MINUTES OF THE meeting
of the
ASSEMBLY Committee on Education
Seventy-First Session
February 12, 2001
The Committee on Educationwas called to order at 4:00 p.m., on Monday, February 12, 2001. Chairman Wendell Williams presided in Room 3143 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List. All exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.
COMMITTEE MEMBERS PRESENT:
Mr. Wendell Williams, Chairman
Ms. Bonnie Parnell, Vice Chairman
Ms. Sharron Angle
Mrs. Barbara Cegavske
Mrs. Vonne Chowning
Mr. Tom Collins
Mr. Don Gustavson
Mrs. Ellen Koivisto
Mr. Mark Manendo
Ms. Debbie Smith
COMMITTEE MEMBERS ABSENT:
Mrs. Marcia de Braga
Ms. Kathy Von Tobel
GUEST LEGISLATORS PRESENT:
None
STAFF MEMBERS PRESENT:
Susan Scholley, Committee Policy Analyst
Linda Corbett, Committee Manager
Mary Drake, Committee Secretary
OTHERS PRESENT:
Kathy Apple, Executive Director, Nevada State Board of Nursing
Kathy Williams, President, Nevada State School Nurses Association
Mary Pierczynski, Assistant Superintendent of Schools, Carson City School District
Dr. Keith Rheault. Deputy Superintendent for Instructional, Research and Evaluative Services, Nevada Department of Education
Following roll call, Chairman Williams opened the hearing on A.B. 1
Assembly Bill No. 1: Revises provisions regarding school nurses.
(BDR 34-135)
Ms. Parnell, Assemblywoman representing District 40 and Chairman of the Assembly Committee on Education, introduced A.B. 1. Ms. Parnell explained A.B. 1 would align state law with the State Board of Nursing regulations by requiring that, in compliance with the Nevada Revised Statutes (NRS) 632, a registered nurse (RN) would supervise health practitioners in school districts. Ms. Parnell noted all committee members were provided copies of letters from the Clark County School District (Exhibit C), Elko County School District (Exhibit D) and the Nevada Nurses Association (Exhibit E) in support of A.B. 1.
Ms. Parnell explained her personal involvement in A.B. 1 began approximately 1-1/2 years ago when an issue arose in the Carson City School District that demonstrated to Ms. Parnell how few people understood the different scopes of practice within the school health practitioner fields. Health practitioners such as school nurses, registered nurses (RNs), licensed practical nurses (LPNs), and emergency medical technicians (EMTs) did not all operate within the same scope of practice. The majority of the health practitioner positions required supervision by an RN. An RN was the only practitioner carrying the term “school nurse”, although that term was often misused.
Ms. Parnell stated she first met with Kathy Apple, Executive Director of the Nevada State Board of Nursing; Kathy Williams, School Nurse in the Washoe County School District and President of the Nevada State School Nurses Association; and, several others in the profession to address the issue of lowering the ratio of students to school nurses. At the meeting, Ms. Parnell realized that a more serious problem existed in the school districts, and that problem was one of the oversights of health practitioners. Staff at the meeting felt Nevada needed legislation to ensure all individuals providing nursing services in the school system were supervised by appropriate personnel and technically working only within their allowed scope of practice. A.B. 1 was drafted to address this issue.
Ms. Parnell pointed out A.B. 1 had no fiscal note attached. Compensation for the chief administrative nurse designation was not the goal of this measure. The primary concern was the quality of care for the students in Nevada schools. Any discussions on the fiscal elements of this measure would be handled at the district level; it was not part of the legislation. Ms. Parnell further added that the term “administrative” in the text of the bill did not mean the administrative nurse would be on the administrative pay scale. Ms. Parnell recognized this was a concern with some of the school districts since school personnel considered the term “administrative” to indicate a different salary scale. Ms. Parnell commented that following testimony at this meeting, the advocates of the measure could look at any concerns about the use of the term “administrative” with a possibility of changing the term.
