REPORT: October/November 2006

Annual Report of the State Board for Nursing

by Barbara Zittel, PhD, RN, Executive Secretary

I am pleased to report that as of July 2006, New York State Education Department (SED) statistics reveal that 247,412 individuals are licensed and registered to practice professional nursing in New York. That statistic reflects a continuing upward trend. Despite the significant number of individuals retiring from the profession, an increase in the number of new licensees is, at this time, mitigating the nursing shortage.

Nearly 11,000 new RN licenses were issued by the department in 2005. Almost half of these were from out-of-state, which includes internationally educated nurses. Approximately 6,000 newly licensed RNs were educated in New York State nursing programs, all of which have reported an increase in the number of graduations.

Unfortunately, a higher number of qualified applicants were denied admission to nursing programs. That number approached 3,000 in 2005, double last year’s number.

A number of surveys conducted in the state cite a lack of nursing faculty as a major bottle-neck in the recruitment pipeline. The State Legislature responded to NYSNA’s requests by allocating funds to attract nurses into the nursing education arena and to provide loan forgiveness to current faculty who received their education in the recent past. In 2005, 85 candidates applied for funds under the Senator Patricia K. McGee Nursing Faculty Scholarship Program. Of these, 34 were deemed to be eligible and 23 are receiving funding. During the same time period, 48 nursing faculty applied to the state Nursing Faculty Loan Forgiveness Incentive Program, with 17 being deemed eligible and 15 receiving funding.

New York State has almost 13,000 nurse practitioners (NPs) practicing in more than 16 specialties. That number appears to be leveling off, with only 700 new certifications issued in 2005. As of July 2006, New York State had 68,306 licensed practical nurses (LPNs) licensed to practice, which represents a decrease of almost 1,000 from the previous year. The number of new LPN licenses issued in 2005 also appears to have stabilized at just over 4,000.

High caseload of disciplinary actions

State Board for Nursing (SBFN) members are kept extremely busy dealing with the highest caseload of disciplinary and moral character charges among the 47 professions licensed by the SED. In 2005, 69 cases were opened against NPs, 1,279 against RNs, and 793 against LPNs. As in previous years, a disproportionately high number of actions are brought against LPNs as compared to RNs or NPs.

“Negligence/incompetence” continues to be the most common charge filed against licensees, no matter what their title. “Conviction of a crime” is now the second most frequent category of charges against RNs, for the first time outranking “substance abuse.” It is disturbing to note that when you add the number of RNs charged with “conviction of a crime” and those charged with “substance abuse,” it is almost the same number as nurses charged with “negligence/incompetence.” I encourage nurse researchers to investigate this alarming trend.

Training for techs in dialysis centers

Approximately 18 months ago, the SBFN was informed that unlicensed dialysis technicians were accessing central lines while providing care to patients in end-stage renal dialysis (ESRD) centers. After a brief series of discussions with Department of Health (DOH) staff, a memorandum was issued to all ESRD centers to cease this activity.

A series of meetings was initiated to discuss this issue. Some of us were shocked to learn that centers receive only $100 in reimbursement to dialyze a patient, a procedure that typically requires four hours of specialized nursing care and surveillance. Based on this reimbursement scheme, DOH explained, an all-RN staff was not feasible. Subsequent meetings among the various stakeholders focused on developing processes that would assure patients were cared for by competent licensed practitioners, given the confines of reality.

As a result, a curriculum was developed for LPNs in ESRD Centers that includes both didactic information and competency testing. Policy was agreed upon that RNs would be responsible for assessing patients and delegating tasks to LPNs who have successfully completed the prescribed course work. They may be assigned only the task of accessing central lines for dialysis care, and only in ESRD Centers. This provision does not apply to LPNs working in acute care or long term care facilities. I appreciate the NYSNA Practice Alert on this policy that was communicated to NYSNA members and thank NYSNA staff for their participation and support.

Color coding for DNR orders

The SBFN met several times with long term care providers to discuss the issue of Do Not Resuscitate (DNR) orders. Because of heightened concern about residents’ privacy, DNR signs are no longer posted in residents’ living quarters. Long term care facilities have begun using colored dots on resident identification bands to inform staff about DNR requests.

