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Nursing Scope of Practice Decisions

Ann Oertwich RN, PhD

Executive Director, Nebraska Board of Nursing

Licensure Unit, Division of Public Health

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ObjectivesDefine nursing scope of practice in the context of Nebraska statutory and regulatory provisions

Discuss the dialysis care tech legislative proposal as it relates to RN practice

Discuss the LPN-C legislative proposal as it relates to RN practice

Introduce/utilize the Nebraska Board of Nursing Scope of Practice Decision-Making Model

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http://dhhs.ne.gov

--Licensure--Professions & Occupations--Nursing

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http://dhhs.ne.gov/publichealth/Licensure/Documents/Nursing-NursePracticeAct.pdf

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Nursing Scope of Practice

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“…the rules, the regulations, and the boundaries within which a fully qualified practitioner with substantial and appropriate training, knowledge, and

experience may practice”

The scope of practice of a healthcare profession is the assurance of the safety of the services it provides.

Safe practice relies on competency and professional accountability.

Pew Health Profession Commission, 1995

Pohl, Hanson, Newland & Cronenwett, 2010

Scope of Practice…A Definition

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Nursing Regulations

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http://www.sos.ne.gov/rules-and-regs/regsearch/Rules/Health_and_Human_Services_System/Title-172/Chapter-099.pdf

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DefinitionsDelegation

î The transfer of authority to perform some type of task or workî Care itself is not delegated – only the tasks

Supervisionî The active process of directing, guiding, and influencing the outcome of an individual’s

performance of an activity

Assignmentî Transfer of accountability and responsibility to another

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Definitions

Accountabilityî Means that someone must be able to explain actions and resultsî Legally – the RN is accountable for nursing care

Responsibilityî Means the reliability, dependability and obligation to accomplish work

at an acceptable level

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DelegationWhy delegate?

î To effectively expand your care giving ability to a large group of clients

To delegate, you MUST understand educational background and scope of practice for those involved

Nebraska Lawî www.dhhs.ne.govî Rules & Regulationsî Title 172, Chapter 99 Provision of Nursing Care

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Nursing Assistant or UAP

National curriculum – 75 hoursTake a registry exam (this is NOT a license)

Basic tasks in support of nursing

î Bathing, feeding, I & O, vitals signs, ambulationî No legal scope of practice – but has knowledge of basic tasks

Medication Aideî Provide medications; state law defines

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Licensed Practical Nurse (LPN)

12 – 18 months educationHold a license to practice

A dependent role with limited scopeNo IV’s unless complete LPN-C*

Contribute to the plan of careScope of practice can not be expanded – only limited by

institutional policy

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Registered Nurse (RN)

2 – 4 years of educationHold a license to practice

Independent and dependent functionsResponsible for developing, implementing and evaluating

the plan of careScope of practice can not be expanded – only limited by

institutional policy

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Five Rights of DelegationRight task

Risk CircumstanceRight person

Right direction/communicationRight supervision

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Supervising the Delegatee

RN is responsible for analyzing data gatheredRN is accountable for initial assessment

RN is accountable for intermittent evaluations

For the RN delegatorî The amount of direct care work may decreaseî However – supervisory work increases

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4 Things You Can NOT Delegate

AssessmentPlanning

EvaluationNursing judgment

www.ncsbn.orgWorking with Others: Delegation and Other Healthcare Interfaces

(2005)

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99-004.01A2 Only RNs licensed in accordance with the Act may delegate nursinginterventions to be performed by others on behalf of the nurse.

Delegated by a Registered Nurse means the transference from an RN to an unlicensed person…selected non-complex nursing interventions on behalf of the RN.

Non-complex interventions means those which can safely be performed according to exact directions, do not require alteration of the standard procedure, and for which the results and client/patient responses are predictable.

Complex interventions means those which require nursing judgment to safely alter standard procedures in accordance with the needs of the patient; or require nursing judgement to determine how to proceed from one step to the next; or require the multidimensional application of the nursing process.

Delegation decision includes determining which nursing intervention(s) may be delegated, selecting which unlicensed person(s) may provide the delegated interventions…

RNs retain accountability for the application of nursing process when making the decision to delegate nursing interventions, and for the adequacy of client/patient care and outcomes related to the delegation decision.

The standards applied at the organizational level must meet or exceed the standards for delegation as defined within these regulations.

http://www.sos.ne.gov/rules-and-regs/regsearch/Rules/Health_and_Human_Services_System/Title-172/Chapter-099.pdf

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LB255 - Adopt the Patient Care Technician Registration Act

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--On-the-job training, national standardized curricula, and certification exam

--RN delegates non-complex nursing interventions

--Important precedent for nursing scope of practice decisions

--Asserts the authority of the RN as a licensed, autonomous health care professional to oversee and manage the care of patients

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LB 283 - change & eliminate provisions relating to LPNs

î Proposes to repeal current LPN-C statute*

î Why?î NCLEX-PN current tests for IV therapy contentî PN Programs currently teach itî Dual licensure is expensive and unnecessary credentialingî Nebraska is one of 4-6 remaining states who require a separate credential, which creates

issues with the Licensure Compact

î What does this mean to a Registered Nurse?î Do we delegate, assign, direct?????

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Scope of Practice Decision-Making Model (DMM)

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http://dhhs.ne.gov/publichealth/Licensure/Documents/ScopeOfPracticeDecisionModel.pdf

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Support for Your Practice of Nursingî The Nurse Practice Act defines the practice nursing

î Nursing regulations (172 NAC 99) clarify assignment & direction to licensed nurses

and delegation to unlicensed nursing/nursing support staff

î Decision-Making Model promotes a systematic examination of all elements related

to a scope of practice decisions

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SummaryKnow what you know,

Know what you don’t know …

And DO NOT be afraid to ask questions!!