Ms. Parnell then introduced Kathy Apple and Kathy Williams to the committee and asked Ms. Apple to give her presentation.
Prior to Ms. Apple giving testimony, Chairman Williams asked for a show of hands of those individuals who opposed the bill or who had any technical concerns with the bill. Only one person signified a concern. Chairman Williams encouraged all advocates of the measure to testify, but asked of those testifying if they would refrain as much as possible from repetition in their testimonies. Ms. Parnell remarked to Chairman Williams that she felt Ms. Apple’s and Ms. Williams’ testimony would answer any technical questions the audience had.
Ms. Apple reviewed the State Board of Nursing’s involvement in A.B. 1. She explained the role of the State Board of Nursing was to ensure any nurse practicing in any setting practiced safely, competently, and legally. Over the past eighteen months, the State Board of Nursing became alarmed over a series of phone calls and questions received from school nurses from various school districts. Ms. Apple noted one inquiry from a health care practitioner, who stated: “I’m being told since I work in a school I don’t have to follow the Nurse Practice Act.” Ms. Apple explained that the Nurse Practice Act was the State Board of Nursing’s reference to Chapter 632 of the Nevada Revised Statutes (NRS) and Chapter 632 of the Nevada Administrative Code (NAC). She emphasized all nurses licensed through the Board of Nursing were required to follow these laws and regulations in any setting they practiced.
Ms. Apple cited another example of a phone call that concerned State Board of Nursing staff. One caller made the comment: “My principal said he can delegate the administration of medications and I don’t have to bother about that.” Ms. Apple stated as far as the Board was concerned, that particular school principal would be practicing nursing without a license, which was a violation of the law and a criminal misdemeanor.
Ms. Apple explained that at that time, the State Board of Nursing had an advisory opinion on the special authority of delegation granted to school nurses. Only school nurses were allowed to legally delegate certain nursing tasks off a laundry list of tasks. That advisory opinion had been in place ten years. Last year, because of the board’s concern over this issue, it moved that advisory opinion into regulation. Another comment received by the board was as follows: “The advisory opinion on delegation is not law so therefore I don’t have to follow it.” Ms. Apple emphasized the advisory opinion had to be followed; that was the expectation.
Ms. Apple stated another nurse remarked she was assigned to three schools, and was told she had to go to a fourth school which was not part of her assignment, develop a care plan for a student, drop that plan off to the LPN at the school, and that was all she was to do. From the State Board of Nursing’s perspective, that violated a number of standards for safe nursing practices. The situation would be analogous to having a pediatric nurse suddenly leave the pediatric unit, go to the intensive care unit to develop a patient care plan for a patient the nurse did not know, and then leave. This was not the standard of practice.
Ms. Apple cited another inquiry that concerned board staff, which was: “Can an LPN (Licensed Practical Nurse) assess a student and set up a care plan?” Ms. Apple explained that was not the role, nor was an LPN authorized within their scope of practice, to do either of these two things. The role of the LPN was developed to assist the RN; it was a dependent role. The functions to assess the patient and their needs and develop a care plan based solely on that assessment legally resided within the scope of practice of an RN. Any LPN performing those functions within a school was practicing beyond his or her scope, and was in potential violation of the law.
In the view of the State Board of Nursing, all those practices mentioned were potential violations of the law, and practices the board would deem unsafe in caring for children in schools. The model of safe nursing practice in the statutes and regulations held one singular registered nurse ultimately responsible for instituting safe standards of nursing practice. This one registered nurse was called a “chief administrative nurse.” The language came directly from the Nurse Practice Act.
Ms. Apple commented none of the questions asked of the Board of Nurses came from school districts that actually had one of their RNs designated as the chief nurse. The Board of Nursing felt the change in statutes proposed by
A.B. 1 helped clarify the nursing model as it applied to the safe practice of nursing in schools; the board therefore supported the bill.
