YOU AND OSBN Oregon State Board of Nursing Scope of Practice Debra Buck, RN, MS Nursing Assistant Program Consultant – OSBN Marilyn McGuire-Sessions, RN, MSN RN/LPN Practice Consultant - OSBN OCHE Meeting – April 20, 2012 Samaritan Lebanon Hospital

Learning Objectives Identify resources – OSBN website journey and National Council of State Boards of Nursing (NCSBN) website Discuss Division 45 – The Oregon Administrative Rule (OAR) of the Oregon Nurse Practice Act (NPA) for Standards and Scope of Practice for RNs and LPNs in Oregon Identify the major differences between RN and LPN practice Review types of circumstances that would be considered “conduct derogatory” to the Standard of Nursing Review “mandatory reporting” section of Division 45

Learning Objectives Review Division 47 – Delegation in a Community-Based Setting Discuss C.N.A 1 & 2 ; C.M.A Authorized Duties, and Issues

Statutory Mandate to Regulate Nursing Practice ORS 678.150 (7) The board shall: (a) Exercise general supervision over the practice of nursing in this state.

Why Regulation of Nursing? OSBN’s 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.

What Is the Role of the Board of Nursing? Public protection. Determines requirements for licensure. Sets standards and scope of practice. Provides scope guidance for nurses and nursing assistants. Identifies inappropriate conduct and performance & takes disciplinary action regarding licensure. Approves nursing programs. Proposes legislative concepts. Influences public policy through testimony & public hearings. Establishes public policy on nursing regulatory issues.

What the Board Doesn’t Do Serve as a membership organization for nurses. Regulate conditions of employment. Regulate practice settings. Independently change the Oregon Revised Statutes. Make or change regulations without a public process.

OSBN Members Nine members appointed by the governor for 3 year terms. 5 RNs (2 in direct care, 1 manager, 1 educator, 1 nurse practitioner). 1 LPN 1 CNA (as of 2010) 2 consumer members. In addition, represent different geographic regions – 2 from eastern Oregon, 3 from southern Oregon

OSBN Organizational Chart GOVENOR BOARD OF NURSING EXECUTIVE DIRECTOR OF OSBN HUMAN RESOURCES INVESTIGATIONS LICENSING FISCAL SERVICES COMMUNCATIONS NURSING CONSULTANTS

Nursing Licensees in Oregon (Data current as of December, 2011) Oregon licenses or certifies seven license types: Registered Nurses; Licensed Practical Nurses; Certified Nursing Assistants; Certified Medication Aides; Nurse Practitioners (10 specialties); Certified Registered Nurse Anesthetists, and Clinical Nurse Specialists. The average age of RNs in Oregon is 47 and the average age of LPNs is 49.

Tour: OSBN Website http://www.oregon.gov/OSBN

Nursing: A Regulated Profession What does “a regulated profession” mean for you?

Nursing As 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.

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. Scope, therefore, cannot be expanded by those outside of nursing (e.g. by physician).

Division 45: Standards and Scope of Practice for RNs and LPNs Definitions Standards for All Licensed Nurses Scope of Practice Standards – LPN Scope of Practice Standards – RN Conduct Derogatory to the Standards of Nursing Criminal Conviction History Mandatory Reporting Civil Penalties

Purpose of Division 45 Start with the definitions -

Standards for ALL Licensed Nurses RNs and LPNs Client Advocacy Environment of Care Ethics – Professional Accountability & Competence Nursing Technology Responsibility for Assigning and Supervising Care Accepting and Implementing Orders

RNs & LPNs Nursing Practice Implementation LPNs practice under clinical direction of RN or other licensed provider who has authority to make changes in plan of care. LPNs perform initial and ongoing focused assessments. RNs perform initial and ongoing comprehensive and focused assessments.

RNs & LPNs (cont’d.) Nursing Practice Implementation RNs establish nursing diagnostic statements; LPNs select them from available resources. RN develops plan of care; LPN contributes to development. Both responsible for implementation and evaluation.

RNs & LPNs (cont’d.) Collaboration with an Interdisciplinary Team All licensed nurses responsible for collaborating, making referrals. RN has additional language about ensuring follow-up on referrals.

