DEPARTMENT OF ADMINISTRATIVE SERVICES
Division of Professional Regulation
1900 Board of Nursing
final
ORDER
Pursuant to due notice of the time and place of hearing published in the News Journal and in the Delaware State News and in compliance with the requirements of 29 Del.C. §10115, the Delaware Board of Nursing ("Board") under its authority to enact rules and regulations specified in 24 Del.C. §1906(1), conducted a public hearing concerning proposed modifications to the Rules and Regulations of the Board. The proposed modifications and additions were published in the Delaware Register of Regulations Volume 8, Issue 3, Wednesday, September 1, 2004 beginning at Page 377. Notice of the hearing was also published in two newspapers of general circulation and on page 499 of Volume 8, Issue 3 of the Delaware Register of Regulations (Hearing Exhibit No. 1). The public hearing was held on October 13, 2004 as scheduled in Conference Room A, Cannon Building, 861 Silver Lake Boulevard, Dover, Kent County, Delaware. A quorum of the Board was present for the hearing.
Summary Of The Evidence
Pursuant to 29 Del.C. §10118, the following is a summary of the evidence and information provided at the hearing.
David Klopfenstein, CRNA, MSN, President, Delaware Association of Nurse Anesthetists presented oral and written comments (Hearing Exhibit No. 2) expressing the opposition of the Delaware Association of Nurse Anesthetists to the proposed Regulation provision which would provide that Advanced Practice Nurses (APN’s), properly trained, could insert and remove epidural catheters. Mr. Klopfenstein noted that objections were based upon a threat to patient safety and that the change did not address an access to care issue and did not advance the profession of nursing.
Delphose E. Price, Jr., CRNA, MSN, stated to the Board that he was knowledgeable concerning the insertion and removal of epidural catheters and that there were patient safety issues with both the insertion and removal of such catheters and that only nurses who were Certified Registered Nurse Anesthetists were properly trained to insert and remove these catheters.
Iva J. Boardman, R.N., M.S.N., Executive Director of the Board of Nursing, was sworn and testified concerning the development of the proposed modification to the Rules and Regulations of the Board. Ms. Boardman noted that the proposed Regulation began in 1989 as a Board position paper and had experienced seven revisions in the intervening years. In February of 2004 in reviewing the use of anesthetic agents by registered nurses prior to intravascular therapy, the Board, upon the advice of legal counsel determined to move the position paper statements into the form of Rules and Regulations of the Board.
Written comments were received by the Board of Nursing. David Klopfenstein, CRNA, MSN, on behalf of the Delaware Association of Nurse Anesthetists wrote to express concern regarding the proposed change relating to the insertion and removal of epidural catheters by APN’s after special training. The letter noted, among other things, that there are already many health care providers in Delaware that are trained and permitted to insert epidurals and that adequate access was available through physicians and nurse anesthetists (Hearing Exhibit No. 2).
Lenhart Fagraeus, MD, PH. D., provided written comments expressing concern with the same propose provision because of safety and education issues and noted that there are enough Anesthesia personnel in the State of Delaware to meet the needs for pain management. Dr. Fagraeus opined that CRNA’s should be the only nurses working with epidural catheters (Hearing Exhibit No. 3).
Sandra P. Como-Fluehr, MSN, RN, APN, BC of the Pain Management Service, Alfred I. DuPont Hospital for Children also provided written comments. She noted that there are many states which allow removal of epidural catheters by properly trained registered nurses. Ms. Como-Fluehr also noted that the insertion of epidural catheters and their removal were separate issues. She supported their removal by trained APNs (Hearing Exhibit No. 4).
Peter B. Panzer, MD, provided written comments proposing further modification to the Rules and Regulations of the Board of Nursing to provide that intradermal or topical anesthetics may be used by the RN or LPN in various situations or settings provided there is an authorized prescribers’ order. Dr. Panzer’s comments recognized that his proposal was not addressed by the section relating to intravascular therapy which was the subject of the present proceeding but sought to have the Board give consideration to his proposal as either a stand-alone section or as part of another section of the Nursing Regulations (Hearing Exhibit No. 5).
Leslie Verucci, RN,MSN, CNS,APRN-BC, CNRP, Chair of the Advanced Practice Council of Delaware Nurses Association provided written comments observing that there are no nurse practitioners who have come forward with a request to insert epidural catheters. Ms. Verucci noted that her Association supported the use of CRNA’s to perform the task of inserting epidural catheters but believed that RN’s with specialized training may remove epidurals safely (Hearing Exhibit No. 6).
Findings Of Fact And Conclusions
The Board finds that the procedures required for the modification of Rules and Regulations have been accomplished as required and that the proposed change furthers the public purposes of the Board of Nursing.
The only area where the proposed Rules and Regulations relating to the provision of intravascular therapy met with any controversy surrounded the proposed provisions relating to the insertion and removal of epidural catheters.
The currently proposed provision 7.8.4.3.1.6 sets forth the existing practice in this state and provides that the Registered Nurse may not insert or remove epidural catheters. The Board finds that it is not appropriate at this time to change this limitation. The proposed section 8.7.16 proposed that it was to be considered to be within the scope of practice of APNs with specialized training to insert and remove epidural catheters. The Board finds that it is not appropriate at this time to adopt this provision because of the information provided by and on behalf of CRNAs raises questions which need to be addressed further concerning patient safety relating to the removal as well as the insertion of epidural catheters. The Board’s Regulations are now silent on who can insert and remove such catheters. CRNAs have historically been engaging in both the removal and insertion of epidural catheters and so the status quo relating to the insertion and removal of epidural catheters will be maintained by the Board’s determination to enact section 7.8.4.3.1.6 and to abstain from enacting section 8.7.16.
The Nursing Practice Committee of the Board will review the question of authorization to insert and remove epidural catheters and will make a recommendation to the Board concerning these matters after further study.
DECISION AND ORDER
Based upon the findings and conclusions set forth above, the undersigned, constituting a quorum of the Delaware Board of Nursing, adopt the proposed modification to the Rules and Regulations published in the Register of Regulations in Volume 8, Issue 3, Wednesday, September 1, 2004, beginning at page 377 as a modification to the Rules and Regulations of the Board, effective December 13, 2004 with the exception of Proposed Section 8.7.16 regarding the insertion and removal of epidural catheters which is not adopted. (See Attached EXHIBIT A).
The written comments of Dr. Peter B. Panzer (Hearing Exhibit No. 5) are referred to the Nursing Practice Committee for consideration and action as appropriate.
The Rules and Regulation Committee of the Board of Nursing shall review the circumstances and situations surrounding the insertion and removal of epidural catheters and make recommendations to the Board as to appropriate additions to the Board’s Rules and Regulations concerning the insertion and removal of such catheters.
SO ORDERED this 20th Day of October, 2004.
BY ORDER OF THE BOARD OF NURSING
7.0 Standards of Nursing Practice
7.1 Authority
“Standards of nursing practice” means those standards of practice adopted by the Board that interpret the legal definitions of nursing, as well as provide criteria against which violations of the law can be determined. Such standards of nursing practice shall not be used to directly or indirectly affect the employment practices and deployment of personnel by duly licensed or accredited hospitals and other duly licensed or accredited health care facilities and organizations. In addition, such standards shall not be assumed the only evidence in civil malpractice litigation, nor shall they be given a different weight than any other evidence.
7.2 Purpose
The purpose of standards is to establish minimal acceptable levels of safe practice for the Registered and Licensed Practical Nurse, and to serve as a guide for the Board to evaluate safe and effective nursing care.