Ms. Williams then testified in support of A.B. 1, and provided a written copy of her testimony (Exhibit F). She explained she had been a school nurse in Nevada for 11 years and was currently the President of the Nevada State Association of Nurses. Ms. Williams emphasized the purpose of A.B. 1 was to ensure that the school-age children in Nevada received the best possible care by the most qualified person: a registered school nurse. She explained this legislation clarified and tied the practice of school nursing to the Nurse Practice Act. Ms. Williams stated the Individuals with Disabilities Education Act (IDEA) heavily impacted school districts, and the reauthorization of IDEA had mainstreamed children with special medical needs into general classroom settings. She stated that without the provisions of nursing services, those children would not be able to attend school safely with their peers and profit from classroom education.
Ms. Williams cautioned case law across the country had established that school districts must provide complex nursing services to medically fragile students. Because of the planning, assessment and evaluation of that type of nursing care, it was critical it be delivered by persons with the nursing skills and knowledge to either provide the type of care needed or delegate the delivery of that care to another. School districts would be held liable for unsafe health care decisions.
Ms. Williams concluded her testimony by stating school nursing was a specialized practice of nursing with national standards of care, and that no child deserved less than the very best of nursing services. She urged the committee to support the passage of A.B. 1.
Ms. Parnell commented she wanted to explain the deletion on page 3 of A.B. 1 (Section 4 of NRS 632.240) which deleted subsection (2) stating the provision did not apply to a county school district whose enrollment was fewer than 35,000 pupils. There were population caps on school district populations concerning the hiring of school nurses. Many of the smaller counties contracted or utilized the services of a state, county or district public health nurse. Ms. Parnell explained the purpose of A.B. 1 was to ensure all schools had this designated person. She realized that in some of the school districts the person designated to oversee health care personnel below RN status came from the state, county or district level ranks; they did not have to be a school nurse. The community nurse could provide that service. A.B. 1 did not place an additional strain on smaller counties by asking them to hire a school nurse to supervise; they could continue to utilize the services of the person who now handled that task.
Mrs. Cegavske asked if one of the purposes of A.B. 1 was to ensure that the NRS matched the new regulations adopted by the Nevada State Board of Nursing.
Ms. Parnell explained the regulation changes were not that recent; the State Board of Nursing regulations had been in place for some time. It was only recently Board of Nursing staff became alarmed that state law was not supporting what the State Board of Nursing was expecting.
Ms. Cegavske said it was her understanding that under current NRS, school districts in the rural areas that did not have a school nurse could utilize the health district nurse.
Ms. Parnell confirmed that was correct. Many smaller school districts did utilize the public health nurse. If that school district also had an Emergency Medical Technician or a Licensed Practical Nurse, the public health nurse could be given the oversight responsibility of those individuals. Ms. Parnell emphasized it was the oversight of nursing staff that was the issue. State law required a registered nurse supervise them. That may not be happening in some of the counties. A.B. 1 would “shore” this up.
Mrs. Chowning asked about the deletion of Section 4 of NRS 632.240. If this provision was eliminated, were there any schools with enrollments of less than 35,000 that did not have the nursing personnel to supervise?
Ms Williams answered that all districts had a public health nurse who could provide the oversight, even though that person was not a school nurse. Someone from a county or health district office was providing those services.
Mrs. Chowning asked for confirmation that the committee would not be characterized as passing policy that would leave children without that type of coverage.
Ms. Williams assured her that would not be the case.
Mrs. Chowning mentioned that Mrs. Van Betten, who was in the audience, had been so helpful in Clark County as a tireless advocate for children and deserved a lot of praise. Mrs. Chowning observed the dire needs of children these days were being underestimated. She said many children were attending school without any form of health insurance coverage. Problems such as scoliosis, visual, dental and other serious health issues were first brought to the attention of the families as a result of a school nurse examination. That made the requirement to comply with state law all the more important.