RNs & LPNs (cont’d.) Leadership (includes Policy) RN formulates, interprets, implements, evaluates policies, protocols, etc. LPN contributes to this. RN assumes responsibility for development and mentoring of other staff. LPN assists. RN uses evidence to identify needed changes in practice; LPN identifies changes in clients and practice environment requiring policy change.

RNs & LPNs (cont’d.) Quality of Care Both identify factors which affect quality of care. RN develops QI standards and processes. LPN contributes to this. RN measures outcomes of nursing care and LPN participates in this.

RNs & LPNs (cont’d.) Health Promotion RN develops and implements evidence-based health education plans; LPN selects or implements them. Both RN and LPN responsible for evaluation of outcomes.

RNs & LPNs (cont’d.) Cultural Sensitivity RN applies a broad knowledge of cultural differences; LPN applies a basic knowledge.

Conduct Derogatory to the Standards of Nursing Conduct related to: Client Safety and Integrity Communication Achieving and maintaining clinical competency Impaired Function Licensure and Certification Relationship with the Board of Nursing Client Families Co-Workers Advanced Nursing Practice

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.

Always Report Always report the following: 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. A pattern of conduct derogatory or a single serious occurrence

Criminal Conviction History: Denial of Licensure – Revocation of Licensure List of Crimes that will not allow for licensure in Division 45 Omitting information on initial licensure or renewing license regarding conviction history can be grounds for revocation of licensure

Civil Penalties Division 45 provides what the monetary penalty could be for certain violations of the Oregon Nurse Practice Act – These are separate from any sanctions on licensure and/or criminal convictions

Exclusive to RN Practice Delegation – Division 47

Division 47 - Intro Rules apply only in settings where RN not regularly scheduled and not available to provide direct supervision. Purpose is to govern practice of nurses, not the practice setting.

Three Main Sections: Division 47 Teaching non-injectable Medication Administration RN Delegation in the Community-Based Setting Teaching for an Anticipated Emergency

Nurses’ Responsibilities to the Board Know the statutes and rules that pertain to nursing. For Oregon, practice 960 hours within 5 years. Report unsafe practice through channels. Keep current name, address and nursing employers on record with the Board.

Other OSBN Information On-line web info at www.oregon.gov/OSBN Board Policies. Nurse Practice Act. Links to helpful sites. Current topics. Licensing information (on-line renewal now available). Main #: 971-673-0685. My direct #: 971-673-0656

CNA 1 & 2; CMA: Authorized Duties & Issues Provided by: Debra K. Buck, RN, MS Nursing Assistant Program Consultant

Be regularly supervised by a licensed nurse Introduction ORS 678.440(4) defines the term “nursing assistant” as a person who assists licensed nursing personnel in the provision of nursing care. Consistent with that definition, a CNA must either: Be regularly supervised by a licensed nurse Work in a setting where there is periodic supervision and evaluation under OAR 851-047-0000 through OAR 851-047-0040 ORS 678.440(4) defines the term “nursing assistant” as a person who assists licensed nursing personnel in the provision of nursing care. Consistent with that definition, a CNA must either: (a) Be regularly supervised by a licensed nurse; or (b) Work in a community-based care setting or other setting where there is no regularly scheduled presence of a licensed nurse provided there is periodic supervision and evaluation of clients under the provisions of OAR 851-047- 0000 through OAR 851-047-0040. 37

Introduction . Have current Oregon CNA 1 Certificate Listed on the Oregon CNA registry Prior to performing CNA 1 authorized duties A CNA must have a current Oregon CNA 1 Certificate and be listed on the Oregon CNA Registry prior to performing CNA 1 authorized duties

Introduction An individual who performs C.N.A.1 duties as an employee of a licensed nursing facility in Oregon must obtain C.N.A.1 certification no later than four months after date of hire

Certification Process NA Level 1 Training Fingerprinting State Competency Exam State Certification

Delegation & Supervision CNA/CMAs In settings other than community based Where nurse is present for supervision http://www.oregon.gov/OSBN/pdfs/policies/NurseDelegation.pdf http://www.oregon.gov/OSBN/pdfs/policies/LNsupervision.pdf

Delegation to CNA Board position Health, safety & welfare underpins all decisions. Competent & supervised CNA/CMAs and UAPs have a role. RNs may delegate tasks of nursing within the authorized duties. Accountability remains with the health professional who delegated task. Limitations to delegation.

Delegation to CNA RN Principles of delegation May only delegate within the RN’s scope of practice. May not delegate the nursing process. Maintains responsibility, accountability, and authority for delegation. Maintains sole responsibility as to whether to delegate or not. May refuse to delegate. Considers training, experience, & competence of caregiver.

Delegation to CNA RN Principles of delegation Delegates only if individual has the necessary skills & competence. Matches client needs with qualified personnel. Communicates directions & expectations. Supervises, monitors performance, progress, & outcomes. Evaluates effectiveness. Revises plan as needed.

AUTHORIZED DUTIES Division 63 C.N.A1 Tasks Associated With: C.N.A.1 Assisting With: Nutrition and Hydration Elimination Personal Care Positioning Devices Restorative Care Infection Control: Standards/Transmission based Precautions Safety and Emergency Procedures Activities of Daily Living (ADLs) Observation and Reporting Documentation End-of-Life care (c) Tasks associated with nutrition and hydration:

Hold a current, unencumbered CNA 1 certificate Requirements for CNA 2 recognition Hold a current, unencumbered CNA 1 certificate Complete a level 2 training program and pass the program’s competency evaluation

CNA 2 CNA 1 Restorative Care Acute Care Dementia Care Level 2 Training Available to a CNA 1 to prepare them for a role in one or more of Board approved category areas

Training hours Restorative Care 16 Classroom/Lab & 16 Clinical hours Core 30 Classroom/ Lab hours Acute Care 10 Classroom/Lab & 24 Clinical hours Dementia Care 18 Classroom/Lab & 16 Clinical hours

CNA 2 Core Skills Suctioning oral pharynx Urine dip-stick testing Testing Stool for occult blood Bladder Scanning Adding fluid to established post pyloric, J & G tube feedings & changing bags CBG Testing Pulse-electronic Interrupting & re-establishing NG suction B/P-forearm, Upper arm, thigh, & lower leg Applying sequential compression devices Reinforcing use of incentive spirometer Assisting with warm & cold therapies B/P-forearm, upper arm, thigh, & lower leg

B/P-forearm, upper arm, thigh, & lower leg CNA 2 Core Skills Discontinuing Foley catheters Assist with complementary therapies such as guided imagery & deep relaxation Clean intermittent straight urinary catheterization for chronic conditions Changing dressing or ostomy appliance/bag which adheres to the skin Measuring & recording &/or emptying output from drainage devices & closed drainage systems Obtaining sterile urine specimen from port of catheter 50 B/P-forearm, upper arm, thigh, & lower leg

CNA 2 Acute Care Assist in & out of CPM machines. Obtain rectal swab. Place electrodes/leads & run EKG. Place electrodes/leads for telemetry. Remove cast in non-emergent situation. Screen newborn hearing. Set up traction equipment. Test gastric contents for occult blood or pH.

CMA: Authorized Duties & Issues CMA means a Certified Nursing Assistant who has had additional training in administration of noninjectable medication and holds a current unencumbered Oregon CMA Certificate.

CMA A certified medication aide is not a CNA 2

CMA Authorized Duties Oral, sublingual, & buccal meds Eye, ear, nasal, rectal, vaginal, skin meds Meds via G & J tubes Pre-measured meds via aerosol/nebulizer Meds via metered hand-held inhalers

CMA Authorized Duties PRN meds In response to specific client requests At the direction of the LN

CMA Authorized Duties CMAs may: Administer regularly scheduled controlled substances Jointly witness wasted controlled substances with LN Count controlled substances with LN or CMA Perform CBG

CMA Authorized Duties CMAs may: Add fluid to established J or G tube feedings & change bags Accept verbal or telephone orders for medication (in adult foster home, assisted living facility, or residential care facility) from a licensed health care professional who is authorized to independently diagnose & treat.

CMA Authorized Duties CMAs may not: Administer meds by: Central lines Colostomy Intramuscular Intrathecal Intravenous Nasogastric Nonmetered inhaler Subcutaneous Intradermal Urethral Epidural Endotracheal

CMA Authorized Duties CMAs may not: Administer the following kinds of meds: Barium & other diagnostic contrast media Chemotherapeutic agents except oral maintenance chemotherapy Meds via medication pumps

Communication with Board of Nursing (971) 673-0636 (971)673-0684 Debra.buck@state.or.us www.oregon.gov/OSBN 17938 SW Upper Boones Ferry Rd Portland, OR 97224-7012