1. 1 Unlicensed Assistive Personnel NCSBN Workshop June 30, 2010

2. 2 RN Delegation to CMA/CMT in Group Home Setting Barbara Newman RN, MS Director of Nursing Practice Maryland Board of Nursing

3. 3 Maryland Demographics Population – 5.6 Million Environment – Mountain-Sea Coal mining – Watermen Hospital (68) 10, 880 beds NH (240) 30,0000 beds

4. 4 Maryland Has 5.6 Million Citizens STATE Total Population 5,618,250 AgeNumber of Citizens % of Total Population 0-4 years370,4046.6% 5-9 years359,9586.4% 10-14 years376,7136.7% 15-19 years410,9147.3% Over 194,10026173%

5. 5 Maryland Has 5.6 Million Citizens STATE Total Population 5,618,250 AgeNumber of Citizens % of Total Population Under 191,517,9891127% 20-44849,72234.6% 45-641,491,44126.6% 65-84578,72210.3% Over 8585,3371.5%

6. 6 Maryland Demographics (Cont.) AL (1300+providers) 20,000 beds DDA (220+providers) 10,000 beds School (24 Counties) 850,000 Students Corrections (24 Counties) 140,000/month Prisons (25) 23,000 average census

7. 7 MBON LICENSURE RN = 65,600 LPN = 13, 600 Advance Practice = 4,500 CNA = 104,000 CMT = 62,000 CMA = 3,900

8. 8 Structured Care Facilities In Mid 1970s developed the Certified Medicine Aide to work in the licensed NH to administer medication: oral suppository topical

9. 9 Structured Care Community Care 1980s and 1990s –Mental Health Facility – group home –Developmental Disabilities facility – group home –Congregate housing – Assisted Living

10. 10 Community Based Setting In Mid 1980s movement of DD clients from State Hospitals to 3 bedroom single dwelling homes in local communities In Mid 1990s movement of Congregate housing adult clients to AL settings (3 bedroom homes to 150 beds)

11. 11 Community based settings (Cont) In Mid 1980s CNAs in school health settings (no longer one RN per school in all Counties). In Mid 1990s shift from correctional officers administering medications to nursing staff.

12. 12 Structured Care to Community Based Setting Increase in population served Increase in sites that serve the population Available licensed staff did not keep pace

13. 13 Who May Administer Medication? RN LPN Certified Medicine Aide (CMA) Certified Medicine Technician (CMT)

14. 14 Certified Medicine Aide (CMA) Created mid 1970s for the licensed NH Must be a CNA/GNA Must have worked for 1 year FT in NH Trained specifically for the NH Client chronic/stable/complex care with acute illness Licensed nurse (RN/LPN) on unit with CMA 24/7 (BON certified CNA/GNA/CMA 1999)

15. 15 CMA (Cont) Administers medication by the following routes: –Oral –Suppositories –Topicals –Eye/ear/nose/gtts –Nebulizer

16. 16 CMA (Cont) In the N.H. setting the CMA does not administer: GT feeding IM/Subq/Intradermal IVs

17. 17 CMA (Cont) Training Program 60+ hours in length 30 hours Theory 30 hours Clinical Clinical in NH with RN Instructor Taught in BON approved Community Colleges

18. 18 Certified Medication Technician (CMT ) Created mid 1980s for community based settings Registered with BON 1999 Certified by BON 2005 Math/Reading Taking meds for self Throwing med in trash etc.

19. 19 CMT (Cont) CNA not required Works in Community based setting Group Homes (AL, DD, JS) Schools Supervised work settings Corrections

20. 20 CMT (Cont) Client chronic/stable/predictable RN not required 24/7 RN makes supervisory visit 14 to 45 days when medications are delegated RN supervisory visits for other delegated nursing tasks is determined by the RN specific to the client needs

21. 21 CMT (Cont) Training program length 20 hours Must pass math/reading exams as prerequisite Theory Simulated med pass Med pass with client with RN Trainer present Taught by RN, CM/DN approved by the BON Administers medication to client who is chronic/stable/predictable

22. 22 CMT (Cont) Administer medications by the following routes: oral eye/ear/nose drops topical patches/creams GT feedings Suppositories Subcutaneous injections

23. 23 CMT (Cont) Does not administer: IM Intradermal IV

24. 24 CMA and CMT perform delegated nursing function of medication administration Requires RN to assess the client and determine: is the client chronic/stable/predictable is task of medication administration routine-performed the same way? is environment conducive to the delegation? is the CMA/CMT competent to perform the administration of medication?

