment
Yes, and
interpret
Yes
Yes
Yes
Case Mgmt Yes Yes, maybe No No
Referral &
Follow-up
Yes May assist
SN
May assist
SN
May assist
SN
Health
Counseling
Yes Yes No No
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Utilization of Qualified
Designated Personnel
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Or be assisted by qualified designated school personnel
Perform services under supervision of SN, PHN, or MD
Be assisted by credentialed SN or certified PHN
CEC 49423.5
Any student with exceptional needs who requires SPHCS
Utilization of Unlicensed
Assistive Personnel (UAP)
NPA does not give RN authority to
delegate nursing tasks & functions
which require substantial knowledge
and skills to unlicensed persons
Authority for UAPs to provide SPHCs
is conferred by Ed Code, not license of
nurse or physician
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Utilization of LVN
RN may delegate to LVN (permitted by
statute)
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Supervision
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Level of Care Required
• SN / RN
• LVN
• UAP
Level of Supervision
• Immediate
• Direct
• Indirect
Training of RN/LVN/UAP
• Initial training
• Return demonstration
• Observation
Level of Care Affected By:
Health Status
Staffing at Home
Complexity, # Procedures, Supervision
School Environment,
Schedule
Need for Immediate
Medical Support
Community Standard of
Care
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5 Factors Affecting
Decision to Assign
Potential for harm
Complexity of task
Problem solving & innovation necessary
Unpredictability of outcome
Level of interaction required
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1
2
3
4
5
Determining Assignment
of Tasks
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Task is considered routine for patient
Poses little potential hazard to patient
Involves little or no modification
Be performed with predictable outcomes
Does not involve ongoing assessment, interpretations, or decision making
Patients for whom UAPs
May Not Be Assigned
Patient is medically fragile,
condition is not chronic or stable
Patient who is usually stable is
experiencing an acute episode
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School Nurse Supervision
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UAP LVN SN,
RN
Medically Stable, Not
Complex
Medically Fragile,
Complex
Continuum of Health Care
School Nurse
Who Trains UAP/LVN?
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Elements of Training
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General principles of care
General written information about condition
Student specific training in assigned task
Written procedure
Demonstration & return demonstration
Identify potential emergencies & what to do (ECP)
Instruction in documentation
Training
Keep copies of everything given to
UAP
Document when training occurred
& outcome of training
If more than one return
demonstration is appropriate,
document
2015 Los Angeles County Office of Education
School Nurse
Who Supervises the UAP/LVN?
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Effective Supervision
*Supervisor: a qualified SN, PHN, or MD who is qualified to perform the procedure. Supervisor shall have privilege to exercise judgment and specify level of supervision required, based on professional judgment & shall advise IEP team.
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Assess real/potential
harm
Consider patient safety
Competency of caregiver
Number & complexity of
tasks
Number of staff SN
supervises
Supervision
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Level & Frequency
Based on SN professional judgment
Health status of student
Complexity of task
Levels of Supervision
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• Supervisor physically present while procedure is being done Immediate
• Supervisor present in same building & available for consultation/ assistance
Direct
• Supervisor available in person or through electronic means to provide guidance, consultation, referral to services as needed
Indirect
Components of Supervision
2015 Los Angeles County Office of Education
Document • Each instance
of supervision
Competency
• Trained personnel
Periodic • Observe the actual
procedure
Periodic
• Confer with the RN, LVN, UAP
Periodic
• Review documentation
Issues of Liability &
Documentation
Are health staff acting under
school nurse’s license?
NO!!!
UAP staff work under umbrella liability policy of school district
Not under school nurse’s license
LVN works under own license
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Issues of Liability &
Documentation
However, when school nurse “assigns” a
health care task:
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School nurse transfers responsibility for completing task to UAP/LVN
School nurse retains accountability for task being done appropriately
Documentation
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If UAP does something
inappropriate…
…And SN cannot demonstrate
(written documentation)
UAP was trained…
…And show (written documentation) UAP has successfully carried out procedure (supervision)
in the past…
…Then SN has put own license in jeopardy
Documentation Tools
Training Checklist
Health Care Contract
Emergency Care Plan
Procedure Checklist
Daily Logs
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Evaluation
Evaluation process for SPHCs in school
includes evaluation of:
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Qualified staff performance of standard healthcare procedures
Nursing interventions (outcomes)
Student’s goal achievement
Guidelines for Contracted Care
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Green Book – Section 2
• Guidelines for Contracted Care
• Sample Agreement
• Orientation Checklist
Site administrator
• Time, schedule, services to be provided
• Who is responsible for technical supervision
• How to contact supervisor
Guidelines for
Contracted Care
Agency nurse works under supervision
of agency supervisor
SN concerns about agency nursing care
should be reported to agency supervisor
All 911 calls should be communicated to
SN and site administrator
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Guidelines for
Contracted Care
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SN orient agency nurse to school site and safety practices
SN be available to interpret district policy
SN orient classroom teacher to guidelines
Agency LVN
Provided by Parent
Follow same procedures as when
District contracts with nursing agency
2015 Los Angeles County Office of Education
Resources
The Green Book: Guidelines for Provision of
Specialized Physical Healthcare Services in
California Schools. CSNO
Children and Youth Assisted by Medical
Technology in Educational Settings: Guidelines for
Care, 2nd Ed. By S. Porter, M. Haynie, T. Bierle, T.
Caldwell, and J. Palfrey (Blue Book)
2015 Los Angeles County Office of Education
Los Angeles County Office of
Education
Susan Chaides, Project Director III
2015 Los Angeles County Office of Education
“He who has health, has hope. And he
who has hope, has everything.”
~Arabic Proverb
2015 Los Angeles County Office of Education