Registered Nurse Supervision

Of

EMT/Paramedic Student Training in Alaska

 A Report and Position Paper by

The Alaska Nurses Association

Professional Practice Task Force

April 2007

Issue: Should staff RNs supervise EMT/Paramedic students for invasive procedures and medication administration?

The AaNA Professional Practice Task Force recommends the following be used as guidance when considering this issue:

1. RNs should continue as a category of professional that is eligible to become EMT instructors.
2. RNs should not delegate invasive procedures or medication administration to EMT/Paramedic students, as these individuals are considered unlicensed assistive personnel.
3. The most appropriate supervision of EMT/Paramedic students is performed by program faculty, authorized program preceptors, and/or medical doctors.
4. AaNA would support exploration of RN supervision of venipuncture performed by EMT/Paramedic students when:
1. Statutory authority exists for this supervision,
2. The BON has oversight and/or coordination of EMT/Paramedic training curriculum,
3. The training program, the hospital, and the staff RN have a formal relationship

• Established preceptor training for those RNs who desire to participate in supervision of EMT/Paramedic students
• Memorandums of agreement are signed and available for review by staff RNs prior to EMT/Paramedic student supervision
• An EMT/Paramedic instructor is onsite

1. RN supervision of medication administration by an EMT/Paramedic student in the hospital is not appropriate.
2. RNs have the right to decline to supervise EMT/Paramedic students if, in the RN’s professional judgment, it would interfere with the RN’s ability to safely provide patient care.

Background

In 2004, a registered nurse forwarded a concern to the Alaska Board of Nursing regarding the nurse’s ability to teach paramedic students about medications and administration of medications. The Alaska Board of Nursing, in turn, queried the Alaska Board of Medicine regarding who can legally train paramedic students.

In December 2004, the Alaska Board of Nursing opined that a paramedic student qualifies as an Unlicensed Assistive Personnel (UAP) as defined in 12 AAC 44.950-990, thus limiting delegating invasive procedures and the administration of medications. The Board of Nursing recommends that “…the supervision of students in the clinical setting be done by an instructor from the paramedic program who is present on-site.” (AK Board of Nursing minutes, December 8-10, 2004)

In August 2005, the AK Board of Nursing sent a letter to Governor Murkowski, stating, “The Board of Nursing has determined that it is not appropriate for Registered Nurses to delegate invasive procedures to Emergency Medical Technician (EMT) and Paramedic students.” (Letter from Catherine Giessel, MS, RN, ANP, dated August 8, 2005)

At the September 2006 meeting of the AK Board of Nursing, a request to reconsider the December 2004 decision came forward from the Emergency Department Director at Fairbanks Memorial Hospital. Specifically, the ED Director would like registered nurses to be able to train EMT/Paramedic students to start IVs. The Board of Nursing reaffirmed the decision of 2004.

In December 2006, Rep. Scott Kawasaki (D-Fbks) introduced HB 36, “An Act related to the authority of Registered Nurses to assist in the training of persons who seek to become emergency medical technicians or mobile intensive care paramedics”

The AK Board of Nursing has forwarded its opposition to HB 36A as it existed in January 2007.

Scope of Issue

Guiding Principles

In previous deliberations about nursing practice issues, the AaNA Professional Practice Committee have recommended that the following Guidelines for Nursing Practice be used by RNs when considering whether a particular skill or task is within the RN’s scope of practice (adapted from the Nursing Practice Guide, Pennsylvania State Board of Nursing, P.O. Box 2469, Harrisburg, PA 17105):

• Is the practice permitted or prohibited by the Alaska nurse practice act or regulations?
• Does the practice require you to have, and do you in fact have, the specialized nursing knowledge, preparation, experience, skill and competency?
• Is the practice consistent with the ethical and quality standards embraced by the professional nursing community in the state?
• Is the practice contained in standards of practice developed by appropriate nursing associations?
• Are you prepared to accept full responsibility for your action and be accountable to the client or patient?

Discussion

1. The Alaska Board of Nursing has issued an opinion that it is outside of the scope of practice for registered nurses to delegate IV catheter insertion and medication administration to EMT/Paramedic students.

2. It is well accepted that performing IV catheter administration and administering medications are both included in basic nursing curricula in Alaska.

