page 6 coming summer 2017...page 2 ohio nurse june 2017 ohio nurse the official publication of the...
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current resident or
Non-Profit Org.U.S. Postage Paid
Princeton, MNPermit No. 14
Volume 10 | Number 3 | June 2017 Quarterly publication direct mailed to approximately 195,000 Registered Nurses in Ohio.
Inside this Issue
What’s inside this issue?The Role of the Nurse in Preventing Opioid Abuse
Page 6
The ONF Holds 17th Annual Nurses Choice Luncheon
Page 8
COmINg summeR 2017
Message from the ONF Chair . . . . . . . . . . . .2Upcoming Events . . . . . . . . . . . . . . . . . . . . .3Editor's Note . . . . . . . . . . . . . . . . . . . . . . . . .3Too Tired to Function: Nurse Fatigue . . . . . . .4The Role of the Nurse in Preventing Opioid Abuse . . . . . . . . . . . . . .6
The CE Roadshow: 2017 Tour . . . . . . . . . . . .7Call for Proposals . . . . . . . . . . . . . . . . . . . . .7Call for Sponsors . . . . . . . . . . . . . . . . . . . . . .717th Annual Nurses Choice Luncheon . . . . . .8Save the Date – 2018 Wellness Conference . . .9Continuing Education: Ohio Nursing Law . . 10-15
The Ohio Nurses Association and the Ohio Nurses Foundation are excited to announce July 3, 2017 as the official release date of the nursing-themed Ohio license plate. Proceeds from the license plate will help fund nursing scholarships and research grants from the Ohio Nurses Foundation – the charitable arm of the Ohio Nurses Association whose mission is to advance nursing through education, research and scholarships.
“We’re thrilled that the Ohio Nurses Foundation has a nursing-themed license plate in Ohio which will fund educational scholarships and research in nursing. It’s specifically
designed for not only nurses, but for all who support nurses. Anyone can purchase the plate to benefit nursing and its future advancement, “stated Lori Chovanak, CEO of the Ohio Nurses Association and President of the Ohio Nurses Foundation.
“I was pleased to work with the Ohio Nurses Foundation to get this measure introduced and enacted into law,” State Representative Jim Hughes, the sponsor of the license plate legislation, said. “Nurses are a critical component to our national healthcare system and are always ready to aid Ohio residents whether it is a simple procedure or a grave diagnosis.”
“I am very happy to learn that the monies raised from the sale of these license plates will go directly to
the Ohio Nurses Foundation to fund scholarships for those who want to become a nurse, one of the oldest and most highly regarded professions in the country,” Hughes added.
The Ohio Nurses Association and the Ohio Nurses Foundation began the journey of securing a license plate in 2015. The groups presented three possible images for the license plate and had the public vote for their favorite, with the winning image unveiled May 6, 2015 – the first day of National Nurses Week. The groups also collected well over 500 petition signatures, with many more nurses calling in asking how they could support the passage of this bill.
Page 2 Ohio Nurse June 2017
OHIO NuRseThe official publication of the Ohio Nurses
Foundation, 4000 East Main St., Columbus, OH 43213-2983, (614) 237-5414.
Web site: www.ohionursesfoundation.org
Articles appearing in the “Ohio Nurse” are presented for informational purposes only and
are not intended as legal or medical advice and should not be used in lieu of such advice. For specific legal advice, readers should contact
their legal counsel.
Ohio Nurses Foundation2015-2017 Board of Directors
CHAIR: Davina Gosnell, Kent
TREASURER: Jonathan Stump, Canton
DIRECTORS:Judith Kimchi-Woods, Worthington
Sally Morgan, ColumbusJoyce Powell, Cuyahoga Falls
Susan Stocker, AshtabulaBarbara Welch, Rushville
Diane Winfrey, Shaker Heights
PRESIDENT: Lori Chovanak, Columbus
The “Ohio Nurse” is published quarterly in March, June, September and December.
Address Changes: The “Ohio Nurse” obtains its mailing list from the Ohio Board of Nursing. Send address changes to the Ohio Board of Nursing:
17 South High Street, Suite 400Columbus, OH 43215614-466-3947www.nursing.ohio.gov
For advertising rates and information, please contact Arthur L. Davis Publishing Agency, Inc., 517 Washington Street, PO Box 216, Cedar Falls, Iowa 50613, (800) 626-4081, [email protected]. ONF and the Arthur L. Davis Publishing Agency, Inc. reserve the right to reject any advertisement. Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement.
Acceptance of advertising does not imply endorsement or approval by the Ohio Nurses Foundation of products advertised, the advertisers, or the claims made. Rejection of an advertisement does not imply a product offered for advertising is without merit, or that the manufacturer lacks integrity, or that this Foundation disapproves of the product or its use. ONF and the Arthur L. Davis Publishing Agency, Inc. shall not be held liable for any consequences resulting from purchase or use of an advertiser’s product. Articles appearing in this publication express the opinions of the authors; they do not necessarily reflect views of the staff, board, or membership of ONF.
Published by:Arthur L. Davis
Publishing Agency, Inc.
www.ohnurses.org
messAge FROm THe ONF CHAIR
Davina J. Gosnell
“Shine On” was the theme of the 16th Annual Nurses Choice Awards Luncheon recently held at the Blackwell Inn on the campus of The Ohio State University. More than 165 registered nurses, student nurses and friends of nursing attended the event. Nine graduate and undergraduate nursing students as well as three nurse researchers were awarded several thousand dollars in scholarships and grants. In addition, the American Heart Association and nurse leader Nancy McManus were given special awards. An inspiring
keynote address was presented by Dr. Heidi Shank, a nurse educator at the University of Toledo and former ONF scholarship recipient.
The purpose of Ohio Nurses Foundation is “to provide funding to advance nursing as a learned profession through education, research, and scholarship.” Since its origin, more than $160,000 has been awarded and each year we endeavor to increase the number and amount of funds being given. Monetary contributions to the ONF are an investment in the future of nursing and are always welcomed. To learn more about how you can donate, please visit: www.ohionursesfoundation.org for further information.
Davina J. Gosnell, RN, PhD, FAANChair, Ohio Nurses Foundation
Nurses shine On
Application deadline: Sept 1Application deadline: Sept 1
Call to learn about your career options with Scarlet Oaks!