7.3 Standards of Practice for the Registered and Licensed Practical Nurse
7.3.1 Standards related to the Registered Nurse.
7.3.1.1 The Registered Nurse shall conduct and document nursing assessments of the health status of individuals and groups by:
7.3.1.1.1 Collecting objective and subjective data from observations, examinations, interviews and written records in an accurate and timely manner. The data include but are not limited to:
7.3.1.1.1.1 Biophysical and emotional status and observed changes;
7.3.1.1.1.2 Growth and development;
7.3.1.1.1.3 Ethno-cultural, spiritual, socio-economic and ecological background;
7.3.1.1.1.4 Family health history;
7.3.1.1.1.5 Information collected by other health team members;
7.3.1.1.1.6 Ability to perform activities of daily living;
7.3.1.1.1.7 Consideration of client’s health goals;
7.3.1.1.1.8 Client knowledge and perception about health status and potential, or maintaining health status;
7.3.1.1.1.9 Available and accessible human and material resources;
7.3.1.1.1.10 Patterns of coping and interaction.
7.3.1.1.2 Sorting, selecting, reporting, and recording the data.
7.3.1.1.3 Analyzing data.
7.3.1.1.4 Validating, refining and modifying the data by using available resources including interactions with the client, family, significant others, and health team members.
7.3.1.1.5 Evaluating data.
7.3.1.2 Registered Nurses shall establish and document nursing diagnoses that serve as the basis for the strategy of care.
7.3.1.3 Registered Nurses shall develop strategies of care based on assessment and nursing diagnoses. This includes, but is not limited to:
7.3.1.3.1 Prescribing nursing intervention(s) based on the nursing diagnosis.
7.3.1.3.2 Initiating nursing interventions through
7.3.1.3.2.1 Giving care.
7.3.1.3.2.2 Assisting with care.
7.3.1.3.2.3 Delegating care.
7.3.1.3.3 Identifying to the identification of priorities in the strategies of care.
7.3.1.3.4 Setting realistic and measurable goals for implementation.
7.3.1.3.5 Identifying measures to maintain comfort, to support human functions and responses, to maintain an environment conducive to well being, and to provide health teaching and counseling.
7.3.1.3.6 Supervising the caregiver to whom care is delegated.
7.3.1.4 Registered Nurses shall participate in the implementation of the strategy of care by:
7.3.1.4.1 Providing care for clients whose conditions are stabilized or predictable.
7.3.1.4.2 Providing care for clients whose conditions are critical and/or fluctuating, under the direction and supervision of a recognized authority.
7.3.1.4.3 Providing an environment conducive to safety and health.
7.3.1.4.4 Documenting nursing interventions and client outcomes.
7.3.1.4.5 Communicating nursing interventions and client outcomes to health team members.
7.3.1.5 Registered Nurses shall evaluate outcomes, which shall include the client, family, significant others and health team members.
7.3.1.5.1 Evaluation data shall be appropriately documented; and
7.3.1.5.1.1 Be communicated to the client, family, significant others and appropriate members of the health care team; and
7.3.1.5.1.2 Used as a basis for modifying outcomes by reassessing client health status, modifying nursing diagnoses, revising strategies of care or prescribing changes in nursing interventions.
7.4 Standards of Practice for the Licensed Practical Nurse
7.4.1 Standards related to the Licensed Practical Nurse’s contributions to the nursing process.
7.4.1.1 The Licensed Practical Nurse shall contribute to and document nursing assessments of the health status of individuals and groups by:
7.4.1.1.1 Sorting, selecting, reporting, and recording the data.
7.4.1.1.2 Collecting objective and subjective data from observations, examinations, interview and written records in an accurate and timely manner. The data include but are not limited to:
7.4.1.1.2.1 Biophysical and emotional status and observed changes;
7.4.1.1.2.2 Growth and development;
7.4.1.1.2.3 Ethno-cultural, spiritual, socio-economic, and ecological background;
7.4.1.1.2.4 Family health history;
7.4.1.1.2.5 Information collected by other health team members;
7.4.1.1.2.6 Ability to perform activities of daily living;
7.4.1.1.2.7 Consideration of client’s health goals;
7.4.1.2 Licensed Practical Nurses shall participate in establishing and documenting nursing diagnoses that serve as the basis for the strategy of care.
7.4.1.3 Licensed Practical Nurses shall participate in developing strategies of care based on assessment and nursing diagnoses.
7.4.1.3.1 Contributing to setting realistic and measurable goals for implementation.
7.4.1.3.2 Participating in identifying measures to maintain comfort, to support human functions and responses to maintain an environment conducive to well-being, and to provide health teaching and counseling.
7.4.1.3.3 Contributing to setting client priorities.
7.4.1.4 Licensed Practical Nurses shall participate in the implementation of the strategy of care by:
7.4.1.4.1 Providing care for clients whose conditions are stabilized or predictable.
7.4.1.4.2 Providing care for clients whose conditions are critical and/or fluctuating, under the directions and supervision of a recognized licensed authority.
7.4.1.4.3 Providing an environment conducive to safety and health.
7.4.1.4.4 Documenting nursing interventions and client outcomes.
7.4.1.4.5 Communicating nursing interventions and client outcomes to health team members.
7.4.1.5 Licensed Practical Nurses shall contribute to evaluating outcomes by appropriately documenting and communicating to the client, family, significant others and the health care team members.
7.5 Standards Related to the Registered and Licensed Practical Nurse’s Competencies and Responsibilities.
7.5.1 Registered and Licensed Practical Nurses shall:
7.5.1.1 Have knowledge of the statutes and regulations governing nursing and function within the legal boundaries of professional and practical nursing practice.
7.5.1.2 Accept responsibility for competent nursing practice.
7.5.1.3 Function as a member of the health team:
7.5.1.3.1 By collaborating with other members of the health team to provide optimum care, or
7.5.1.3.2 As an LPN under the direction and supervision of a recognized licensed authority.
7.5.1.4 Consult with nurses, other health team members and community agencies for continuity of care and seek guidance as necessary.
7.5.1.5 Obtain instruction and supervision as necessary when implementing nursing techniques.
7.5.1.6 Contribute to the formulation, interpreting, implementing and evaluating of the objectives and policies related to professional and practical nursing practice within the employment setting.
7.5.1.7 Participate in evaluating nurses through peer review.
7.5.1.8 Report unsafe nursing practice to the Board and unsafe practice conditions to recognized legal authorities.
7.5.1.9 Practice without discrimination as to age, race, religion, sex, sexual orientation, national origin, or disability.
7.5.1.10 Respect the dignity and rights of clients regardless of social or economic status, personal attributes or nature of health problems.
7.5.1.11 Respect the client’s right to privacy by protecting confidentiality unless obligated by law to disclose the information.
7.5.1.12 Respect the property of clients, their families and significant others. In addition to the proceeding, the Registered Nurse shall:
7.5.1.13 Delegate to others only those nursing interventions that those persons are prepared or qualified to perform.
7.5.1.14 Supervise others to whom nursing interventions are delegated.
7.5.1.15 Retain professional accountability for care when delegating.
7.5.1.16 Teach safe practice to other health care workers as appropriate.
7.6 Dispensing
7.6.1 Definitions
7.6.1.1 “Dispensing” means providing medication according to an order of a practitioner duly licensed to prescribe medication. The term shall include both the repackaging and labeling of medication from bulk to individual doses.