Ms. Parnell added that the Joint Hearings of the Natural Resources, Agricultural and Mining and the Health and Human Services Committees on the Fallon cancer clusters illustrated what school-nursing practitioners dealt with. Those nurses were dealing with emotional upsets, questions from parents, and, in some cases, near hysteria trying to cope with this health issue, and the impact on the nursing practitioners was tremendous. The school nurse practitioners were a much more important part of the school setting than they were often credited for.
Mrs. Cegavske stated she was prepared to make a motion, but requested that the individual in the audience who had questions be given an opportunity to talk. Mrs. Cegavske felt this was a bill that needed to be moved along.
Chairman Williams asked if anyone else in the audience wished to address the committee on A.B. 1.
Mrs. Mary Pierczynski, Assistant Superintendent of Schools for the Carson City School District and head of the District‘s Human Resources Department, felt there needed to be a fiscal impact notation on the bill. Mrs. Pierczynski stated that in terms of Carson City, the school district had a regular administrator who oversaw the nurses, and Registered Nurses (RNs) who oversaw the Licensed Practical Nurses (LPNs). The school district did not expect personnel to take on additional supervisory duties without more compensation. This bill could require additional money for that individual.
Mrs. Pierczynski asked for clarification on the chief nurse. Did the chief nurse position have to be an RN who was in the school district, and that an educational administrator could no longer oversee the nurses? In many districts that would require additional personnel or an additional position. In Carson City School District’s situation, all nurses were assigned to a school. If they were asked to take on the additional responsibilities of supervising all other nurses in the district, then it appeared that would be an additional position.
Chairman Williams said he saw there were individuals in the room who disagreed with Mrs. Pierczynski’s interpretation. He emphasized if there was a fiscal note, even for the local school districts, the bill, if successful on the Floor, would be re-referred to Committee on Ways and Means to discuss the fiscal impacts. The Committee on Education could decide now if there was a fiscal impact, but Chairman Williams assured Mrs. Pierczynski if there was the possibility of a fiscal note, the Committee on Ways and Means would review the bill, and the fiscal impacts would be debated at that time. The Committee on Education dealt with the policy questions; the money committees explored the fiscal impacts.
Mrs. Cegavske stated in her discussions of this measure with school districts and the head nurse for the Clark County School District, it was her understanding that there was no pay scale level with that terminology. The title “chief administrative nurse” did not mean there was a pay scale for that title.
Mrs. Pierczynski stated she felt that would depend on the nurses’ contract with the school district.
Mrs. Cegavske indicated that, at least in Clark County, it was not in the pay scale. She understood in her discussions with the school districts that A.B. 1 did not involve a pay hike. The bill also specified there was no fiscal note on either local or state government. Mrs. Cegavske stated if there was some fiscal note involved, the committee needed to know. Mrs. Cegavske reiterated that in her research and in discussions with others concerning the bill, there was no fiscal note.
Chairman Williams stated if the committee moved forward with the bill and it was determined there was a fiscal note, he would re-refer the bill back to the Committee on Education for discussion and then refer the bill to the Committee on Ways and Means. Mr. Williams said that would give Mrs. Pierczynski time to do her own investigation to determine if there were any fiscal impacts, and the committee would do the same.
Mrs. Pierczynski agreed with Chairman Williams’ suggestion. She added she wanted clarification if the measure would require additional personnel in the district. Her discussions with other individuals on this measure indicated no additional personnel were required.
Mr. Collins added that in terms of collective bargaining agreements versus filling a new position, the law as he understood it entitled someone with the right qualifications taking on added responsibilities to be paid an additional 4 or 5 percent. That amount of money may not meet the legislative threshold for bills to be heard in the Committee on Ways and Means. Mr. Collins asked Mrs. Pierczynski if it would be satisfactory to her if, prior to the bill going to the Floor for a vote, the Legislative Counsel Bureau’s Research Division clarified that the intent of A.B. 1 was that existing employees performed the job without having to hire a new employee.
