Oregon State Board of Nursing Nurse Practice Act: Laws, Rules, and Policies Joy Ingwerson, MSN, RN,...

Oregon State Board of NursingNurse Practice Act:

Laws, Rules, and PoliciesJoy Ingwerson, MSN, RN, CNE

Policy Analyst, Nursing Education and Assessment

October 27, 2015

Objectives for Today

• Understand regulated professions• Review the laws, rules, and policies

associated with the Nurse Practice Act• Analyze individual scope of practice• Describe the leadership functions of the

LPN• Use the Nurse Practice Act to avoid

disciplinary actions against a license

• Oregon Revised Statute (ORS) 678 governs the practice of nursing.• ORS 678.021: It shall be unlawful for any person

to practice nursing or offer to practice nursing in this state or to use the title or abbreviation, sign, card, or device to indicate the person is practicing nursing unless the person is licensed at the level for which the indication of practice is made and the license is valid and in effect.

Statutory Mandate Regulates Nursing Practice – It’s the Law!

What Does the OSBN Do?

Mission Statement

• The Oregon State Board of Nursing safeguards the public's health and well-being by providing guidance for, and regulation of, entry into the profession, nursing education and continuing safe practice.

• The OSBN exists for public safety, not professional advocacy…

What Is the Role of the Board of Nursing?

• Public protection:• Determines requirements for licensure• Sets standards and scope of practice• Provides guidance for licensees and certificate-holders

on practice/duties• Identifies inappropriate conduct and takes disciplinary

action• Approves nursing and training programs• Proposes legislative concepts• Participates in public policy through testimony in

public venues• Establishes Board policies on nursing regulatory issues

The OSBN Does Not…..

• Serve as a membership organization for nurses• Regulate conditions of employment• Regulate practice settings• Make or change regulations without a public process

Who Makes Up “The Board”

• Nine members appointed by the governor and subject to Senate confirmation, for three year terms• Five RNs (two in direct care, one manager/administrator,

one educator, one nurse practitioner)

• One LPN• One CNA • Two public members

Licensing Statistics: June 2014

• Certified Medication Aides: 1,116• Certified Nursing Assistants: 19,051• Clinical Nurse Specialists: 202• Certified Registered Nurse Anesthetists 608• Licensed Practical Nurses 4,786• Nurse Practitioners 3,037• Registered Nurses 52,537

• Total Licensees/Certificants 81,337

What Did Nursing Look Like in 1933?

• Name four kinds of pneumonia.• What is the recommended diet in Typhoid Fever?• When nursing intestinal diseases, what symptoms should the

nurse record?• What do you suggest should be done with nurses who discuss

their patients in public places?• What is a Bradford frame?• List three ductless glands and give the function of each.• List the food allowed in restricted liquid diets, soft diets, light

diets and full diets.• Exceprts from the Oregon State Board for Examination of

Registered Nurses as administered in 1933

Did You Pass?

Oregon Nurse Practice Act• Oregon Revised Statutes (ORS) 678 • ORS 678 governs the practice of nursing in Oregon• Tend to be very broad• Note WA has Revised Codes of Washington (RCW)

• Oregon Administrative Rules (OAR) 851 • OARs interpret and specify ORSs:• have the effect of law• help define statutory expectations and how they are enacted

• Note WA has Washington Administrative Code (WAC)

A Regulated Profession

•What does it mean to be part of a regulated profession?

Characteristics of a Regulated Profession

• Legislative decisions affect you. • You must meet standards to be

licensed.• Your practice is regulated by the Nurse

Practice Act and the OSBN.• You must practice within scope and

standards set by law.• Failure to function within standards

and scope may subject you to disciplinary action.

Chapter 851 Oregon Administrative Rules

•Major Divisions/Sections• 21- Educational Programs• 31 – Licensure• 45 – Scope and Standards RN and LPN• 47 – Community-based RN Delegation• 50’s – Advanced Practice and Prescribing• 60’s – Certified Nursing Assistants &

Medication Aides• 70 – Health Professionals Services Program

The Regulation of Nursing

Professional Regulation

Legal Regulation

Self-Regulation

Division 45: Standards and Scope of Practice for the LPN and RN

Scope of practice: The actions and processes that are permitted for a licensed individual.

What is Scope of Practice?

• All of the activities in which a nurse may engage at his/her level of licensure.• Each nurse has an individual scope within

broader scope.• Individual scope determined by in-service

education, continuing education, practice experience, etc.

Scope of Practice (cont’d)

• Documentation of how competency in new nursing activity is achieved and how it is maintained is required.• Activities within scope must be recognized by

nursing profession as proper to be performed by Oregon nurse.• Cannot be expanded by those outside of nursing (e.g. by physician).

Division 45: Scope of PracticeAuthorities & Responsibilities

1. Client Advocacy2. Environment of Care3. Ethics, Professional Accountability, Competence4. Nursing Technology5. Assign and Supervise Care6. Accept and Implement Orders7. Nursing Practice Implementation8. Collaboration w/Interdisciplinary Team9. Leadership 10. Quality of Care11. Health Promotion 12. Cultural Sensitivity13. Delegation

Division 45 Sections

• Section defining the scope for ALL Licensed Nurses• Section defining

the scope for LPNs• Sections defining

the scope for RNs

ALL Licensed Nurses• Advocate for clients• Promote client safety (identify issues and take action)• Guided by ethical practice• Know laws and regulations• Follow laws, regulations, policies• Accept only assignments for which one is prepared• Maintain professional boundaries

• Use technology and informatics appropriately• Assign and supervise care• Follow-up on problems with assignments and take action

• Accept and implement medical orders• Question any order that is unclear, unsafe, contraindicated, or

inconsistent with the plan of care

What Are The Differences?LPNs Perform focused assessments Contribute to the plan of care Implement the plan of care Collaborates with the healthcare

team Makes appropriate referrals Contributes to policy

development Contributes to quality

improvement Provides client teaching based on

prepared materials Recognize basic cultural impacts

on care

RNs Responsible for comprehensive

assessments Develop the comprehensive plan of

care Collaborates with the healthcare team Follow-up on referrals Develops policies Leads quality improvement processes Develops client teaching materials to

be used in teaching plans Develops evidence-based client

teaching materials Applies broad knowledge of cultural

impacts on care May delegate tasks of nursing to others

in addition to assigning care to others

Comprehensive Assessment

The extensive collection and analysis of data for the purpose of judging a client’s health status…..

Comprehensive assessment involves, but is not limited to, the synthesis….. of the client’s condition or needs……..for the purpose of establishing nursing diagnostic statements, and developing, implementing and evaluating a plan of care.

OAR 851-045-0030(2)(c)

Focused Assessment

An appraisal of a client’s status and situation at hand, through observation and collection of objective and subjective data. Focused assessment involves identification of normal and abnormal findings, anticipation and recognition of changes or potential changes in client’s health status, and may contribute to a comprehensive assessment performed by the Registered Nurse.

OAR 851-045-0030(2)(f)

Common Differentiation Words• Basic vs. in-depth

knowledge• Stable vs. unstable

condition• Predictable vs.

unpredictable situation• Routine vs.

constantly changing

LPN Requires Clinical Direction• The LPN must always

work under the clinical direction of the RN or a licensed independent practitioner (such as a physician)• Clinical direction links

to the comprehensive plan of care

Think It Through…..

•How can the LPN be the “charge nurse” and the RN be assigned as the treatment nurse for the day?

Think It Through……

•How can the LPN be assigned to cover a shift when there is no RN in the building?

The Practice Act Dilemma

The “Missoni” Valve

Specific Scope of Practice

• Look at context of care• Determine what facility policies exist• Determine if national evidence-based

practice standards exist• Follow Scope of Practice Decision-

Making Guideline• Series of questions to guide your

application of critical thinking and clinical judgment

“Context of Care”

• The factors affecting the way an individual nurse may practice. Factors include:• nursing role• position description• practice setting• regulations governing the setting• population served• facility policies• current community and industry standards

Self Regulation

• Major expectation of all nurses• Must be aware of the situation and own

competencies• Differentiate appropriate from inappropriate

orders and assignments• Be able to clearly state own limitations• Up-to-date on latest information to provide

evidence-based care• Lifelong learning

Scope of Practice Decision-Making Guideline• Define the activity• Is it prohibited by other laws, rules, policies?• Consistent with nursing care standards?• Has the nurse been educated to carry out the activity?• Does the nurse possess the needed knowledge

currently?• Is there documentation of competency and skill?• Would a reasonable and prudent nurse perform the

activity?• Is the nurse ready to accept the consequences of action

taken?

Washington State

Scope of Practice Requires Thought….

Nurses Regulate Nurses

• No one from another licensed profession can expand the scope of practice for the nurse• An employer may set policies that are more

restrictive than the OSBN but may not be more expansive• Limitations on scope are often set by clinical

agencies or outside forces (third party payers)• Limitations on scope are often historical rather

than based on the Nurse Practice Act• When in doubt, THINK and be ready to provide

your rationale

LPN Leadership Functions• Collaborates with the healthcare team on integrated client-

centered plans of care• Contributes to the formulation, implementation and

evaluation of policies, protocols, and operating guidelines for nursing practice

• Assists with the development and mentoring of other members of the healthcare team

• Identifies changes in the practice environment that require change in policy

• May have management functions as part of position description in some settings (such as interviewing, completing performance reviews, etc.)

All Nursing Leaders

• Role model professional behavior• Communicate appropriately with co-workers• Problem-solve• Plan ahead• Take initiative• Know their resources• Use the “chain of command”• Act prudently• Know how to CUS

Phrases Not Used by Nurse Leaders

• “I had an order” or “I was just following the doctor’s order”• “Another nurse did it that way on the last shift”• “Get the patient need met now and get the order signed

off later”• “I assumed the other shift already knew about…..”• “I didn’t have any choice. I had to……”• “Nothing would get done around here unless we took

shortcuts”• “I didn’t have time to follow the procedure”• “We did this all the time in the state I came from”

CUS?

• I’m Concerned….• I’m

Uncomfortable…• This situation

isn’t Safe…..

Scope of Practice Scenario #1• Which clients are most appropriate for the LPN

scope of practice in an Urgent Care Clinic?• 30 y/o female with diffuse abdominal pain of

three days duration, nausea and vomiting for past 24 hours• 22 y/o male with softball injury, R/O fracture• 62 y/o female with foot laceration from a

garden tool• 44 y/o stating “has the flu”, skin clammy and

sweating profusely

Scope of Practice Scenario #2

• Using the Scope Decision Guide, decide what steps you would take to determine whether or not nurses in your facility could perform sharp wound debridement.

Scope of Practice Scenario #3

• Using the Scope Decision Guide, decide if the LPN in an office setting could infiltrate the tissue with a local anesthetic before a procedure.

Protect Your Practice• Review the Nurse Practice Act• Keep up with changes – Review The Sentinel• Put on the brakes and THINK• Use the designated chain of command• Stay updated on facility policies• Listen to your inner “Florence”• Not only do you have the right to refuse to carry out an order,

you are expected to question orders that are potentially unclear, unsafe, contraindicated

• Address system issues through appropriate reporting• Apply your clinical judgment and critical thinking in all

instances

Pointers and Pitfalls for Assigning to Others

• “Drive-by” assignments• “Always” mentality for given tasks (e.g. CBGs)• Unaware of assistive personnel competency• Lack of timely follow-up – must monitor

performance• Expanding assigned duties without authority to

do so• Resistance to idea of supervising others

Common Conduct Derogatory Themes

• Too busy to follow typical process or policy• Not following up on questionable

action/order/direction• Not using available chain of command• Crossing professional boundaries• Breeching patient confidentiality• Not following LIP orders and not communicating

same to LIP• Lack of follow-up (with interdisciplinary team,

assistive personnel, LIP, etc)

Mandatory Reporting• Don’t need to report every nursing error.• Decision to report based on:• Past performance history.• Pattern of substandard practice.•Magnitude of occurrence for

actual/potential harm to public.

Should I Report a Colleague?

• Do I have concerns about this person working someplace else (in another facility or unit)?•Would I be comfortable with this person

caring for a member of my family?• Does this person learn from a mistake or

not?• Is this an employment issue?

When in doubt….. REPORT

ALWAYS Report

• A nurse imposter• Practicing nursing with an expired license• Arrest for or conviction of a crime which

relates adversely to the practice of nursing• Dismissal from employment due to unsafe

practice or conduct derogatory• Client abuse• Substance abuse

What Substances May A Nurse Use?

• Also known as the “marijuana card” question• Must follow employer policies• For the Board, impairment is impairment is

impairment…..etc• Must be able to perform safely in the nursing role• Expectation is on the individual to self-identify

when they cannot do so• Expectation is on colleagues and employer to

report an individual who is impaired while providing care

Remember: Public Protection

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