7.6.1.2 “Prescription label” - a label affixed to every prescription or drug order which contains the following information at a minimum.
7.6.1.2.1 A unique number for that specific drug order.
7.6.1.2.2 The date the drug was dispensed.
7.6.1.2.3 The patient’s full name.
7.6.1.2.4 The brand or established name and manufacturer and the strength of the drug to the extent it can be measured.
7.6.1.2.5 The practitioner’s directions as found on the prescription order.
7.6.1.2.6 The practitioner’s name.
7.6.1.2.7 The initials of the dispensing nurse.
7.6.1.2.8 The name and address of the facility or practitioner from which the drug is dispensed.
7.6.1.2.9 Expiration date.
7.6.1.3 “Standing order” - An order written by the practitioner which authorizes a designated registered nurse or nurses to dispense prescription drugs to his/her patients(s) according to the standards listed below.
7.6.2 Authority to Dispense
7.6.2.1 Registered Nurses may assume the responsibility of dispensing as defined in the Nurse Practice Act.
7.6.2.2 Licensed Practice Nurses may assume the responsibility of dispensing as authorized by the Nurse Practice Act and defined in these Regulations, Section 7.6.2.2.1., 7.6.2.2.2, and 7.6.2.2.3
7.6.2.2.1 Licensed Practical Nurses may provide to a patient pre-packaged medications in accordance with the order of a practitioner duly licensed to prescribe medication where such medications have been pre-packaged by a person with lawful authority to dispense drugs.
7.6.2.2.2 Licensed Practical Nurses, per written order of a physician, dentist, podiatrist, advanced practice nurse, or other practitioner duly licensed to prescribe medication, may add the name of the client to a preprinted label on a pre-packaged medication.
7.6.2.2.3 Licensed Practical Nurses in a licensed methadone clinic may apply a preprinted label to a pre-packaged medication.
7.6.3 Standards for Dispensing
7.6.3.1 All licensed nurses engaged in dispensing shall adhere to these standards.
7.6.3.1.1 The medication must be prepackaged by a pharmaceutical company or prepared by a registered pharmacist.
7.6.3.1.2 The nurse shall be responsible for proper drug storage of the medication prior to dispensing.
7.6.3.1.3 The practitioner who originated the prescription or drug order must be on the premises or he/she or their designated coverage shall be available by telephone during the act of dispensing.
7.6.3.1.4 Once a drug has been dispensed it shall not be returned for reuse by another or the same patient in an institutional setting.
7.6.3.1.5 The nurse may not delegate any part of the dispensing function to any other individual who is not licensed to dispense.
7.6.3.1.6 The dispensing nurse must assure compliance to the state generic substitution laws when selecting the product to be dispensed.
7.6.3.1.7 The nurse-dispensed prescription may not be refillable; it requires the authority of the prescriber with each dispensing.
7.6.3.1.8 A usage review process must be established for the medicines dispensed to assure proper patient usage.
7.6.3.1.9 All dispensed drugs must be labeled as defined above and dispensed in proper safety closure containers that meet the standards established by the United States Pharmacopoeia for stability.
7.6.3.1.10 Record keeping must include the maintenance of the original written prescription of drug order for at least three years, allow retrospective review of accountability, and provide an audit trail. All dispensing records must be maintained on site, and available for inspection by authorized agents of the Board of Health, Pharmacy, and Nursing.
7.6.3.1.11 The dispensing nurse shall assume the responsibility of patient counseling of drug effects, side-effects, desired outcome, precautions, proper storage, unique dosing criteria, drug interactions, and other pertinent data, and record evidence of patient education.
7.6.3.1.12 Conformance to paragraphs 6 through 11 are not necessary if the original prescription was dispensed by a pharmacist for that specific patient.
7.7 Delegation
7.7.1 Definitions
7.7.1.1 “Accountability” - The state of being accountable, answerable, or legally liable for actions and decisions, including supervision.
7.7.1.2 “Delegation” - Entrusting the performance of selected nursing duties to individuals qualified, competent and legally able to perform such duties while retaining the accountability for such act.
7.7.1.3 “Supervision” - The guidance by a registered nurse (RN) for the accomplishment of a function or activity. The guidance consists of the activities included in monitoring as well as establishing the initial direction, delegating, setting expectations, directing activities and courses of action, critical watching, overseeing, evaluating, and changing a course of action.
7.7.1.4 “Unlicensed Assistive Personnel” - Individuals not licensed to perform nursing tasks that are employed to assist in the delivery of client care. The term “unlicensed assistive personnel” does not include members of the client’s immediate family, guardians, or friends; these individuals may perform incidental care of the sick in private homes without specific authority from a licensed nurse (as established in 24 Del.C. §1921(a)(4) of the Nurse Practice Act).
7.7.2 Conditions
7.7.2.1 The following conditions are relevant to delegation:
7.7.2.1.1 Only RNs may delegate.
7.7.2.1.2 The RN must be knowledgeable regarding the unlicensed assistive personnel’s education and training and have opportunity to periodically verify the individual’s ability to perform the specific tasks.
7.7.2.1.3 The RN maintains accountability for determining the appropriateness of all delegated nursing duties and responsibility for the delivery of safe and competent care. Unlicensed assistive personnel may not reassign a delegated act.
7.7.3 Criteria
7.7.3.1 The RN may delegate only tasks that are within the scope of sound professional nursing judgment to delegate.
7.7.3.2 Determination of appropriate factors include, but are not limited to:
7.7.3.2.1 stability of the client’s condition
7.7.3.2.2 educational background, skill level, or preparation of the individual
7.7.3.2.3 nature of the nursing act that meets the following:
7.7.3.2.3.1 task is performed frequently in the daily care of a client
7.7.3.2.3.2 task is performed according to an established sequence of steps
7.7.3.2.3.3 task may be performed with a predictable outcome
7.7.3.2.3.4 task does not involve ongoing assessment, interpretation or decision making that cannot be logically separated from the task itself.
7.7.3.3 The RN must be readily available in person or by telecommunication.
7.7.4 Exclusions
7.7.4.1 The following activities require nursing knowledge, judgment, and skill and may not be delegated by the RN to an unlicensed assistive person. These exclusions do not apply to Advanced Practice Nurses.
7.7.4.2 Physical, psychological, and social assessment which requires professional nursing judgment, intervention, referral, or follow-up;
7.7.4.3 Development of nursing diagnosis and care goals;
7.7.4.4 Formulation of the plan of nursing care and evaluation of the effectiveness of the nursing care provided;
7.7.4.5 Specific tasks involved in the implementation of the plan of care which require nursing judgment, skill, or intervention, that include, but are not limited to: performance of sterile invasive procedures involving a wound or anatomical site; nasogastric, newly established gastrostomy and jejunostomy tube feeding; nasogastric, jejunostomy and gastrostomy tube insertion or removal; suprapubic catheter insertion and removal; (phlebotomy is not considered a sterile, invasive procedure);
7.7.4.6 Administration of medications, including prescription topical medications; and
7.7.4.7 Receiving or transmitting verbal orders.
1 DE Reg. 1888 (6/1/98)
6 DE Reg. 1195 (3/1/03)
7.8 Intravascular Therapy By Licensed Nurses
Intravascular therapy encompasses several components, some of which require primarily skill proficiency with a minimum of critical judgement. Other aspects of intravascular therapy require skill proficiency and more importantly a high degree of knowledge, critical judgement and decision making to perform the function safely.