Mrs. Pierczynski said that would be satisfactory. She explained the current structure within the Carson City School District was one RN supervised one LPN and was paid a stipend for those additional responsibilities. Currently there were three RNs who supervised three LPNs. The actual head of the nursing staff in the school district was a regular school administrator who was the head of special services. The nursing staff fell under that person’s supervision.
Mrs. Pierczynski said her concern was, for example, asking the head nurse at Carson High School to supervise all school district nurses as well as administer to 2,459 students. That probably could not be accomplished without hiring an additional person.
Mr. Collins offered that the size of the Carson City School District probably required an administrator over the department who was not a registered nurse, and that was likely the case in some of the smaller districts. Conversely, larger school district had a registered nurse over those departments who also qualified as an administrative person. The concern was more with the title than filling the position.
Mrs. Pierczynski agreed, and said that was the case in Carson City as well as nine other rural school districts. She was not stating opposition to A.B. 1; she just wanted clarification on the issue.
Chairman Williams said he would give Mrs. Pierczynski time to clarify that issue. He assured Mrs. Pierczynski the bill would not be passed to the Senate if there was any fiscal question. It would be re-referred back to this committee, and if it moved forward, it would be referred to the Committee on Ways and Means.
Dr. Keith Rheault, Deputy Superintendent with the Nevada Department of Education, said he wanted clarification on one point in A.B. 1, and that was with Section 1 of NRS 391.207. Dr. Rheault said he understood the intent of A.B. 1 was to allow rural school districts the opportunity to use county, state or local health professionals. He indicated he read the new language in the new Section 2 of NRS 391.207, which covered the provision of nursing services, to mean all nursing services in a school district must be provided by a person who met both subsections (a) and (b). Subsection (a) stated the individual must satisfy the requirements as set forth in NRS 632.240, which was an RN and chief administrator; and (b) stated the individual held an endorsement to serve as a school nurse, which meant they were licensed to serve as a school nurse. Dr. Rheault felt that with these new provisions, services provided by the passage of the bill would have to be performed by an individual who was a licensed school nurse and chief administrator.
Dr. Rheault said that to his knowledge, he did not think most county, state or local nurses were licensed school nurses. The new language required that they be both, which may prevent school districts from utilizing state, county, or local personnel if they had to be both licensed and chief administrators. Dr. Rheault suggested the “and” in Section 2 of NRS 391.207 be changed to “or”. This would allow a chief administrator as set forth in NRS 632.240 or a licensed school nurse, who must be an RN with a baccalaureate degree.
Mr. Collins stated he felt the existing language in subsection 5 of Section 3 of NRS. 392.420 covered that issue.
Dr. Rheault indicated he interpreted that provision to be specific to vision screenings and scoliosis; it did not speak to general nursing services.
Chairman Williams stated the concerns expressed were valid, but the legislation was important enough to not appoint a subcommittee to address these issues. Chairman Williams felt that if the committee decided to move forward with the bill, the bill could be held in committee until those concerns were addressed as opposed to appointing a subcommittee and going to amendments. If the concerned parties could work out these issues, the bill could be moved forward and if amendments were needed, the committee would work on the amendments and take them to the Floor. This allowed everyone to get together and make sure the concerns were worked out.
Dr. Rheault said he was concerned there was no misunderstanding of what was passed. He did not want to later find the position had to be licensed and the school districts could not use the local or state personnel.
Chairman Williams said he would accept a motion.
ASSEMBLYMAN COLLINS MOVED TO DO PASS A.B. 1
ASSEMBLYWOMAN KOIVISTO SECONDED THE MOTION
Chairman Williams repeated that those with concerns had the assurance of the committee the concerns would be addressed by all parties involved.
THE MOTION PASSED UNANIMOUSLY
Chairman Williams adjourned the meeting at 4:41 p.m.
RESPECTFULLY SUBMITTED:
Mary Drake
Committee Secretary
APPROVED BY:
Assemblyman Wendell Williams, Chairman
DATE: