SCOPE OF PRACTICE

Report
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.
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)
CNA, 19,528
CNA2, 7,325
RN, 47,621
CMA, 1,264
LPN,
4,417
CNS, 175
CNS-PP, 27
CRNA, 515
NP, 2,563
CNA
CNA2
CMA
CNS
CNS-PP
CRNA
LPN
NP
RN
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
 Division 45
 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
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
Introduction
Have
current
Oregon
CNA 1
Certificate
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/NurseDele
gation.pdf
 http://www.oregon.gov/OSBN/pdfs/policies/LNsupervi
sion.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:
 Infection Control:





Standards/Transmission
based Precautions
Safety and Emergency
Procedures
Activities of Daily Living
(ADLs)
Observation and Reporting
Documentation
End-of-Life care
C.N.A.1 Assisting With:
 Nutrition and Hydration
 Elimination
 Personal Care
 Positioning Devices
 Restorative Care
CNA 2
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
 Level 2 Training
 Available to a
CNA 1 to prepare
them for a role in
one or more of
Board approved
category areas
Restorative
Care
CNA
1
Dementia
Care
Acute
Care
Training hours
Acute Care
10 Classroom/Lab
&
24
Clinical hours
Restorative Care
16
Classroom/Lab &
16
Clinical hours
Core
30
Classroom/
Lab hours
Dementia Care
18 Classroom/Lab &
16
Clinical hours
CNA 2 Core Skills
Urine dipstick testing
Adding fluid to
established post pyloric,
J & G tube feedings &
changing
bags
Testing Stool for
occult blood
Bladder
Scanning
CBG
Testing
Pulseelectronic
B/P-forearm,
Upper arm, thigh,
& lower leg
Reinforcing use
of
incentive spirometer
Suctioning
oral
pharynx
Assisting with warm &
cold therapies
Interrupting &
re-establishing
NG suction
Applying
sequential
compression
devices
CNA 2 Core Skills
Clean intermittent
straight urinary
catheterization for
chronic conditions
Discontinuing
Foley catheters
Changing dressing
or ostomy
appliance/bag
which adheres to
the skin
Obtaining sterile urine
specimen from port of
catheter
Assist with
complementary
therapies such as
guided imagery &
deep relaxation
Measuring
& recording
&/or emptying
output from
drainage devices
& closed drainage
systems
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
Intrathecal
Nonmetered inhaler
Intradermal
Endotracheal
Colostomy
Intramuscular
Intravenous
Nasogastric
Subcutaneous
Urethral
Epidural
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
[email protected]
www.oregon.gov/OSBN
17938 SW Upper Boones Ferry Rd
Portland, OR 97224-7012

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