Sample Letter on Missing Information

DATE

Joelle Stein
Board Counsel
Board of Registration in Nursing
239 Causeway Street
Boston, Massachusetts  02114

Dear Ms. Stein:

As a practicing nurse in the Commonwealth, I am writing to express my comments and concerns regarding the most recent draft of the Board's proposed revised regulations dated June 1, 2000.

In comparing this draft with the previous version of July 1999, I am particularly concerned about certain language and provisions at 244 CMR 2.03, Standards of Conduct for Nurses, that have been deleted from the current version of the regulations.  These omissions deal with actions and functions that are at the heart of nursing practice - assessment, advocacy, and accountability - and, as such, should rightfully be addressed in the standards.  Their omission from the current version of the regulations is disturbing, and I urge the Board to reinstate appropriate language relative to these areas following consideration of the comments expressed below.

(1) Nursing Assessment

Standard #14 in the prior version of the regulations, this has been deleted from the current draft.  Nursing assessment is a fundamental cornerstone of nursing practice, and is the basis for all other nursing interventions which are taken on behalf of the patient.  Assessment is an ongoing process that influences a diverse range of actions, including the provision of direct patient care, the adequacy of staffing assignments, decisions to delegate tasks to ancillary staff, and reimbursement for services. 

The language in the prior draft of the regulations recognized the significance of nursing assessment and should be reinstated.

(2) Duty to Safeguard Patient

Previously appearing as Standard #23, this language is now absent.  Perhaps more than any other standard, the nurse's role as patient advocate defines the nursing profession itself.  Advocacy is an ethical and legal obligation that nurses instinctively understand and attempt to carry out every day to the best of their ability under increasingly difficult circumstances.

The language in the prior draft of the regulations addresses this obligation and, in fact, encompasses several of the other listed standards such as:  #7, Aiding Unlawful Activity; #15, Patient Abuse, Neglect, Mistreatment, Abandonment or Other Harm; #17, Patient's Dignity and Privacy; #19 and #21, Undue Influence or Gain; #23, Sexual Contact; #30 through #34, Fraud and/or Misrepresentation. 

Most importantly, reinstating language relative to the advocacy role of the nurse eliminates the need for specific proposed regulatory requirements for Mandatory Reporting of Nurses to the Board (#26) and Practice While Impaired (#36).  This would accomplish the Board's intent to remove dangerous practitioners from practice without creating a process for doing so that fails to provide adequate legal protections to colleagues who report them to the Board.

(3) Delegation

Included in the Board's prior draft as Standard #47, this language is missing from the current version of the regulations.  Delegation is a critical issue for nurses and has become more so in the face of mergers and facility downsizing of staff.  It is also closely tied to the nursing assessment function, as it is the nurse who is ultimately responsible for decisions to delegate patient care tasks to unlicensed or ancillary staff.  In today's health care environment, nurses have virtually no choice but to delegate in order to ensure that patients' needs are met.

It is apparent that the Board itself considers delegation to be a significant area as it has issued relevant policy statements and guidelines for nurses.  Delegation is so important that the Board devoted its entire Summer 1997 issue of Nursing Board News to the subject.

Including a standard on delegation in the proposed regulations protects patients by prohibiting nurses, voluntarily or under pressure, from authorizing unqualified personnel to perform patient care tasks.  It also protects nurses by helping to ensure that their employers have adequate numbers of appropriately-trained staff.  The previous language should be reinstated.

(4) Supervision Following Delegation

This previously appeared as Standard #48 and should be reinstated in conjunction with the delegation standard discussed above.  This language deals with the nurse's accountability for decisions to delegate tasks to other staff.   However, I would urge that any reference to "supervising" the person to whom an activity is delegated be deleted, and that "monitoring" be substituted instead.  This clarifies that the delegating nurse may not in every case have a supervisory relationship to the other individual, but that s/he retains accountability for assuring the delegated task was carried out. 

In closing, I would ask that the Board view these comments in the context of its intent in issuing new regulations.  The Board's mission is to protect the public by ensuring that only safe and competent practitioners are allowed to practice.  That mission is best served by issuing regulations that are clear, relevant, and meaningful, reflect recognized standards of nursing practice, and foster professional conduct. 

Sincerely,
 
 

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