7.8.1 Definition Of Terms
7.8.1.1 Vascular system - is composed of all peripheral and central veins and arteries.
7.8.1.2 Intravascular therapy (IV) - is the broad term including the administration of fluids and medications, blood and blood derivatives into an individual's vascular system.
7.8.1.3 Intravenous fluids - include solutions, vitamins, nutrient preparations, and commercial blood fractions designed to be administered into an individual's vascular system. Whole blood and blood components, which are administered in the same manner, are considered intravenous fluids in this definition.
7.8.1.4 Intravenous and intra-arterial medications - are drugs administered into an individual's vascular system by any one of the following methods:
7.8.1.4.1 By way of infusion diluted in solution or suspended in fluid and administered over a specified time at a specified rate.
7.8.1.4.2 Through an established intra-vascular needle or catheter (referred to as "IV push").
7.8.1.4.3 By venipuncture carried out for the sole purpose of administering the medication. This method is referred to as direct medication injection (direct IV push).
7.8.1.5 Vascular access - Utilization of an established device or the introduction of a needle or catheter into an individual’s vascular system.
7.8.1.6 Venipuncture - Introduction of a needle or catheter into an individual's peripheral vein for the purpose(s) of withdrawing blood or establishing an infusion or administering medications.
7.8.1.7 Intravascular therapy maintenance - Monitoring of the therapy for changes in patient's condition, appropriate flow rate, equipment function, the hanging of additional fluid containers and the implementation of site care.
7.8.1.8 Termination of intravascular therapy - Cessation of the therapy either by withdrawing a needle or catheter from an individual’s vascular system or by discontinuing the infusion and maintaining the device as a reservoir.
7.8.1.9 Supervision - a registered nurse, licensed physician or dentist is physically present in the unit where the patient is being provided care, or within immediate electronic/telephone contact.
7.8.2 Conditions Of Performing Intravascular Therapy Procedures By Licensed Nurses
7.8.2.1 Intravascular therapy must be authorized by a written order from a state licensed and authorized prescriber.
7.8.2.2 The performance of any procedures of intravascular therapy by a licensed practical nurse will be done under the supervision of a registered nurse, APN, or person licensed to practice medicine, surgery, or podiatry.
7.8.2.3 Admixed intravascular solutions documented and instituted by one licensed nurse and subsequently interrupted may be re-instituted by another licensed nurse after confirmation with the state licensed and authorized prescriber's order.
7.8.2.4 Admixed intravascular solutions documented and prepared by one licensed nurse may be initiated or continued by another licensed nurse after confirmation with the state licensed and authorized prescriber's order.
7.8.2.5 Intradermal or topical anesthetics may be used by the RN or LPN when initiating vascular access therapy in various situations or settings, provided there is an authorized prescriber’s order and organizational policy/procedure to support use of these medications. All RNs and LPNs must have documented educational preparation according to the employing agency’s policies and procedures. Documented evidence must include both theoretical instruction including anatomy and physiology, pharmacology, nursing management and education of patients and demonstration of clinical proficiency in performance of the task.
7.8.3 Functional Scope Of Responsibility For Intravascular Therapy Procedures
7.8.3.1 Registered Nurses bear the responsibility and accountability for their nursing practice under the license granted by the Board of Nursing and are permitted to perform the following:
7.8.3.1.1 Assessment of the patient and the prescribed intravascular therapy before, during and after the therapy is carried out.
7.8.3.1.2 Acceptance and confirmation of intravascular therapy order(s).
7.8.3.1.3 Calculation of medication dosage and infusion rate for intravascular therapy administration.
7.8.3.1.4 Confirmation of medication dosage and infusion rate for intravascular therapy administration.
7.8.3.1.5 Addition of prescribed medications in intravascular solution, labeling and documenting appropriately.
7.8.3.1.6 Start initial solution or add replacement fluids to an existing infusion as prescribed.
7.8.3.1.7 Vascular access for establishing an infusion or administering medications.
7.8.3.1.8 Administration of medications by "IV push".
7.8.3.1.9 Intravascular therapy maintenance.
7.8.3.1.10 Termination of intravascular therapy, including the removal of subclavian and PICC lines.
7.8.3.1.11 Access the vascular system for the purpose of the withdrawal of blood and to monitor the patient's condition before, during, and after the withdrawal of blood.
7.8.3.2 Licensed Practical Nurses bear the responsibility and accountability for their nursing practice under the license granted by the Board of Nursing and are permitted to perform the following for peripheral lines:
7.8.3.2.1 Acceptance of intravascular therapy order(s).
7.8.3.2.2 Calculation of medication dosage and infusion rate of intravascular medications prescribed. This does not include titration.
7.8.3.2.3 Confirmation of medication dosage and infusion rate for intravascular therapy administration.
7.8.3.2.4 Addition of mediations in intravascular solutions, label and document appropriately.
7.8.3.2.5 Venipuncture with needle device to establish access to the peripheral vascular system.
7.8.3.2.6 Start initial solution or add replacement fluids to an existing infusion as prescribed.
7.8.3.2.7 Intravascular therapy maintenance including the flushing of peripheral lines with Heparin and/or saline solution.
7.8.3.2.8 Termination of peripheral intravascular therapy.
7.8.3.2.9 Performance of venipuncture for the purpose of the withdrawal of blood and to monitor the patient's condition before, during and after the withdrawal of blood.
7.8.3.3 The Licensed Practical Nurse is permitted to perform the following procedures for central lines:
7.8.3.3.1 Acceptance of intravascular therapy order(s).
7.8.3.3.2 Calculation of medication dosage and infusion rate of intravascular medications prescribed. This does not include titration.
7.8.3.3.3 Confirmation of medication dosage and infusion rate for intravascular therapy administration.
7.8.3.3.4 Addition of medications in intravascular solutions, label and document appropriately.
7.8.3.3.5 Intravascular therapy maintenance, including the flushing of central lines with Heparin and/or saline solution.
7.8.3.3.6 Dressing and tubing changes, including PICC lines.
7.8.3.3.7 Addition of replacement fluids to an existing infusion as prescribed.
7.8.4. Special Intravascular Procedures By Registered Nurses
7.8.4.1 Chemotherapy - Only intravascular routes are addressed in these rules. Review of the Oncology Nursing Society’s current guidelines is recommended before the administration of anti-neoplastic agents.
7.8.4.1.1 Definition of Terms
7.8.4.1.1.1 Cancer Chemotherapy - is the broad term including the administration of anti-neoplastic agents into an individual's vascular system.
7.8.4.1.1.2 Anti-neoplastic agents - are those drugs which are administered with the intent to control neoplastic cell growth.
7.8.4.1.2 The Registered Nurse who administers cancer chemotherapy by the intravascular route must have documented educational preparation according to the employing agency's policies and procedures.
7.8.4.1.3 The Registered Nurse must have documented evidence of knowledge and skill in the following:
7.8.4.2 Central Venous Access Via Peripheral Veins
7.8.4.2.1 Definition of Terms
7.8.4.2.1.1 Central venous access - is that entry into an individual's vascular system via the insertion of a catheter into a peripheral vein threaded through to the superior vena cava with placement confirmed by x-ray.
7.8.4.2.2 The Registered Nurse who performs central venous access via peripheral veins must have documented educational preparation according to the employing agency's policies and procedures.
7.8.4.2.3 Documented evidence must include, but is not limited to, evidence of both theoretical instruction and clinical proficiency in performance of the task.