RN & LPN PositioNs oPeN
Apply online:www.scarletoaks.jobapponline.com
Contact Tresta Davis, DON or Leah Marcum, Executive Director at (513) 861-0400
www.scarletoakshc.com | 440 Lafayette Ave. Cincinnati, OH
June 2017 Ohio Nurse Page 3
OHIO NuRses AssOCIATION uPCOmINg eveNTs2017 Dates
The Retired Nurses Forum of the Ohio Nurses Association:
https://www.ohnurses.org/retirednurses/June 6-7, 2017 Location: OCLC, Dublin, Ohio
ONA Convention: http://www.ohnurses.org/convention/October 6-8, 2017 Location: Hilton at Polaris, Columbus, Ohio
The CE Roadshows: https://www.ohnurses.org/ceroadshow/• May31–ToledoOhioRoadshow Location: University of Toledo, College of Nursing-
3000 Arlington Ave, Toledo, OH 43614• June21–DaytonOhioRoadshow Location: Wright State University, Nutter Center
(Gate 9) in Berry Room- 3640 Colonel Glenn Hwy #430, Fairborn, OH 45324
• July13–CincinnatiOhioRoadshow Location: TBD• July19–ChillicotheOhioRoadshow Location: Adena PACCAR Medical Education
Center, 446 Hospital Road, Chillicothe, OH 45601• August8–ClevelandOhioRoadshow Location: TBD
• September7–YoungstownOhioRoadshow Location: Youngstown State University, Kilcawley
Center- 1 University Plaza, Youngstown, OH 44505
2018 SAVE THE DATES
Wellness Conference: https://www.ohnurses.org/wellnessconference/March 9-10, 2018 Location: OSU James Cancer Hospital Conference Rooms
The Retired Nurses Forum of the Ohio Nurses Association:
https://www.ohnurses.org/retirednurses/June 5-6, 2018 Location: TBD
Annual Nursing Professional Development Conference:
https://www.ohnurses.org/npd/April 20, 2018 Location: TBD
For more information on events, please visit ONA’s website at http://www.ohnurses.org/events-calendar/
edITOR's NOTeIn this issue of the Ohio Nurse, we’re excited to bring
you 2 Contact Hours of Category A Ohio Nursing Law & Rules, just in time for re-licensure! RN and APRN renewal begins July 1st, and the Ohio Board of Nursing is encouraging nurses to register their accounts early in the Ohio eLicense system so they’re ready to renew starting July 1. You can get instructions on how to register and renew at the Ohio Board of Nursing’s website at http://www.nursing.ohio.gov/.
Staffing and mandatory overtime remain key issues that nurses are paying attention to since it directly affects the quality of care provided to patients. In this issue, we bring you an article explaining what nurse fatigue is, how it relates to mandatory overtime and the role of not only the nurse but also the employer in mitigating nurse fatigue. We hope you not only learn some new strategies to prevent yourself from becoming fatigued but are also empowered to know what to expect of your employer to prevent fatigue. To get directly involved in helping with this issue at the legislative level, visit www.ohnurses.org/staffing
A record 2,698 people died from opioid overdoses in Ohio in 2015, more than any other state in the country, which is why we’ve published “The Role of the Nurse in Preventing Opioid Abuse.” This article highlights the important role nurses play in reducing the number of deaths and helping to reduce addiction problems - and how to protect themselves from possible legal action stemming from opioids.
It’s the goal of the Ohio Nurse to connect Ohio’s RN’s with the highest quality continuing education opportunities available throughout the state. As always, throughout this issue you’ll find numerous opportunities for continuing education, from live CE events to online continuing education at CE4Nurses. We hope you take advantage of them, especially ONA members who get 3 free continuing education courses per quarter online at www.CE4Nurses.org which are listed in this issue.
Finally, we invite you to submit your letters to the editor and welcome your suggestions for content and opinions on nursing issues in Ohio. Please keep your submissions to under 500 words, include your name, city and email address. We reserve the right to edit for length and clarity. Email your submissions to Dodie Dowden at [email protected] with “Ohio Nurse Letter to the Editor” in the subject line.
We hope you enjoy this issue!
What’s the big news at ONA?The Ohio Nurses Association (ONA) is
launching a new grant service to members!
Goal of the grant program• Encourage and support nurses in pursuing
research that improves patient outcomes and the profession.
• Encourage Ohio nurses to take the leadin identifying and analyzing issues in our health care environments and finding the solutions to those obstacles.
• Encourage research to improve patientoutcomes, nursing, and health care as a whole.
Why create the program? • ThisgrantserviceaugmentstheOhioNurses
Foundation support for nursing research. • While the Foundation will continue its 16
year history of supporting Ohio’s nurse researchers, we want to bring to your attention outside funding opportunities to propel your work further.
How will it work?• Funding opportunities available through
private and public sources will be posted on the ONA website on an ongoing basis.
• The site will provide grant fundingopportunity summaries, funding levels, due dates, and links to additional information.
• The website portal will be open to thepublic. The funding opportunity service for ONA members will also include support on searches for specific projects and guidance in determining which funding opportunities best align with an individual nurse’s interest.
• ONA will be hosting a three partinformational webinar series. The webinars will cover the grant process from searching for prospective funding sources to developing your actual grant application packet.
The webinar dates are June 20th at 12:00 p.m., June 21st, at 12:00 p.m., and June 22nd at 12:00 p.m. Please watch for registration information at connect.ohnurses.org > MyAccount > ONA Member Grant Program.
For more information, visit the funding opportunity at www.ohio nurses.org. or contact Lisa Walker, Health Policy Specialist, at [email protected] or 614-448-1031.
As President of the Ohio Nurses Foundation and on behalf of our Board of Directors I’d like to thank everyone who attended the Nurses Choice Awards and Scholarship Luncheon and donated to the Ohio Nurses Foundation.
For the past 16 years, the Ohio Nurses Foundation has held this fundraiser to support nurs ing students and fund important research grants, and we’re honored and humbled to have the support of so many nurses and friends of nursing who care deeply about the future of nursing in Ohio. This year’s scholarship winners are our nurse leaders of the future, and the Foundation is proud to be able to support their education. It was a pleasure to see so many new faces at this year’s event and we plan to have even more in attendance next year!
Exciting things are happening at the Ohio Nurses Foundation in 2017. A portion of the proceeds from the Ohio Nursing License Plate will go directly to the Ohio Nurses Foundation, allowing us to provide more scholarships and research grants. And the Ohio Nurses Association just launched a grant service to support funding for nursing research, so while the Ohio Nurses Foundation will continue its 16 year history of supporting Ohio’s nurse researchers, ONA can bring to your attention to outside funding opportunities to propel your work further.
Keep your eye on future issues of the Ohio Nurse for even more exciting news and opportunities from the Ohio Nurses Foundation.
Lori Chovanak, MN, APRN-BCPresident of Ohio Nurses Foundation
____________________________________________
Lori is the Chief Executive Officer of the Ohio Nurses Association and a practicing nurse practitioner.
Prior to coming to the Ohio Nurses Association, Lori was the Executive Director of the Montana Nurses Association. She has spent the majority of her career in executive leadership, applying her experience as both an executive and as a nurse building strong relationships to address the issues facing nurses, patients and healthcare.
Lori remains close to patient care by practicing as a Nurse Practitioner in Cardiology with the amazing cardiac team at Ohio Health.
During her time as Executive Director at Montana, Lori was named Montana Nurses Association’s Nurse of the Year for 2014-2015 for her exceptional leadership and advocacy for nurses and the nursing profession at the state and national level. She was awarded the American Academy of Nurse Practitioners State Advocate of the Year Award in 2014.
Lori has earned her bachelor’s degree from Carroll College, masters of nursing from the Montana State University, and is currently completing her doctorate of nursing practice.
PResIdeNT's messAge
Lori Chovanak
ONA Launches grant Program to support Funding for Nursing Research
Page 4 Ohio Nurse June 2017
TOO TIRed TO FuNCTION: NuRse FATIgueBarbara Brunt, MA, MN, RN-BC, NE-BC, FABC
Nurse fatigue is defined by the American Nurses Association (ANA) as impaired function resulting from physical labor or mental exertion. There are three types of fatigue: physiological (reduced physical capacity), objective (reduced productivity) and subjective (weary or unmotivated feeling). Both registered nurses (RNs) and employers have an ethical responsibility to carefully consider the need for adequate rest and sleep when deciding whether to offer or accept work assignments, including on-call, voluntary, or mandatory overtime. Evidence-based strategies must be implemented to proactively address nurse fatigue and sleepiness; to promote the health, safety, and wellness of registered nurses; and to ensure optimal patient outcomes (ANA, 2014).
The following definitions are provided to ensure that everyone has the same understanding of terms.
Culture of safety: core values and behaviors resulting from a collective and
sustained commitment by employers and health care workers to emphasize safety over competing goals.
Fatigue countermeasures: a range of evidence-based strategies aimed at either temporarily reducing and counteracting the effects of fatigue or sleepiness. Examples are the strategic (therapeutic) use of caffeine or naps and the combination of caffeine and naps to temporarily increase alertness.
Mandatory overtime: employer-mandated work hours beyond normally
scheduled or contracted hours in a day or week, including required work over 40 hours in any seven-day period.
Sleepiness: the increased propensity to fall asleep. In contrast to fatigue, sleepiness is specifically due to imbalance in sleep and wake time, disrupted circadian rhythms, or inadequate quantity and quality of sleep.
Stakeholders: departments, organizations, union, individuals, families, communities, and populations that can affect or be affected by any policy, guideline, or change in a process that is implemented.
Voluntary overtime: work hours above and beyond the routinely recognized hours for the workweek without undue pressure from the management (ANA, 2014, pp. 8-9).
This article will provide background information, outline responsibilities of RNs and employers, and review research related to this issue.
BackgroundInadequate sleep and resulting fatigue can affect a RN’s ability to deliver
optimal patient care. Working fatigued can lead to an increased risk of error; a decline in short-term and working memory; a reduced ability to learn; a negative impact of divergent thinking, innovation, and insight; increased risk-taking behavior; and impaired mood and communication skills. In addition, fatigue and sleep-deprived nurses are more likely to report clinical decision regret, which occurs when their behaviors do not align with professional nursing practice standards or expectations (ANA, 2014).
Fatigue also has major implications for the health and safety of RNs. Substantial scientific evidence links shift work and long working hours to mood
disorders, obesity, diabetes mellitus, metabolic syndrome, cardiovascular disease, cancer, and adverse reproductive outcomes (ANA, 2014).
In addition, driving when drowsy endangers the lives of both the driver and other people on the road.
With this being ANA’s Year of the Healthy Nurse, it behooves all of us to implement strategies to maintain our own health, to protect the health of those we serve.
In addition to the health and safety risks, the effects of fatigue and sleepiness have financial ramifications. Direct costs to employers include increases in health care costs, workers’ compensation claims, early disability costs, recruitment and training costs, and legal fees (ANA, 2014). Nurse fatigue is frequently linked to patient safety initiatives. Despite regulations on shift length and cumulative working hours for resident physicians and people in other industries, there are no national work hour policies for RNs. Staffing issues, coupled with a weak economy, have motivated nurses to work past the end of their scheduled shift or to work additional shifts. One study using a sample of 22,275 RNs from four states showed that the longer the shift, the greater the likelihood of adverse nurse outcomes such as burnout and patient dissatisfaction (ONA, 2015). The Institute of Medicine recommends that RNs not exceed 12 hours of work in a 24-hour period and 60 hours of work within seven days (Institute of Medicine of the National Academies [IOM], 2004).
The Centers for Disease Control and Prevention provides training for nurses on shift work and long work hours through two free continuing education programs: CDC course numbers WB2408 and WB2409. The purpose of this online training program is to educate nurses and their managers about the health and safety risks associated with shift work, long work hours, and related workplace fatigue issues. Part 1 is designed to increase knowledge about the wide range of risks linked to these work schedules and related fatigue issues and promote understanding about why these risks occur. Part 2 is designed to increase knowledge about personal behaviors and workplace systems to reduce these risks. Content for this training program is derived from scientific literature on shift work, long work hours, sleep, and circadian rhythms (NIOSH, 2015).
Responsibilities of RNsAs advocates for health and safety, RNs are accountable for their practice and
have an ethical responsibility to address fatigue and sleepiness in the workplace that may result in harm and prevent optimal patient care. Nurses need to arrive at work alert and well rested, and should take meal and rest breaks and implement fatigue countermeasures as necessary to maintain alertness. RNs are responsible for negotiating or even rejecting a work assignment that compromises the availability of sufficient time for sleep and recovery from work. The amount of recovery time necessary depends on the amount of work, including regularly scheduled shifts and mandatory or voluntary overtime (ANA, 2014).
Examples of evidence-based fatigue countermeasures and personal strategies to reduce the risks of fatigue are outlined in the ANA position statement background information:
1. Sleep 7-9 hours within a 24-hour period and consider implementing strategies to improve the quality of sleep, such as adjusting the sleep environment so it is conducive to sleep (e.g. very dark, comfortable, quiet, and cool) and removing distractions such as bright lights and electronics from the sleep environment.
2. Rest before a shift to avoid coming to work fatigued.3. Be aware of side effects of over-the-counter and prescription medications that
may impair alertness and performance.4. Improve overall personal health and wellness through stress management,
nutrition, and frequent exercise.5. Use benefits and services provided by employer, such as wellness programs,
education and training sessions, worksite fitness centers, and designated rest areas.
6. Take scheduled meals and breaks during the work shift.7. Use naps in accordance with workplace policies.8. Follow established policies, and use existing reporting systems to provide
information about accidents, errors, and near misses.9. Follow steps to ensure safety while driving, such as recognizing the warning
signs of drowsy driving, using naps or caffeine to be alert enough to drive, and avoiding driving after even small amounts of alcohol when sleep-deprived. Actions such as putting windows down, pinching themselves, or turning up the radio do not work.
10. Consider the length of a commute prior to applying for employment.11. Prior to accepting a position, consider the employer’s demonstrated
commitment to establishing a culture of safety and to reducing occupational hazards, including nurse fatigue (ANA, 2014).
If necessary, a RN should seek a schedule that is a better fit for his or her needs by negotiating with the employer or by seeking other employment if negotiation is not possible.