3. The professional nursing community in Alaska is committed to providing high quality care to patients and clients. Achieving national patient safety goals is a high priority for all of Alaska’s nurses, and a significant factor in determining the types of nursing skills that can be delegated to unlicensed assistive personnel.

4 & 5. Registered nurses are ethically required to evaluate the knowledge, skills, and experience before delegating or assigning components of nursing care to others. “Employer policies or directives do not relieve the nurse of responsibility for making judgments about the delegation and assignment of nursing care tasks” (ANA Code of Ethics, 2001).

The profession of nursing is a dynamic discipline with practice boundaries shifting and growing with the expansion and change of knowledge in response to health care needs of the consumer and health care industry. A determination of whether a particular practice or technique falls within the practice of nursing must therefore rely on qualitative criteria rather than a set list of tasks as any particular list would be rapidly out of date. The profession of nursing is impacted and defined by four main institutions:

• nursing education curricula
• state and national professional nursing association standards, scope of practice statements and certification bodies
• state nurse practice acts
• workplace job requirements

Findings, Alaska Nursing Education Curricula

In 2007, there are three Registered Nursing education programs in Alaska, all offered by the University of Alaska Anchorage:

• Associate of Applied Science (AAS), Nursing Program
• Bachelor of Science (BS), Nursing Program
• Master of Science (MS), Nursing Program

Students in the two generic nursing education programs receive an introduction to the Alaska Nurse Practice Act by the Executive Officer of the Alaska Board of Nursing. Further, the curricula of both undergraduate nursing programs include learning objectives that relate to delegation of nursing tasks to unlicensed assistive personnel (UAP).

Findings, Nursing Association Standards, Scope of Practice Statements, and Certification Bodies

Is the practice or therapy consistent with the ethical and quality standards embraced by the professional nursing community in the State?

• Standards of care are the skills and learning commonly possessed by members of a profession.
• Standards of Nursing Practice are guidelines for providing high-quality nursing care and criteria for evaluating care.
• Ethics is the science or study of moral values or principles that guide right conduct.
• In Alaska, the ANA Scope and Standards of Practice provide the framework for nursing practice. The ANA Code of Ethics for Nurses provides the framework for conduct of nurses.

In August 2005, the Alaska Nurses Association solicited information from Constituent Member Associations (CMAs) regarding RN supervision of EMT/Paramedic students in clinical experiences. Twelve CMAs responded as follows, note the regulatory authority for EMS in each state:

• 8 said “Yes” (AZ, ANA/California, DE, MO, NV, NC, OH, WI; although OH said no to medications, yes to IV start)
• Arizona: EMS regulated by Bureau of EMS & Trauma Systems, AZ Dept of Health Services
• California: EMS Authority
• Delaware: EMS, Division of Public Health
• Missouri: Bureau of EMS, Dept of Health & Senior Services
• Nevada: Committee on EMS Services, NV State Health Division
• Ohio: State EMS Board, Dept of Public Safety
• Wisconsin: EMS Advisory Board, Dept Health & Family Services
• 4 said “No” (AR, NY, PA, WA)
• Arkansas: Section of EMS & Trauma Systems, Board of Health
• New York: EMS & Trauma Prevention
• Pennsylvania: Bureau of EMS, Dept of Health
• Washington: Bureau of EMS, Dept of Health

Additionally, the Kansas Board of Nursing clarified the RN’s role in education and training of EMS personnel in 2005: the statute allows physicians and professional nurses to supervise EMS students and attendants during training. Kansas regulates EMS providers through a separate Board of EMS.

Findings, Workplace Job Requirements

• A valid registered nurse credential fulfills one requirement for EMT II/III Instructor Certification in the State of Alaska.
• Many Alaska registered nurses become EMT II/III instructors, particularly in small communities.

Additional factors impacting RN supervision of EMT/Paramedic training

• Definitions of delegation and supervision

• Delegation: “The transfer of responsibility for the performance of a task from one individual to another while retaining accountability for the outcome.” (ANA, Principles of Delegation, September 2005, p. 4)
• Supervision: “The active process of directing, guiding and influencing the outcome of an individual’s performance of a task. Supervision is generally categorized as on-site (the RN being physically present or immediately available while the task is being performed) or off-site (the RN has the ability to provide direction through various means of written and verbal communications).” (ANA, Principles of Delegation, September 2005, p. 4)

• RN experiences in Alaska communities

• EMT/Paramedic program instructor was not present in the facility while EMT/Paramedic students were assigned to staff RNs.
• EMT/Paramedic program instructor was supervising up to 16 students located in different inpatient units throughout the facility.
• The level of EMT/Paramedic student was not made clear to the RN that was expected to provide supervision.
• Memoranda of Understanding/Agreement were not available to the staff RNs expected to provide supervision.