7.8.4.2.3.1 Theoretical instruction must include, but is not limited to, anatomy and physiology, pharmacology, nursing management, and education of patients as they relate to central venous access via peripheral veins.
7.8.4.2.3.2 A preceptor must supervise the learning experience and must document the Registered Nurse's competency in the performance of the procedure.
7.8.4.3 Pain Management Via Epidural Catheter
7.8.4.3.1 It is within the scope of practice of a Registered Nurse to instill analgesics (opiates)/low dose anesthetics at analgesic levels into an existing catheter under the following conditions/exceptions:
7.8.4.3.1.1 The epidural catheter is in place.
7.8.4.3.1.2 The position of the epidural catheter was verified as correct by a physician at the time of insertion.
7.8.4.3.1.3 Bolus doses and/or continuous infusions, as pre-mixed by anesthesiologists, C.R.N.A.s, or pharmacists, of epidural analgesics/low does anesthetics at analgesic levels can be administered by the Registered Nurse only after the initial dose has been administered. Changes in medication and/or dosage of the same medication are not defined as the initial dose.
7.8.4.3.1.4 Only analgesics (opiates)/low dose anesthetics at analgesic levels will be administered via this route for acute and chronic pain management.
7.8.4.3.1.5 The Registered Nurse must complete a course that includes, but is not limited to, a) anatomy, physiology, pharmacology, nursing management, assessment, and education of patients as they relate to epidural administration of opiates/low dose anesthetics at analgesic levels; b) a credentialed preceptor must supervise the learning experience and must document the Registered Nurse's clinical competency in the performance of the procedure.
7.8.4.3.1.6 The Registered Nurse may not insert or remove epidural catheters
8.0 Rules and Regulations Governing the Practice of Nursing as an Advanced Practice Nurse in the State of Delaware
8.1 Authority
These rules and regulations are adopted by the Delaware Board of Nursing under the authority of the Delaware Nurse Practice Act, 24 Del.C. §§1902(d), 1906(1), 1906(7).
8.2 Purpose
8.2.1 The general purpose of these rules and regulations is to assist in protecting and safeguarding the public by regulating the practice of the Advanced Practice Nurse.
8.3 Scope
8.3.1 These rules and regulations govern the educational and experience requirements and standards of practice for the Advanced Practice Nurse. Prescribing medications and treatments independently is pursuant to the Rules and Regulations promulgated by the Joint Practice Committee as defined in 24 Del.C. §1906(20). The Advanced Practice Nurse is responsible and accountable for her or his practice. Nothing herein is deemed to limit the scope of practice or prohibit a Registered Nurse from engaging in those activities that constitute the practice of professional nursing and/or professional nursing in a specialty area.
8.4 Definitions
“Advanced Practice Nurse” as defined in 24 Del.C. §1902(d)(1). Such a nurse will be given the title Advanced Practice Nurse by state licensure, and may use the title Advanced Practice Nurse within his/her specific specialty area.
“Audit” The verification of existence of a collaborative agreement for a minimum of 10% of the total number of licenses issued during a specified time period.
“Board” The Delaware Board of Nursing
“Certified Nurse Midwife (C.N.M.)” A Registered Nurse who is a provider for normal maternity, newborn and well-woman gynecological care. The CNM designation is received after completing an accredited post-basic nursing program in midwifery at schools of medicine, nursing or public health, and passing a certification examination administered by the ACNM Certification Council, Inc. or other nationally recognized, Board of Nursing approved certifying organization.
“Certified Registered Nurse Anesthetist (C.R.N.A.)” A Registered Nurse who has graduated from a nurse anesthesia educational program accredited by the American Association of Nurse Anesthetists’ Council on Accreditation of Nurse Anesthesia Educational programs, and who is certified by the American Association of Nurse Anesthetists’ Council on Certification of Nurse Anesthetists or other nationally recognized, Board of Nursing approved certifying organization.
“Clinical Nurse Specialist (C.N.S.)” A Registered Nurse with advanced nursing educational preparation who functions in primary, secondary, and tertiary settings with individuals, families, groups, or communities. The CNS designation is received after graduation from a Master’s degree program in a clinical nurse specialty or post Master’s certificate, such as gerontology, maternal-child, pediatrics, psych/mental health, etc. The CNS must have national certification in the area of specialization at the advanced level if such a certification exists or as specified in 8.9.4.1 of these Rules and Regulations. The certifying agency must meet the established criteria approved by the Delaware Board of Nursing.
“Clinical Nursing Specialty” a delimited focus of advanced nursing practice. Specialty areas can be identified in terms of population, setting, disease/pathology, type of care or type of problem. Nursing administration does not qualify as a clinical nursing specialty.
3 DE Reg. 1373 (4/1/00)
“Collaborative Agreement” Written verification of health care facility approved clinical privileges; or health care facility approved job description; or a written document that outlines the process for consultation and referral between an Advanced Practice Nurse and a licensed physician, dentist, podiatrist, or licensed Delaware health care delivery system.
“Guidelines/ Protocols” Suggested pathways to be followed by an Advanced Practice Nurse for managing a particular medical problem. These guidelines/protocols may be developed collaboratively by an Advanced Practice Nurse and a licensed physician, dentist or a podiatrist, or licensed Delaware health care delivery system.
“National Certification” That credential earned by a nurse who has met requirements of a Board approved certifying agency.
The agencies so approved include but are not limited to:
“Nurse Practitioner (N.P.)” A Registered Nurse with advanced nursing educational preparation who is a provider of primary health care in a variety of settings with a focus on a specific area of practice. The NP designation is received after graduation from a Master’s program or from an accredited post-basic NP certificate program of at least one academic year in length in a nurse practitioner specialty such as acute care, adult, family, geriatric, pediatric, or women’s health, etc. The NP must have national certification in the area of specialization at the advanced level by a certifying agency which meets the established criteria approved by the Delaware Board of Nursing.
“Post Basic Program”
A combined didactic and clinical/preceptored program of at least one academic year of full time study in the area of advanced nursing practice with a minimum of 400 clinical/preceptored hours.
The program must be one offered and administered by an approved health agency and/or institution of higher learning,
Post basic means a program taken after licensure is achieved.
“Scope of Specialized Practice” That area of practice in which an Advanced Practice Nurse has a Master’s degree or a post-basic program certificate in a clinical nursing specialty with national certification.
“Supervision” Direction given by a licensed physician or Advanced Practice Nurse to an Advanced Practice Nurse practicing pursuant to a temporary permit. The supervising physician or Advanced Practice Nurse must be periodically available at the site where care is provided, or available for immediate guidance.
8.5 Grandfathering Period
8.5.1 Any person holding a certificate of state licensure as an Advanced Practice Nurse that is valid on July 8, 1994 shall be eligible for renewal of such licensure under the conditions and standards prescribed herein for renewal of licensure.