Responsibilities of EmployersEmployers of RNs are responsible for establishing a culture of safety, a healthy
work environment, and for implementing evidence-based policies, procedures, and strategies that promote healthy nursing work schedules and that improve alertness. Safe levels of staffing are essential to providing optimal patient care and ensuring a safe environment for patients and RNs (ANA, 2014).
Employers should limit shifts (including mandatory training and meetings) to a maximum of 12 hours in 24 hours. Those limitations should include on-call hours worked in addition to actual work hours. In addition, they should conduct regular audits to ensure scheduling policies are maintained. Employers have a duty to ensure that nurses can take meal and rest breaks during work shifts. Furthermore, employers should facilitate the use of naps during scheduled breaks, as the benefits of napping during long shifts are well supported by research (ANA, 2014).
ANA recommends implementation of the following evidence-based strategies:1. Eliminate the use of mandatory overtime as a staffing solution.
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2. Have employers adopt – as official policy- the position that RNs have the right to accept or reject a work assignment to prevent risks from fatigue, that such rejection does not constitute patient abandonment, and that RNs should not suffer adverse consequences in retaliation for rejecting in good faith a work assignment to prevent risks from fatigue. This should include a system to evaluate instances of RNs rejecting assignments to evaluate causes and effectiveness of staffing patterns.
3. Institute an anonymous reporting system for employees so they can give information about their accidents, errors, and near misses. Factors that increase the risk for fatigue-related errors should be included in incident investigations so employers can determine if fatigue was a contributing factor.
4. Institute policies that address the design of work schedules, such as limits on overtime; actions to take when a worker is too fatigued to work; and policies and procedures during emergencies caused by weather and major disasters, when a large influx of patients may unexpectedly arrive at the health care organization.
5. Design schedules according to evidence-based recommendations. This includes involving nurses in the design of work schedules, using a regular and predictable schedule so the nurse can plan for work and personal responsibilities, and examining work demands with respect to shift length. Other strategies include limiting shifts to 12 hours, limiting work weeks to 40 or fewer hours per week, promoting frequent, uninterrupted rest breaks during work shifts, and planning two rest days after three consecutive 12-hour shifts, and limiting the number of consecutive 12-hour shifts to three shifts.
6. Reduce risks of drowsy driving by providing transportation home when a nurse is too tired to drive safely or by providing sleeping rooms close to the health care facility.
7. Promote fatigue management training and education for employees and managers, including education about sleep disorders (ANA, 2014).
Research StudiesWolf and colleagues (2017) studied the effects of
sleep and fatigue on cognitive performance. Their sample consisted of 1,506 nurses who worked at least one shift a week in an Emergency Department in the United States. They evaluated their performance on timed cognitive skill tests on medication dosage calculations. Although there were not statistically significant relationships between the speed and
accuracy of their responses with sleep patterns, sleep quality and fatigue, a significant percentage of the sample reported high levels of sleepiness and chronic and acute fatigue that impeded full function both at work and at home. Although the authors could not determine from this study whether levels of self-reported fatigue affect cognitive function, participants did report difficulty with providing both self-care and patient care. Further research is needed.
A qualitative interview study was conducted by Steege and Rainbow (2017) to explore barriers and facilitators within the hospital nurse work system to nurse coping and fatigue. Twenty-two nurses working in intensive care and medical-surgical units within a large academic medical center participated in the interviews. All nurses in the study experienced fatigue, yet they had varying perspectives on the importance of addressing fatigue in relation to other health system challenges. A new construct related to nursing professional culture was identified and defined as “supernurse.” Identified subthemes of supernurse included: extraordinary powers used for good; cloak of invulnerability; no sidekick; Krpytonite, and an alterego. These values, beliefs, and behaviors define the aspect of culture that can act as barriers to fatigue risk management programs and patient safety initiatives.
Sagherian and colleagues (2016) conducted a descriptive cross-sectional study looking at the association between fatigue, work schedules, and perceived work performance among nurses. Seventy-seven bedside nurses participated in this study. Nurses’ acute and chronic fatigue levels were significantly associated with performance of physical and mental nursing care activities. Low intershift recovery was associated with inadequate hours of sleep, waking not fully refreshed, and working overtime. These findings indicated nurses had insufficient time to restore depleted energy levels outside work hours, which has patient safety implications. The findings of this study are consistent with the findings of a larger study (n=340) conducted by Steege, Pasupathy, and Drake (2017).
A risk management model for nurse executives to address occupational fatigue in nurses was described by Steege and Pinekenstiein (2016). They synthesized existing evidence on fatigue risk management and decision making in nursing leadership and developed a conceptual model of multilevel fatigue risk management in nursing work systems to address current fatigue management challenges. Their model included data sources, nurse fatigue monitoring, decision-support tools and risk management responsibilities/controls to improve patient outcomes. Evaluation of the effectiveness of specific hazard controls in minimizing fatigue and mitigating its associated risks is needed to guide nurse leaders in practice.
Fatigue is an issue that must be addressed to promote quality patient care. All nurses need to be aware of fatigue countermeasures and implement strategies to ensure they can safely function, whether taking care of themselves or others.
ReferencesAmerican Nurses Association. (2014). Position statement:
Addressing nurse fatigue to promote safety and health: Joint responsibilities of registered nurses and employers to reduce risks. Silver Spring, MA: Author.
Institute of Medicine of the National Academies, Committee on the work Environment for Nurses and Patient Safety Board on Health Care Services. (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academies
NIOSH, Caruso, C.C., Geiger-Brown, J., Takahashi, M., Tinkoff, A., & Natkata, A. (2015). NIOSH training for nurses on shift work and long work hours. DHHS (NIOSH) Publication No. 2015-115. Cincinnati OH: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Retrieved from: http://www.cdc.gov/niosh/docs/2015-115/
Ohio Nurses Association. (2015). Reference proposal: Preventing nurse fatigue. Columbus, OH: Author.
Sagherian, K., Clinton, M. E., Huijer, H. A., & Geiger-Brown, J. (2016). Fatigue, work schedules, and perceived performance in bedside care nurses. Workplace Health and Safety. Doi: 10.1177/2165079916665398
Steege, L. M., Pasupathy, K. S., & Drake, D. A. (2017). A work systems analysis approach to understanding fatigue in hospital nurses. Ergonomics. Doi: http://dx.doi.org/10.1080.00140139.2017.1280186
Steege, L. M. & Pinekenstein, B. (2016). Addressing occupational fatigue in nurses: A Risk management model for nurse executives. Journal of Nursing Administration, 46(4), 193-200. Doi: 10.1097/NNA.0000000000000325
Steege, L. M. & Rainbow, J. G. (2017). Fatigue in hospital nurses – “Supernurse” culture is a barrier to addressing problems: A qualitative interview study. International Journal of Nursing Studies, 67, 20-28. Doi: http://dx.doi.org/10.1016/j.ijnurstu.2016.11.014
Wolf, L. A., Perhats, C., Deloa, A., & Martinovich, Z. (2017). The effect of reported sleep, perceived fatigue, and sleepiness on cognitive performance in a sample of emergency nurses. Journal of Nursing Administration, 47(1), 41-49. Doi: 10.1097/NNA.0000000000000435
_________________________________________________
Barbara Brunt, MA, MN, RN-BC, NE-BC is currently an Education Consultant for Brunt Consulting Services. She has 28 years of experience in various nursing professional development (NPD) positions, from instructor, coordinator, to director. She retired from Summa Health System in February 2016 where she served as Magnet Program Director. She is an ANCC appraiser for continuing education through the American Nurses Credentialing Center and is the content editor for TrendLines, a monthly newsletter for NPD practitioners.