There is a lack of a uniform color system among facilities, however, which has resulted in confusion. This is especially true for new staff, those who are employed in multiple facilities, or those who are agency or “travel” nurses. In several instances, family members were devastated to learn that CPR had not been initiated for their loved ones when no DNR order existed or CPR had been initiated despite a DNR order.

In addition to suggesting a uniform color-coded system, the Board clarified that CPR was a universally accepted standard of care and that failure to provide this intervention could result in a charge of professional misconduct.

Changes in nurse practitioner practice

Two major legal decisions related to NP practice were made during the past year. The first interpretation clarifies Part 29 of the Regents Rules, which states that unprofessional conduct includes “directly or indirectly offering, giving, soliciting, or receiving or agreeing to receive, any fee or other consideration to or from a third party for the referral of a patient or client or in connection with the performance of professional services.” For nurse practitioners, the Office of the Professions has interpreted this rule to mean that an NP may pay a collaborating physician for the fair market value of services such as chart review and consultation.

There is no compulsion, however, for the NP to enter into such an arrangement nor is it appropriate to include such terms within the written collaborative agreement. When a payment agreement does exist, the payment may not influence the nature of the chart review nor result in any exclusive arrangement between the NP and physician for patient referrals in exchange for the services rendered.

It is understood that in certain instances, NPs may refer patients to their collaborating physicians when medically necessary, such as situations when an NP may not be granted hospital privileges. Such instances would not automatically be considered professional misconduct unless NPs bind themselves into exclusive arrangements for referrals to collaborating physicians or otherwise give or receive compensation for such referrals.

The second decision defines birth through 21 years of age as the acceptable age standard of care for individuals certified as Pediatric Nurse Practitioners.

Regulatory changes related to nursing

A number of regulatory changes were made directly related to nursing. The first of these eliminated a provision that permitted NPs certified in one specialty to obtain certification in an additional specialty through continuing education and on-the-job-training. The updated regulations reflect current standards for safe professional practice. Advances in technology and NP education have rendered obsolete the notion that with a few short courses and 1,000 hours of supervised experience or 300 hours of academic-based experience, an NP certified in one specialty can become qualified to practice in an additional specialty. NPs wishing to receive certification in an additional specialty will now need to complete a collegiate educational program in that specialty.

A second regulation would permit RNs to execute non-patient-specific orders and protocols in administering HIV tests. This provision permits RNs, especially those who work in jails, prisons, and municipal health departments, to perform HIV tests on patients without patient-specific orders. The draft regulations have been submitted to SED and we expect their adoption by early 2007.

New immunizations

Based on the recommendations from the Centers for Disease Control and Prevention (CDC) and the state DOH, four new immunizations are being added to those that can be provided through non-patient specific orders and protocols. They are the Acellular Pertussis vaccine and Human Papilloma Virus (HPV) vaccine for adults and the Rotavirus vaccine and HPV vaccine for children.

Recent changes in state law require RNs who visit children’s homes as part of their regular duties to report signs of an unlawful methamphetamine laboratory. The law further requires organizations that employ RNs to provide information to them that will help them identify such laboratories. A brochure to assist you in becoming aware of the new requirements, How to Recognize the Signs of a Clandestine Laboratory, is available at www.oasas.state.ny.us/meth/index.htm.

A new Article 165 of the Education Law, the “Clinical Laboratory Technology Practice Act,” defines the practice of clinical laboratory technology and provides for the licensing of clinical laboratory technologists and cytotechnologists and for the certification of clinical laboratory technicians. Licensure and certification of these individuals began in September 2006. Physicians, physician assistants, dentists, podiatrists, or certified nurse practitioners who perform laboratory tests or procedures as an adjunct to the treatment of patients are not required to obtain an additional license.

The federal emergency preparedness grant to NYSNA and SED was used to fund photo identification cards for RNs who had volunteered for the NurseResponse program. Based on the success of that project, I am pleased to report that this summer the department began to provide photo IDs with licensure registration certifications. This is a voluntary service available for a $20 fee. The service will be phased in, based on RNs’ re-registration dates.

Individuals can, however, write to the SED and request a photo ID prior to their re-registration date. The photo will be obtained electronically from Department of Motor Vehicles files, so the name on your RN registration must exactly match the name maintained by DMV.