8.6 Standards for the Advanced Practice Nurse
8.6.1 Advanced Practice Nurses view clients and their health concerns from an integrated multi-system perspective.
8.6.2 Standards provide the practitioner with a framework within which to operate and with the means to evaluate his/her practice. In meeting the standards of practice of nursing in the advanced role, each practitioner, including but not limited to those listed in 8.6.2 of these Rules and Regulations:
8.6.2.1 Performs comprehensive assessments using appropriate physical and psychosocial parameters;
8.6.2.2 Develops comprehensive nursing care plans based on current theories and advanced clinical knowledge and expertise;
8.6.2.3 Initiates and applies clinical treatments based on expert knowledge and technical competency to client populations with problems ranging from health promotion to complex illness and for whom the Advanced Practice Nurse assumes primary care responsibilities. These treatments include, but are not limited to psychotherapy, administration of anesthesia, and vaginal deliveries;
8.6.2.4 Functions under established guidelines/protocols and/or accepted standards of care;
8.6.2.5 Uses the results of scientifically sound empirical research as a basis for nursing practice decisions;
8.6.2.6 Uses appropriate teaching/learning strategies to diagnose learning impediments;
8.6.2.7 Evaluates the quality of individual client care in accordance with quality assurance and other standards;
8.6.2.8 Reviews and revises guidelines/protocols, as necessary;
8.6.2.9 Maintains an accurate written account of the progress of clients for whom primary care responsibilities are assumed;
8.6.2.10 Collaborates with members of a multi-disciplinary team toward the accomplishment of mutually established goals;
8.6.2.11 Pursues strategies to enhance access to and use of adequate health care services;
8.6.2.12 Maintains optimal advanced practice based on a continual process of review and evaluation of scientific theory, research findings and current practice;
8.6.2.13 Performs consultative services for clients referred by other members of the multi-disciplinary team; and
8.6.2.14 Establishes a collaborative agreement with a licensed physician, dentist, podiatrist, or licensed Delaware health care delivery system to facilitate consultation and/or referral as appropriate in the delivery of health care to clients.
8.6.3 In addition to these standards, each nurse certified in an area of specialization and recognized by the Board to practice as an Advanced Practice Nurse is responsible for practice at the level and scope defined for that specialty certification by the agency which certified the nurse.
8.7 Generic Functions of the Advanced Practice Nurse Within the Specialized Scope of Practice include but are not limited to:
8.7.1 Eliciting detailed health history(s)
8.7.2 Defining nursing problem(s)
8.7.3 Performing physical examination(s)
8.7.4 Collecting and performing laboratory tests
8.7.5 Interpreting laboratory data
8.7.6 Initiating requests for essential laboratory procedures
8.7.7 Initiating requests for essential x-rays
8.7.8 Screening patients to identify abnormal problems
8.7.9 Initiating referrals to appropriate resources and services as necessary
8.7.10 Initiating or modifying treatment and medications within established guidelines
8.7.11 Assessing and reporting changes in the health of individuals, families and communities
8.7.12 Providing health education through teaching and counseling
8.7.13 Planning and/or instituting health care programs in the community with other health care professionals and the public
8.7.14 Delegating tasks appropriately
8.7.15 Prescribing medications and treatments independently pursuant to Rules and Regulations promulgated by the Joint Practice Committee as defined in 24 Del.C. §1906(20).
[8.7.16 Inserting and removing epidural catheters after specialized training.]
8.8 Criteria for Approval of Certification Agencies
8.8.1 A national certifying body which meets the following criteria shall be recognized by the Board to satisfy 24 Del.C. §1902(d)(1).
8.8.2 The national certifying body:
8.8.2.1 Is national in the scope of its credentialing.
8.8.2.2 Has no requirement for an applicant to be a member of any organization.
8.8.2.3 Has educational requirements which are consistent with the requirements of these rules.
8.8.2.4 Has an application process and credential review which includes documentation that the applicant’s education is in the advanced nursing practice category being certified, and that the applicant’s clinical practice is in the certification category.
8.8.2.5 Uses an examination as a basis for certification in the advanced nursing practice category which meets the following criteria:
8.8.2.5.1 The examination is based upon job analysis studies conducted using standard methodologies acceptable to the testing community;
8.8.2.5.2 The examination represents the knowledge, skills and abilities essential for the delivery of safe and effective advanced nursing care to the clients;
8.8.2.5.3 The examination content and its distribution are specified in a test plan (blueprint), based on the job analysis study, that is available to examinees;
8.8.2.5.4 Examination items are reviewed for content validity, cultural sensitivity and correct scoring using an established mechanism, both before use and periodically;
8.8.2.5.5 Examinations are evaluated for psychometric performance;
8.8.2.5.6 The passing standard is established using acceptable psychometric methods, and is reevaluated periodically; and
8.8.2.5.7 Examination security is maintained through established procedures
8.8.2.6 Issues certification based upon passing the examination and meeting all other certification requirements.
8.8.2.7 Provides for periodic recertification which includes review of qualifications and continued competency.
8.8.2.8 Has mechanisms in place for communication to Boards of Nursing for timely verification of an individual’s certification status, changes in certification status, and changes in the certification program, including qualifications, test plan and scope of practice.
8.8.2.9 Has an evaluation process to provide quality assurance in its certification program.
8.9 Application for Licensure to Practice as an Advanced Practice Nurse
8.9.1 Application for licensure as a Registered Nurse shall be made on forms supplied by the Board.
8.9.2 In addition, an application for licensure to practice as an Advanced Practice Nurse shall be made on forms supplied by the Board.
8.9.2.1 The APN applicant shall be required to furnish the name(s) of the licensed physician, dentist, podiatrist, or licensed Delaware health care delivery system with whom a current collaborative agreement exists.
8.9.2.2 Notification of changes in the name of the licensed physician, dentist, podiatrist, or licensed Delaware health care delivery system shall be forwarded to the Board office.
8.9.3 Each application shall be returned to the Board office together with appropriate documentation and non-refundable fees.
8.9.4 A Registered Nurse meeting the practice requirement as listed in 8.11 and all other requirements set forth in these Rules and Regulations may be issued a license as an Advanced Practice Nurse in the specific area of specialization in which the nurse has been nationally certified at the advanced level and/or has earned a Master’s degree in a clinical nursing specialty.
8.9.4.1 Clinical nurse specialists, whose subspecialty area can be categorized under a broad scope of nursing practice for which a Board-approved national certification examination exists, are required to pass this certification examination to qualify for permanent licensure as an Advanced Practice Nurse. This would include, but not be limited to medical-surgical and psychiatric-mental health nursing. If a more specific post-graduate level certification examination that has Board of Nursing approval is available within the clinical nursing specialist’s subspecialty area at the time of licensure application, the applicant may substitute this examination for the broad-based clinical nursing specialist certification examination.
8.9.4.2 Faculty members teaching in nursing education programs are not required to be licensed as Advanced Practice Nurses. Those faculty members teaching in graduate level clinical courses may apply for licensure as Advanced Practice Nurses and utilize graduate level clinical teaching hours to fulfill the practice requirement as stated in 8.11.2.1.
8.9.5 Renewal of licensure shall be on a date consistent with the current Registered Nurse renewal period. A renewal fee shall be paid.
8.9.6 The Board may refuse to issue, revoke, suspend or refuse to renew the license as an Advanced Practice Nurse or otherwise discipline an applicant or a practitioner who fails to meet the requirements for licensure as an Advanced Practice Nurse or as a registered nurse, or who commits any disciplinary offense under the Nurse Practice Act, 24 Del.C. Ch. 19, or the Rules and Regulations promulgated pursuant thereto. All decisions regarding independent practice and/or independent prescriptive authority are made by the Joint Practice Committee as provided in 24 Del.C. §1906(20) - (22).
8.10 Temporary Permit for Advanced Practice Nurse Licensure
8.10.1 A temporary permit to practice, pending Board approval for permanent licensure, may be issued provided that:
8.10.1.1 The individual applying has also applied for licensure to practice as a Registered Nurse in Delaware, or
8.10.1.2 The individual applying holds a current license in Delaware, and
8.10.1.3 The individual submits proof of graduation from a nationally accredited or Board approved Master’s or certificate advanced practice nursing program, and has passed the certification examination, or
8.10.1.4 The individual is a graduate of a Master’s program in a clinical nursing specialty for which there is no certifying examination, and can show evidence of at least 1000 hours of clinical nursing practice within the past 24 months.