Page 6 Ohio Nurse June 2017
The Role of the Nurse in Preventing Opioid Abuse
Guest Post By David Griffiths Nurses Service Organization – a benefit partner
of the Ohio Nurses Association
Overdose deaths related to prescription opioids have quadrupled since 1999, according to the Centers for Disease Control and Prevention (CDC). That makes this a top priority in health care. Nurses can play an important role in reducing these deaths, as well as addiction problems, by assessing and monitoring patients. In taking these steps, nurses can also protect themselves from possible legal action stemming from opioids.
Scope of the problemStatistics illustrate the depth and breadth of
prescription opioid abuse:• Atleasthalfofallopioidoverdosedeathsinvolve
a prescription opioid.• In 2014, almost 2 million people in the
United States abused or were dependent on prescription opioids.
• Every day,more than 1,000 people are treatedin emergency departments for misusing prescription opioids.
The most common drugs associated with prescription opioid overdose deaths are methadone, oxycodone, and hydrocodone. According to the CDC, prescription opioid overdose rates between 1999 and 2014 were highest among people age 25 to 54.
Role of the nurseA 2016 study by Baker and colleagues notes that
there is significant variability in the amount of opioids prescribed, and the most commonly dispensed opioid was hydrocodone (78 percent), followed by oxycodone (15.4 percent). Interestingly, a 2015 study in the American Journal of Preventive Medicine reported a decrease in the rate of prescribing opioids (-5.7 percent), perhaps indicating that more healthcare providers are becoming aware of the addiction issue.
Screen patientsNurses are well positioned to detect patients with
substance misuse.One simple screening tool is the NIDA or
National Institute on Drug Abuse Quick Screen. If a substance use disorder is suspected, the nurse should remain nonjudgmental while referring patients for further evaluation and treatment, so they receive the care they need.
One model for follow-up of possible substance abuse is Screening, Brief Intervention, and Referral to Treatment (SBIRT), from the Substance Abuse
and Mental Health Services Administration. SBIRT is a method for ensuring that people with substance use disorders and those at risk for developing these disorders receive the help they need.
Assess the patient carefullyPain medication should be matched to the
individual patient’s needs. This begins with a detailed history, including a list of currently prescribed and past medications. Ask about a history of substance use or substance use disorders in the patient and the patient’s family. If opioids are being considered, assess the patient’s psychiatric status. A physical exam should also be completed, keeping in mind signs and symptoms of possible substance abuse such as advanced periodontitis, traumatic lesions, and poor oral hygiene. If patients are already being managed for chronic pain, the nurse should consult with the appropriate provider.
Apply evidence-based pain managementTo provide optimal patient care, as well as to
protect themselves from legal action, nurses should practice evidence-based pain management. That includes considering non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, as first-line pain medication. NSAIDs have been shown to be at least as effective (if not more so) than opioids for managing pain, particularly in combination with acetaminophen. For example, in a 2013 review by Moore and Hersh, the authors wrote that the combination “may be a more effective analgesic, with fewer untoward effects, than are many of the currently available opioid-containing formulations.” Before patients begin taking NSAIDs, verify that they are not taking other anticoagulants, including aspirin, and check for hepatic or renal impairment.
One resource for managing pain is the algorithm available from the Institute for Clinical Systems Improvement. Nurses should complete continuing education courses in pain management and document they did so, which can provide evidence of their knowledge in event of a legal case.
Educate patientsNurses need to educate patients about the role of
pain medication in their care. This education should include pain medication options and the reasons why non-opioids are preferred.
Verbal and written instructions after the procedure need to contain name of drug, dosage, adverse effects, how long the drug should be taken, and how to store it. Results from a 2016 survey published in JAMA Internal Medicine found that more than half (61 percent) of those no long taking opioid medication keep it for future use, so patients need to be told to dispose of unused drugs and how to do so. (Patients can search for places that collect controlled substance drugs at www.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e1s1). The same survey found that about 20 percent shared the opioid with another person, so education material should mention not to do this. Nurses should also discuss the perils of driving or undertaking complex tasks while taking an opioid. Document in the patient’s health record that this information was provided and the patient acknowledged receipt and understanding. An office visit can also provide the opportunity for nurses to address opioid abuse on a larger scale.
Refer patients as indicatedPatients who need pain management beyond the
acute phase should be referred to another provider with this expertise. Be sure to document the referral in the patient’s health record. Nurses also should consider referral for patients who seek opioids beyond when they are likely to be needed.
Pain medications cautionsBelow are some considerations for the use of pain
medication in patients:• Use non-steroidal anti-inflammatory drugs
(NSAIDs) as the first option. Consider a selective NSAID to avoid increased risk of bleeding. Know that using acetaminophen in combination with NSAID may have a synergistic effect in pain relief. (Do not exceed 3,000 mg/day in adults.)
• Providepatienteducation.• Document patient communications, education,
and referrals in the health record.
Protecting patients and nursesNurses who assess and monitor patients for
treatment of pain are encouraged to be mindful of and have respect for their inherent abuse potential. Doing so protects patients from harm and nurses from potential liability.
About the authorDavid Griffiths is senior vice president of Nurses
Service Organization (NSO), where he develops strategy and oversees execution of all new business acquisition and customer retention for the group’s allied healthcare professional liability insurance programs. With more than 15 years of experience in the risk management industry, he leads a team covering account management, marketing and risk management services. More at www.nso.com.
This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 650,000 nurses since 1976. INS endorses the individual professional liability insurance policy administered through NSO and underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to [email protected] or call 1-800-247-1500. www.nso.com.
ResourcesBaker JA, Avorn J, Levin R, Bateman BT. Opioid
prescribing after surgical extraction of teeth in Medicaid patients, 2000-2010. JAMA. 2016;315(15)1653-1654.
Centers for Disease Control and Prevention. Prescription opioid overdose data. 2016. www.cdc.gov/drugoverdose/data/overdose.html.
Kennedy-Hendricks A, Gielen A, McDonald E, et al. Medication sharing, storage, and disposal practices for opioid medications among US adults. JAMA Int Med. June 13, 2016.