25. 25 Community Based Settings fewer resources fewer supports complaints regarding quality of nursing assessment/oversight/competency in delegation BON developed training program for the RN

26. 26 Community Based Setting Client is usually not in setting for health care: School Health – education Detention Center/Prisons-incarceration DD-promote community/home like care psychosocial model AL – maintenance of independence/supervision of nutritional intake/medication Juvenile Service - incarceration

27. 27 Community based setting RN not familiar/comfortable with: working in a system without a defined nursing system with clear boundaries being the only RN or licensed health care person in the facility/agency

28. 28 Registered Nurse, Case Manager/ Delegating Nurse (RN, CM/DN) Required training for a RN working in AL, JS, Sch. Hlth., Corrections, DDA Approximately 16 hours in length Developed by BON with Community Implemented 1999 2 nd Revision 2005 Beginning 3 rd revisions 2010 Taught in 11 BON approved educational facilities

29. 29 Registered Nurse, Case Manager/ Delegating Nurse (RN, CM/DN) Cont Training is specific to practice setting: Assisted Living Developmental Disabilities School Health/Juvenile Services Corrections

30. 30 Registered Nurse, Case Manager/ Delegating Nurse (RN, CM/DN) Cont Content of the training program: 1. History of setting Description of aggregate client population Regulations governing the setting Nurse Practice Act Other regs Commission on Correctional Standards Maryland State Department of Education Juvenile Service Assisted Living Developmental Disabilities

31. 31 Content of the Training Program Overview of Role and Responsibilities of the RN, CM/DN: For specific setting such as: Corrections Maryland State Department of Education Assisted Living Developmental Disabilities Juvenile Service Documentation Reporting requirements

32. 32 Content of the Training Program (Cont) How to teach the CMT: Prerequisite to CMT Training (math/ reading exam) Training Program Content Evaluation of CMT Competency Required Clinical Update

33. 33 Content of the Training Program (Cont) Case Manager – Principles Planning Coordination Resource utilization

34. 34 Content of the Training Program (Cont) Principles of Delegation Standards of Delegation (COMAR 10.27.09) Delegation of Nursing Functions (COMAR 10.27.11) CMA Regulations (COMAR 10.39.03) Regulations Governing the CMT (COMAR 10.39.04) Code of Ethics for the CNA/CMT (COMAR 10.39.07)

35. 35 Content of the Training Program (Cont) Legal/Ethical Issues Code of Ethics Client Advocacy Legal constraints

36. 36 Content of the Training Program (Cont) Communication Is the effective foundation to delegation/supervision

37. 37 Content of the Training Program (Cont) Adult Learning Principles for teaching CMT Training Program Pedagogy/Andogagy Core goals/needs of adult learner Cultural diversity Engaging student in learning

38. 38 What have we learned CMT ISSUES Difficulty with reading and math No ownership of their certification Poor historians Poor compliance with renewal process – everyone else is responsible Believe it is just another training necessary for the job.

39. 39 What have we learned CMT ISSUES (Cont) The CMT Requires remediation during the site visit by RN, CM/DN Does not always document administration consistently Does not always notify RN of new medications Does not always notify RN of changes in patient

40. 40 What have we learned RN ISSUES Some difficulty with working in isolation (JS, DDA, AL setting) O ther RNs absent Other staff with health background absent Feels as if they are a lone voice in wilderness Negotiating skills limited Case management skills limited Does not consistently determine competency of people they are delegating to.

41. 41 What have we learned RN ISSUES Time management/multitasking in community based setting some times difficult. Leadership skill and coordinating with house manager sometime difficult RN, CM/DN voices need for peer support group

42. 42 What would we do differently RN ISSUES Strengthen knowledge & skill in interviewing (The RN instruction and supervision is based in part upon CMT reporting) Strengthen knowledge and skill set in: Coordination with unlicensed people who serve as managers of the home Directing the care workers to do the delegated tasks Determining competency of the CMT/CNA Encourage/partner with association to create peer support group

43. 43 What has been successful RN ISSUES(Cont) Strengthen ties with other state agencies –DDA – 4 Regional RNS –AL-OHCQ (new regs) –School Health - MSDE –Corrections - MCCS Reasonable expectations of RN in isolated setting

44. 44 If We Could Start Over CMT ISSUES Require CMT to be CNA CNA functions need to be the basis for the CMT Require CMT training in Community College Require CMT Clinical Update to be done by Community College

45. 45 If All Could Start Over RN ISSUES Require all RNs to take a RN, CM/DN refresher Course every 2 years Do not permit the RN in the setting to teach the CMT Training Program Require the RN to have at least two (2) years of RN experience Strengthen negotiation/coordination/interviewing skills L imit role to delegating and supervising (not training the CMT)