8.10.1.5 Application(s) and fee(s) are on file in the Board office.
8.10.2 A temporary permit to practice, under supervision only, may be issued at the discretion of the Executive Director provided that:
8.10.2.1 The individual meets the requirements in 8.10.1.1 or 8.10.1.2, and 8.10.1.5 and;
8.10.2.2 The individual submits proof of graduation from a nationally accredited or Board approved Master’s or certificate advanced practice nurse program, and;
8.10.2.3 The individual submits proof of admission into the approved certifying agency’s examination or is seeking a temporary permit to practice under supervision to accrue the practice hours required to sit for the certifying examination or has accrued the required practice hours and is scheduled to take the first advanced certifying examination upon eligibility or is accruing the practice hours referred to in 8.10.2.4; or,
8.10.2.4 The individual meets 8.10.2.1 and 8.10.2.2 hereinabove and is awaiting review by the certifying agency for eligibility to sit for the certifying examination.
8.10.3 If the certifying examination has been passed, the appropriate form must accompany the application.
8.10.4 A temporary permit may be issued:
8.10.4.1 For up to two years in three month periods.
8.10.4.2 At the discretion of the Executive Director.
8.10.5 A temporary permit will be withdrawn:
8.10.5.1 Upon failure to pass the first certifying examination
8.10.5.1.1 The applicant may petition the Board of Nursing to extend a temporary permit under supervision until results of the next available certification exam are available by furnishing the following information:
8.10.5.1.1.1 current employer reference,
8.10.5.1.1.2 supervision available,
8.10.5.1.1.3 job description,
8.10.5.1.1.4 letter outlining any extenuating circumstances,
8.10.5.1.1.5 any other information the Board of Nursing deems necessary.
8.10.5.2 For other reasons stipulated under temporary permits elsewhere in these Rules and Regulations.
3 DE Reg. 1373 (4/1/00)
8.10.6 A lapsed temporary permit for designation is equivalent to a lapsed license and the same rules apply.
8.10.7 Failure of the certifying examination does not impact on the retention of the basic professional Registered Nurse licensure.
8.10.8 Any person practicing or holding oneself out as an Advanced Practice Nurse in any category without a Board authorized license in such category shall be considered an illegal practitioner and shall be subject to the penalties provided for violations of the Law regulating the Practice of Nursing in Delaware, (24 Del.C. Ch. 19).
8.10.9 Endorsement of Advanced Practice Nurse designation from another state is processed the same as for licensure by endorsement, provided that the applicant meets the criteria for an Advanced Practice Nurse license in Delaware.
8.11 Maintenance of Licensure Status: Reinstatement
8.11.1 To maintain licensure, the Advanced Practice Nurse must meet the requirements for recertification as established by the certifying agency.
8.11.2 The Advanced Practice Nurse must have practiced a minimum of 1500 hours in the past five years or no less than 600 hours in the past two years in the area of specialization in which licensure has been granted.
8.11.2.1 Faculty members teaching in graduate level clinical courses may count a maximum of 500 didactic course contact hours in the past five years or 200 in the past two years and all hours of direct on-site clinical supervision of students to meet the practice requirement.
8.11.2.2 An Advanced Practice Nurse who does not meet the practice requirement may be issued a temporary permit to practice under the supervision of a person licensed to practice medicine, surgery, dentistry, or advanced practice nursing, as determined on an individual basis by the Board.
8.11.3 The Advanced Practice Nurse will be required to furnish the name(s) of the licensed physician, dentist, podiatrist, or licensed Delaware health care delivery system with whom a current collaborative agreement exists.
8.11.4 Advanced Practice Nurses who fail to renew their licenses by February 28, May 31, or September 30 of the renewal period shall be considered to have lapsed licenses. After February 28, May 31, or September 30 of the current licensing period, any requests for reinstatement of a lapsed license shall be presented to the Board for action.
8.11.5 To reinstate licensure status as an Advanced Practice Nurse, the requirements for recertification and 1500 hours of practice in the past five years or no less than 600 hours in the past two years in the specialty area must be met or the process described in 8.11.4 followed.
8.11.6 An application for reinstatement of licensure must be filed and the appropriate fee paid.
8.12 Audit of Licensees
8.12.1 The Board may select licensees for audit two months prior to renewal in any biennium. The Board shall notify the licensees that they are to be audited for compliance of having a collaborative agreement.
8.12.1.1 Upon receipt of such notice, the licensee must submit a copy of a current collaborative agreement(s) within three weeks of receipt of the notice.
8.12.1.2 The Board shall notify the licensee of the results of the audit immediately following the Board meeting at which the audits are reviewed.
8.12.1.3 An unsatisfactory audit shall result in Board action.
8.12.1.4 Failure to notify the Board of a change in mailing address will not absolve the licensee from audit requirements.
8.12.2 The Board may select licensees for audit throughout the biennium.
8.13 Exceptions to the Requirements to Practice
8.13.1 The requirements set forth in 8.9 shall not apply to a Registered Nurse who is duly enrolled as a bona fide student in an approved educational program for Advanced Practice Nurses as long as the practice is confined to the educational requirements of the program and is under the direct supervision of a qualified instructor.
8.14 Definitions
8.14.1 Collaborative Agreement - Includes
8.14.1.1 A true collegial agreement between two parties where mutual goal setting, access, authority, and responsibility for actions belong to individual parties and there is a conviction to the belief that this collaborative agreement will continue to enhance patient outcomes and
8.14.1.2 a written document that outlines the process for consultation and referral between an Advanced Practice Nurse and a duly licensed Delaware physician, dentist, podiatrist or licensed Delaware health care delivery system. This document can include, but not be limited to, written verification of health care facility approved clinical privileges or a health care facility approved job description of the A.P.N. If the agreement is with a licensed Delaware health care delivery system, the individual will have to show that the system will supply appropriate medical back-up for purposes of consultation and referral.
8.14.2 National Certification - That credential earned by an Advanced Practice Nurse who has met requirements of a Board of Nursing approved certifying agency.
8.14.3 Pharmacology/Pharmacotherapeutics - refers to any course, program, or offering that would include, but not be limited to, the identification of individual and classes of drugs, their indications and contraindications, their likelihood of success, their dosages, their side-effects and their interactions. It also encompasses clinical judgement skills and decision making. These skills may be based on thorough interviewing, history taking, physical assessment, test selection and interpretation, patho-physiology, epidemiology, diagnostic reasoning, differentiation of conditions, treatment decisions, case evaluation and non-pharmacologic interventions.
8.14.4 Prescription Order - includes the prescription date, the name of the patient, the name, address, area of specialization and business telephone number of the advanced practice nurse prescriber, the name, strength, quantity, directions for use, and number of refills of the drug product or device prescribed, and must bear the name and prescriber ID number of the advanced practice nurse prescriber, and when applicable, prescriber’s D.E.A. number and signature. There must be lines provided to show whether the prescription must be dispensed as written or substitution is permitted.
8.15 Requirements for Initial Independent Practice/prescriptive Authority
An APN who has not had independent prescriptive authority within the past two years in Delaware or any other jurisdiction who is applying for independent practice and/or independent prescriptive authority shall:
8.15.1 Be an Advanced Practice Nurse (APN) holding a current permanent license issued by the Board of Nursing (BON). If the individual does not hold national certification, eligibility will be determined on a case by case basis.