MCauley JL, Leite RS, Melvin CL, Fillingim RB, Brady KT. Opioid prescribing practices and risk mitigation strategy implementation: identification of potential targets for provider-level intervention. Substance Abuse. 2016;37(1):9-14.
Prescription Drug Monitoring Program Training and Technical Assistance Center. Prescription drug monitoring frequently asked questions (FAQ). www.pdmpassist .org/content /prescription-drug-monitoring-frequently-asked-questions-faq.
Substance Abuse and Mental Health Services Administration. Screening, brief intervention, and referral to treatment (SBIRT). 2016. www.samhsa.gov/sbirt.
Thorson D, Biewen P. Bonte B, et al. Acute pain assessment and opioid prescribing protocol. Institute for Clinical Systems Improvement. 2014. www.icsi.org/_asset/dyp5wm/opioids.pdf
June 2017 Ohio Nurse Page 7
CALL FOR PROPOsALsONA Biennial Convention
The Ohio Nurses Association is planning the 2017 Biennial Convention to be held from October 6 – October 8, 2017 at the Hilton Polaris, Columbus, Ohio. You are invited to submit
abstracts for a CE poster session. For the CE poster session, topics that would relate
to nurses in multiple settings will be considered. Topics to be considered include health and safety, nursing practice, research, education, management and professional development.
The poster session will be held on Friday, October 6, 2017 (starting at 4:30 p.m.).
Guidelines1. Dimensions for each poster should not exceed 30”
by 39” in order to fit on the easel.2. Poster presenters must register and be available to
present their poster during the poster session time.3. ONA will supply one easel and one chair per
person for each poster presentation. No tables are available.
4. No audio-visual equipment will be available. 5. The fee for poster time is $0 for ONA members,
one (1) chair per presenter and one (1) easel per poster.
6. The fee for poster time is $50.00 for non-ONA members includes one (1) chair per presenter and one (1) easel per poster. If you are attending the convention, you do not need to pay the $50.00 fee.
7. Please note that participants will be able to receive contact hours for participating in the review of the posters and discussions with the presenters.
Please submit one copy of a one page abstract with a cover letter that lists the name(s), credentials, address(es), phone number(s), fax number(s), and e-mail addresses of the poster presenter(s). Also submit one copy of the ONA Biographical Data Form for each person involved. If more than one person is listed, please indicate the primary contact person. A list of references that show content is based on best available and current evidence needs to be included also.
Request for Proposals must be postmarked by September 15, 2017 and sent to:
Sandy Swearingen, Continuing EducationOhioNursesAssociation•4000E.MainSt.•
Columbus, Ohio 43213-2983Phone:614-448-1027•Fax:614-237-6074•E-mail:
CE Poster Session Presenters will be notified of acceptance no later than September 15, 2017.
THe Ce ROAdsHOw AgeNdA8:30 am – Registration9:00 am – ONA Update/ District introduction9:30 am – Nurse Practice & Fatigue: A Wake up
Call: Linda Warino BSN RN CPAN10:15 am – Cultural Appreciation: Heidi Shank
DNP. MSN, RN (Cultural presentation subject to change per location)
11:00 am – Break11:15 am – When the Workplace Turns Toxic:
Incivility & Bullying: Linda Council MSN RN & Tahnee Andrews MSN RN
12:00 pm – Lunch12:30 pm – Scope of Practice, what does that
even mean? Jan Lanier JD RN [1.0 Category A CE credit]
1:30 pm – Break2:00 pm – Impact Teen Drivers: Heidi Deane
*Brought to you by California Casualty* 2:45 pm – Ground Zero: Ohio’s Battle with
Opioids Sally Morgan, RN, MS, ANP-BC, GNP-BC – [1.0 Pharm hours for APRN]
3:45 pm – Close
Get on the list for 2018! More information about CE Roadshows at
https://www.ohnurses.org/ceroadshow/
Page 8 Ohio Nurse June 2017
The Ohio Nurses Foundation Holds 17th Annual Nurses Choice LuncheonThe Ohio Nurses Foundation held its annual luncheon and fundraiser on April 28th at the Blackwell in Columbus, Ohio.
The luncheon serves as a celebration of nursing, which includes Nurses Choice Awards, and the awarding the nursing scholarships and research grants. Scholarship and research grant applications are due in January. Visit www.ohionursesfoundation.org to apply!
Congratulations to the 2017 Winners!
Research Grant Winners• Tania Von Visger, APRN, PhD(c), CNS, CCNS,
PCCN Research title: Feasibility and acceptability
of the integrative therapy for management of symptoms in person with pulmonary hypertension.
• RandiA.Bates,MS,RN,PCN,CNP(FNP-C) Research title: Early childhood self-regulation
and persistent stress• YvonneSmith,PhD,RN,CNS Research title: Nurses’ perceptions of their
effectiveness as governing board members
Scholarship Winners• JenniferSanders–KentState• DulceyWagner–Chamberlain• AnitraWatkins-Bradley–Chamberlain
• AlexSchirripa–KentState• JaunieMay–StarkState• ThomasCodyMorrison–UrsulineCollege• KathleenColvin–BishopReadyHigh
School• MadelineSmith–BuckeyeSeniorHigh
School
Award Winners• NursesChoiceWinner,Organization-The
American Heart Association• GingyHarshey-MeadeExcellencein
Leadership Award – Nancy Stimler McManus
Thank you to our Platinum Sponsors!• ArthurDavisPublishingAgency,Inc.• Cloppert,Latanick,SauterandWashburn• DavinaGosnell• HealthcareCreditUnionSystem
June 2017 Ohio Nurse Page 9
At every ONA Biennial Convention, there is a special continuing education event called the Cornelius Congress Conference. Topics focus on current issues in healthcare, communication, and workplace advocacy.
This year’s conference is open to all nurses (You do not have to be a member of ONA to attend) and will be held at the Hilton Polaris (8700 Lyra Drive, Columbus, OH 43240). The Cornelius Conference will be on Thursday, October 5, 2017 between 8:00 am – 3:30 pm.
Dorothy Alice Cornelius was Executive Director of the Ohio Nurses Association from 1957 to 1983; President of the International Council of Nurses, Geneva, Switzerland, from 1973 to 1977; President of the American Nurses Association, from 1968 to 1970; and President of the American Journal of Nursing company, the largest publisher of nursing periodicals in the world, from 1967 to 1968. She was the only person who served in all of these positions.
She served the United States government on many committees and commissions, at the request of the President starting with Dwight D. Eisenhower. Her presidential commendations crossed political lines and included Lyndon Johnson and Richard Nixon. In all of these efforts, her leadership, knowledge, and concern for her fellow citizens were recognized by everyone.
Dorothy Cornelius’ commitment to nursing and those who receive nursing care was unparalleled. She graduated from Conemaugh Valley Memorial Hospital School of Nursing, Johnstown, Pennsylvania, in 1939 and earned her BS in nursing education at the University of Pittsburgh School of Nursing. During World War II she was in the US Navy Nurse Corps. Miss Cornelius was a public health nurse and the chief nurse of the American Red Cross Blood Program.