• Alaska Nurse Practice Act (March 2007)

Applicable sections

Sec. AS 08.68.410 (9) "practice of registered nursing" means the performance for compensation or personal profit of acts of professional service that requires substantial specialized knowledge, judgment, and skill based on the principles of biological, physiological, behavioral, and sociological sciences in assessing and responding to the health needs of individuals, families, or communities through services that include

(A) assessment of problems, counseling, and teaching

(i) clients to maintain health or prevent illness; and

(ii) in the care of the ill, injured, or infirm;

(B) administration, supervision, delegation, and evaluation of nursing practice;

(C) teaching others the skills of nursing;

(D) execution of a medical regimen as prescribed by a person authorized by the state to practice medicine;

(E) performance of other acts that require education and training that are recognized by the nursing profession as properly performed by registered nurses; performance of acts of medical diagnosis and the prescription of medical therapeutic or corrective measures under regulations adopted by the board.

12 AAC 44.770. Unprofessional Conduct. Nursing conduct that could adversely affect the health and welfare of the public constitutes unprofessional conduct under AS 08.68.270 (7) and includes the following:

(4) failing to exercise adequate supervision over persons who are authorized to practice only under the supervision of the licensed professional;

• Alaska Statutes and Regulations, Medicine

12 AAC 40.325, Internship Requirements (May 11, 1985): An internship for a mobile intensive care paramedic must meet the following requirements:

(1) all procedures performed by an intern must be under the direct supervision of a physician sponsor or another physician, physician assistant, registered nurse, or mobile intensive care paramedic, licensed or certified in the state where the internship takes place, who has been designated the responsibility of supervision by the physician sponsor;

(2) the successful completion of the internship must be verified, on a form approved by the board, by the physician sponsor, attesting that the mobile intensive care paramedic intern is capable of performing the activities listed in 12 AAC 40.370 (a) including any other specific emergency procedures authorized by the physician sponsor under 12 AAC 40.370 (a)(8); and

(3) verification from the supervising physician of the successful completion of 20 twenty-four hour shifts, or the equivalent number of hours, completed at a location approved in advance by the board.

12 AAC 40.370. Scope of Authorized Activities. (a) A licensed mobile intensive care paramedic, when under the supervision of a sponsor physician, may perform the activities listed in this subsection. The direct supervision of an activity may be delegated to another physician when the mobile intensive care paramedic is caring for a patient in a hospital, at the scene of a medical emergency when voice contact is monitored by a physician and direct communication is maintained, or when under the specific written standing order of a physician. The activities are

(1) electrocardiographic monitoring and defibrillation;

(2) initiating and maintaining intravenous routes using approved intravenous techniques and solutions;

(3) performing endotracheal intubation and pulmonary ventilation by approved methods;

(4) performing gastric suction by intubation;

(5) obtaining blood for laboratory analysis;

(6) administering parenterally, orally, or topically any approved agents or solutions;

(7) use of pneumatic antishock devices; and

(8) performing other emergency procedures authorized by a sponsoring physician.

(b) A person enrolled in a mobile intensive care paramedic training program may perform the activities set out in (a) of this section insofoar as:

(1) the activities are required as part of the training program;

(2) the activities that take place in a hospital are supervised by a physician, physician assistant, or nurse; and

(3) the activities that take place outside a hospital are supervised by a licensed mobile intensive care paramedic, or physician sponsor, or the physician sponsor’s designee.

(d) The scope of authorized activities for a mobile intensive care paramedic does not include primary patient care, such as dispensing nonemergency medications, performing physical examinations for nonemergency purposes, and treatment of nonemergency medical conditions included in the scope of practice for a physician, physician assistant, or nurse, unless specifically authorized by the board.

Attachment A - AaNA Professional Practice Task Force Members:

A list of task force members is included as Attachment A. Vitae are on file at the AaNA office.