8.15.2 Have completed a post basic advanced practice nursing program that meets the criteria as established in Section 4.7 of Article 7 of the Rules and Regulations of the Delaware Board of Nursing with documentation of academic courses in advanced health assessment, diagnosis and management of problems within the clinical specialty, advanced patho-physiology and advanced pharmacology/pharmacotherapeutics. In the absence of transcript verification of the aforementioned courses, applicants shall show evidence of content integration through course descriptions, course syllabi, or correspondence from school officials. If the applicant cannot produce the required documentation, such applicant may petition the Joint Practice Committee for consideration of documented equivalent independent prescriptive authority experience.
8.15.3 Submit a copy of the current collaborative agreement to the Joint Practice Committee (JPC). The collaborative agreement(s) shall include arrangements for consultation, referral and/or hospitalization complementary to the area of the nurse's independent practice.
8.15.4 Show evidence of the equivalent of at least thirty hours of advanced pharmacology and pharmacotherapeutics related continuing education within the two years prior to application for independent practice and/or independent prescriptive authority. This may be continuing education programs or a three credit, semester long graduate level course. The thirty hours may also occur during the generic APN program as integrated content as long as this can be documented to the JPC. All offerings will be reviewed and approved by the JPC.
8.15.5 Demonstrate how submitted continuing education offerings relate to pharmacology and therapeutics within their area of specialty. This can be done by submitting the program titles to show content and dates attended. If the JPC questions the relevance of the offerings, the applicant must have available program descriptions, and/ or learner objectives, and/or program outlines for submission to the JPC for their review and approval.
8.16 Requirements for Independent Practice/prescriptive Authority by Endorsement
An APN who has had prescriptive authority in another jurisdiction who is applying for independent practice and/or independent prescriptive authority shall:
8.16.1 Show evidence of meeting 8.15.1 and 8.15.3.
8.16.2 Show evidence of having current prescriptive authority in another jurisdiction.
8.16.3 Have no encumbered APN designation(s) in any jurisdiction.
8.16.4 Show evidence of completion of a minimum of ten hours of JPC approved pharmacology/pharmacotherapeutics related continuing education within the area of specialization and licensure within the past two years.
8.17 Application
8.17.1 Names and credentials of qualified applicants will be forwarded to the Joint Practice Committee for approval and then forwarded to the Board of Medical Practice for review and final approval.
8.18 Prescriptive Authority
8.18.1 APNs may prescribe, administer, and dispense legend medications including Schedule II - V controlled substances, (as defined in the Controlled Substance Act and labeled in compliance with 24 Del.C. §2536(C), parenteral medications, medical therapeutics, devices and diagnostics.
8.18.2 APNs will be assigned a provider identifier number as outlined by the Division of Professional Regulation.
8.18.3 Controlled Substances registration will be as follows:
8.18.3.1 APNs must register with the Drug Enforcement Agency and use such DEA number for controlled substance prescriptions.
8.18.3.2 APNs must register biennially with the Office of Narcotics and Dangerous Drugs in accordance with 16 Del.C. §4732(a).
8.18.4 APNs may request and issue professional samples of legend, including schedule II-V controlled substances, and over-the-counter medications that must be labeled in compliance with 24 Del.C. §2536(C).
8.18.5 APNs may give verbal prescription orders.
8.19 Prescriptive Writing
8.19.1 All prescription orders will be written as defined by the Delaware Board of Pharmacy as defined in 8.14.4.
8.20 Renewal
8.20.1 Maintain current APN licensure.
8.20.2 Maintain competency through a minimum of ten hours of JPC approved pharmacology/pharmacotherapeutics related continuing education within the area of specialization and licensure per biennium. The pharmacology/ pharmacotherapeutics content may be a separate course or integrated within other offerings.
8.21 Disciplinary Proceedings
8.21.1 Pursuant to 24 Del.C. §1906(19)(c), the Joint Practice Committee is statutorily empowered, with the approval of the Board of Medical Practice, to grant independent practice and/or prescriptive authority to nurses who qualify for such authority. The Joint Practice Committee is also empowered to restrict, suspend or revoke such authority also with the approval of the Board of Medical Practice.
8.21.2 Independent practice or prescriptive authority may be restricted, suspended or revoked where the nurse has been found to have committed unprofessional conduct in his or her independent practice or prescriptive authority or if his or her mental or physical faculties have changed or deteriorated in such a manner as to create an inability to practice or prescribe with reasonable skill or safety to patients.
8.21.3 Unprofessional conduct, for purposes of restriction, suspension or revocation of independent practice or prescriptive authority shall include but not be limited to:
8.21.3.1 The use or attempted use of any false, fraudulent or forged statement or document or use of any fraudulent, deceitful, dishonest or immoral practice in connection with any acquisition or use of independent practice or prescriptive authority;
8.21.3.2 Conviction of a felony;
8.21.3.3 Any dishonorable or unethical conduct likely to deceive, defraud or harm the public;
8.21.3.4 Use, distribution or prescription of any drugs or medical devices other than for therapeutic or diagnostic purposes;
8.21.3.5 Misconduct, incompetence, or gross negligence in connection with independent or prescriptive practice;
8.21.3.6 Unjustified failure upon request to divulge information relevant to authorization or competence to independently practice or exercise prescriptive authority to the Executive Director of the Board of Nursing or to anyone designated by him or her to request such information.
8.21.3.7 The violation of the Nurse Practice Act or of an Order or Regulation of the Board of Nursing or the Board of Medical Practice related to independent practice or prescriptive authority.
8.21.3.8 Restriction, suspension, or revocation of independent practice or prescriptive authority granted by another licensing authority in any state, territory or federal agency.
8.21.4 Complaints concerning the use or misuse of independent practice or prescriptive authority received by the Division of Professional Regulation or the Board of Nursing shall be investigated in accordance with the provisions of Title 29, Section 8807 governing investigations by the Division of Professional Regulation. As soon as convenience permits, the Board of Nursing shall assign an Investigating Board Member to assist with the investigation of the complaint. The Investigating Board Member shall, whenever practical, be a member of the Joint Practice Committee.
8.21.5 Upon receipt of a formal complaint from the Office of the Attorney General seeking the revocation, suspension or restriction of independent practice or prescriptive authority, the Committee Chairperson shall promptly arrange for not less than a quorum of the Committee to convene for an evidentiary hearing concerning such complaint upon due notice to the licensee against whom the complaint has been filed. Such notice shall comply with the provisions of the Administrative Procedures Act (29 Del. C. Ch. 101).
8.21.6 The hearing shall be conducted in accordance with the Administrative Procedures Act (29 Del.C. §101), and after the conclusion thereof, the Joint Practice Committee will promptly issue a written Decision and Order which shall be based upon the affirmative vote of a majority of the quorum hearing the case.
8.21.7 Any written Decision and Order of the Joint Practice Committee which imposes a restriction, suspension or revocation of independent practice or prescriptive authority shall not be effective prior to the approval of the Board of Medical Practice.
4 DE Reg. 296 (8/1/00)
5 DE Reg. 1606 (2/1/02)
* Please Note: As the rest of the sections were not amended they are not being published. A complete set of the Board of Nursing rules and regulations are available at:
http://www.state.de.us/research/AdminCode/title24/1900%20Board%20of%20Nursing.shtml#TopOfPage