She received Honorary Recognition from ONA in 1969, the Honorary Membership Award from ANA in 1972, and Honorary Recognition from ANA in 1978. She was named a fellow in the American Academy of Nursing in 1977. The ONA Headquarters building was named and dedicated the Dorothy A. Cornelius Building in 1977; and she was named executive director emeritus of ONA upon her retirement in 1983. She died in 1992.
Contact hours will be awarded. The Ohio Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. (OBN-001-91)
Please go to http://www.ohnurses.org/onaevents/ona-biennial-convention-save-date/ for details and registration information, or contact Sandy Swearingen at [email protected] (614-448-1030).
Cornelius Congress ConferenceHigh quality, relevant continuing education from ONA’s
award-winning continuing education program
To be held during the 2017 ONA BiennialConvention–October5,2017
Page 10 Ohio Nurse June 2017
CONTINuINg eduCATION
Ohio Nursing Law: The Basis that every Nurse Needs to KnowOhio Nurses Association
Board of Nursing in Ohio
The Board of Nursing (Board) is a public body whose sole purpose is to protect the public, in part by ensuring its licensees and certificate holders are at least minimally competent to practice and by taking action when a licensee poses a threat to public safety. Part of the executive branch of government, the Board’s 13 members are appointed by the governor to serve a four-year term, and they may be re-appointed for one additional term. The eight registered nurses (RNs), two of whom must be advanced practice registered nurses (APRNs); four licensed practical nurses (LPNs); and one consumer member are charged with issuing licenses to qualified individuals, approving pre-licensure nursing education and other training programs, and taking disciplinary action when a licensee violates Section 4723.28 Ohio Revised Code (ORC). The Board meetings (held at the Board office in Columbus in January, March, May, July, September and November) are open to the public. Meeting materials are posted on the Board’s web site immediately prior to each meeting along with specific meeting dates and times. The 13-member Board appoints the executive director, and the executive director then names additional staff members who carry out the directives of the appointed Board members. (Section 4723.05 ORC).
The Board has authority over only the individuals it regulates. As the largest regulatory board in the state, the Board has jurisdiction over 280,000 individuals. That includes RNs, LPNs, APRNs, dialysis technicians, community health workers, and medication aides. Not on that list are medical assistants, state-tested nurse aides, patient care technicians or associates, physician assistants, hospitals, nursing homes, clinics etc.
In addition to having specific responsibilities defined by the Nurse Practice Act (also known as Chapter 4723 of the Revised Code or the law regulating nursing practice) the Board also has rule making authority relative to its statutory responsibilities. Rules of the Board can be found in Chapters 4723-1 through 4723-27 of the Ohio Administrative Code (OAC). The Board is charged with enforcing the laws enacted by the Ohio General Assembly that affect nurses and nursing practice. Typically, the law (found in the Revised Code) sets out what is required, while the rules (found in the Administrative Code) are more detailed and describe how the requirements are met. The rules must be consistent with the law, and once adopted the rules have the force and effect of law. Therefore, nurses must be aware of both the law and the rules in order to make sure their practice is in keeping with all legal requirements.
TAKEAWAYS√ TheBoardofNursingwasestablished toprotect the
public.√ Laws regulating nursing practice differ from state to
state.√ The law enacted by the General Assembly is often
less detailed than rules adopted by the Board of Nursing. The law tells nurses what they must do. The rules explain how the legal requirements are to be met.
√ The Ohio Board of Nursing regulates RNs, LPNs,APRNs, dialysis technicians, community health workers, and medication aides.
√ Information about the Board and Ohio nursing lawsand rules can be found at the Board’s website: www.nursing.ohio.gov.
Licensing competent individuals
Requirements for licensureIn order to engage in the activities that comprise
the practice of nursing in Ohio one must hold a current valid Ohio license. (Section 4723.03 ORC). (More about those activities later in this study). The law in Ohio does not differentiate as to whether the individual is engaged in nursing practice for compensation or without compensation. In other words, an individual who volunteers to provide care that would constitute the practice of nursing in Ohio may do so ONLY if holding a current valid Ohio license (unless the individual meets one of the exceptions set out in Section 4723.32 (ORC) described more fully below).
This independent study was developed by: Jan Lanier, JD, RN.
INDEPENDENTSTUDYThis independent study has been developed for nurses who are new to Ohio and who must complete two contact hours of continuing education on Ohio Law and rules in order to be eligible for licensure by endorsement. 2.0 contact hours of Nursing Law and Rules (Category A) will be awarded for successful completion of this independent study.
The Ohio Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation (OBN-001-91).
Expires 5/2019. Copyright 2017 Ohio Nurses Association
OUTCOMEThe nurse will have a better understanding of Ohio Nursing Law and Rules as it pertains to their practice.
The author and members of the planning committee have no conflict of interest.
STUDYIf you have any questions, please feel free to call Sandy Swearingen, 614-448-1030.
This independent study is intended for the nurse who is new to Ohio who must complete two hours of continuing education on Ohio laws and rules in order to be eligible for licensure by endorsement. (Rule 4723-7-05 (B)(4) Oh Adm. Code). It will also provide any nurse who is practicing in Ohio a refresher course on key laws and rules regulating nursing practice. It begins with information about the Board of Nursing, its make-up and responsibilities; and then focuses on laws and administrative rules that are likely to affect a nurse’s daily practice.
Nurses are responsible for knowing the law and rules of the state in which they are practicing. While there may be similarities from state-to-state there are also key differences. In addition, laws and rules change frequently and some of those changes may be significant. So while every effort is made to ensure this study includes the most current information, if you have questions be sure to check the laws and rules via the Board of Nursing web site (www.nursing.ohio.gov).
An initial license to practice nursing in Ohio may be obtained by examination or endorsement. A license by examination is awarded to an individual who has never been licensed to practice as a nurse in any state and who has completed an approved pre-licensure nursing education program and received a passing score on the NCLEX-RN or NCLEX-PN ® examination. The applicant must also complete a criminal records check. (Rule 4723-7-02 OAC). An individual who holds a current valid license to practice nursing in another state or jurisdiction may apply for licensure by endorsement. That applicant must also complete a criminal records check. (Rule 4723-7-05 OAC). A nurse may be licensed simultaneously in multiple states but must meet each state’s renewal requirements to ensure that the license is considered current and valid in that location. Only in certain circumstances (described more fully below) may a nurse who is licensed in another state engage in nursing practice in Ohio based on valid licensure held elsewhere.
An APRN license is awarded to an RN who has earned a graduate degree in a nursing specialty or related field that qualifies the individual to sit for the certification examination of a national certifying organization accepted by the Board, and who has successfully passed that certification examination.
A license is valid for a defined period of time—generally two years depending upon when the initial license is issued. For LPNs the license must be renewed in the even-numbered years and for RNs (including APRNs) renewal is in the odd-numbered years. Effective in 2016, licenses expire as of November 1st of the renewal year. Renewal applications must be submitted to the Board by September 15th. Failure to do so will subject the licensee to a late fee of $50 in addition to the renewal fee of $65 for an RN or LPN license. APRNs must hold both an RN and APRN license. The fee for renewing the APRN license that includes prescriptive authority is $135. The fee for initial licensure by examination or endorsement is $75 for RNs and LPNs and $150 for APRNs. Licensure fees are set in statute (Section 4723.08 (ORC) and therefore can be changed only through legislative action. Regulatory boards in Ohio must generate sufficient revenue to be financially self-sustaining. That means fees collected by the Board are the sole source of revenue used to support its activities. No taxpayer dollars are allocated.
The Board will send out a license renewal notice via the U.S. mail to remind nurses that renewal begins July 1st and to provide them the information needed to access the online renewal process. These notices will be sent to the licensee’s last known address; and for security reasons, the notice will not be forwarded should the licensee no longer live at that address. It is important, therefore, for nurses to keep the Board apprised of address changes. In fact every licensee is required to give the Board written notice of a change of name or address within 30 days of the change. (Section 4723.24(B) ORC). Failure to do so could result in licensees not receiving critical information from the Board.
Licensureexceptions–Section4723.32ORCNot surprisingly, with every law there are also
exceptions or exemptions. Ohio allows individuals to engage in nursing practice without an Ohio license in the following circumstances:
• Students enrolled in and actively pursuingcompletion of a nursing education program, including graduate degree programs if:o The program is located in Ohio and approved by
the Board or by another board in a jurisdiction that is a member of the National Council of State Boards of Nursing;
o The student is acting under the auspices of the program; and
o The student is under the supervision of an RN faculty member.
• Individuals rendering medical assistance tolicensed physicians, dentists, or podiatrists if the individual is under the direction, supervision, and control of the licensed physician, dentist, or podiatrist.
• Individualsemployedasnursingaides,attendants,orderlies, or other auxiliary workers in patient homes, hospitals, home health agencies, or similar institutions.
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June 2017 Ohio Nurse Page 11
• Individualsprovidingcare to familymembersor inemergency situations.
• Individuals caring for the sick when doing so inconnection with the practice of religious tenets of any church by or for its members.
Section 4723.32 ORC
These exemptions may seem broad, but all associated restrictions or limitations must be met before the exemption applies. For example, a nursing student is allowed to engage in activities reserved to licensed nurses, such as medication administration, ONLY if the student is doing so as part of an educational program’s clinical experience. Students who work in a health care setting outside of that nursing education program framework are considered unlicensed persons and may engage only in activities that any other unlicensed persons may perform.
Ohio also recognizes that individuals holding current valid licenses to practice nursing in a state other than Ohio may engage in certain activities in Ohio without an Ohio license. Those activities include:
• Discharging official duties while employed by orunder contract with the United States government.
• TransportingapatientintooroutofOhioaslongaseach trip does not exceed 72 hours.
• Consulting with an individual in Ohio who islicensed to practice a health-related profession.
• Teachingasaguestlectureratanursingeducationprogram, nursing continuing education, or in-services.
• Evaluatingnursingcareonbehalfofanaccreditingorganization.
• ProvidingnursingcaretosomeonewhoisinOhioon a temporary basis not to exceed six months in a calendar year if the nurse is directly employed by or under contract with a person acting on the patient’s behalf.
• Providingnursingcareduringanofficiallydeclareddisaster.
Section 4723.32 ORC
The exemptions are intended to strike a balance so that licensure requirements do not hamper legitimate activities while still ensuring the public is protected from unsafe nursing practices. It is important for nurses going to another state to engage in nursing practice to check that state’s licensure requirements to avoid unexpected challenges, pitfalls, and possible criminal prosecution.
Ohio law does not provide an exemption or exception from licensure for nurses practicing electronically across state lines. Should a licensed nurse located in a state other than Ohio engage in activities that would be considered the practice of nursing in Ohio for a patient located in Ohio, the nurse would need to hold an Ohio license. While some states have enacted the multi-state licensure compact that allows nurses in those states to practice in other compact states on a single license, Ohio is not part of the compact.
The Board has no jurisdiction or authority over unlicensed individuals who engage in nursing practice or who hold themselves out as nurses. The only recourse the Board has is to submit its findings to a county prosecutor for possible criminal prosecution for engaging in the unauthorized practice of nursing, which is a felony.
TAKEAWAYS:√ If practicing nursing in Ohio, an individual must be
licensed by the Board to do so even if the nurse is activing in a volunteer capacity.
√ Licensesmustberenewedeverytwoyears–LPNsineven-numbered years; RNs, including APRNs, in odd-numbered years.
√ Exemptions to the licensure requirement exist, butthey have specific criteria, all of which must be met for the exemption to apply.
√ A state’s licensure exemptions will vary so a nurseshould check a state’s practice act before engaging in practice there, even on a temporary basis. To find a link to boards of nursing in other jurisdictions, go to: www.ncsbn.org.
Protected titlesIn addition to authorizing the holder to engage in the
practice of nursing, the license also entitles the holder to use the titles protected under Ohio law. Those titles include licensed practical nurse (LPN), registered nurse (RN) advanced practice registered nurse (APRN), APRN-CRNA (for a certified registered nurse anesthetist) APRN-CNS (for a clinical nurse specialist) APRN-CNP (for a certified nurse practitioner) and APRN-CNM (for a certified nurse midwife). In addition, individuals may not use any other title that implies the person is authorized to practice nursing. Examples include but are not limited
to graduate nurse (GN) or trained nurse (TN). (Sections 4723.03 & 4723.44 ORC). Using a protected title without a nursing license is a felony of the 5th degree for the first offense and a felony of the 4th degree for each subsequent offense. An RN, LPN, or APRN who uses the protected title when holding a lapsed or inactive license is guilty of a minor misdemeanor, which is a criminal offense and could lead to other disciplinary action by the Board. (Section 4723.99 ORC). A nurse whose license is on inactive status or has lapsed may not use the protected titles.
License preclusionNot everyone who applies for a license to practice
nursing in Ohio is eligible to receive one. An individual who has been convicted of, pleaded guilty to, or had a judicial finding of guilt to specific criminal offenses are totally precluded from licensure in the state. Those offenses include: aggravated murder, murder, voluntary manslaughter, felonious assault, kidnapping, rape, sexual battery, gross sexual imposition, aggravated arson, aggravated robbery, and aggravated burglary. (Section 4723.092 ORC). Individuals seeking an Ohio license who have been convicted or had a judicial finding of guilt relative to criminal offenses other than the ones noted above may or may not be granted a license. In these cases, the Board will consider the circumstances surrounding the offense and will decide whether the potential licensee poses any danger to the public. If the Board members decide to issue a license it may include restrictions that limit the job locations or positions the nurse may hold.
TAKEAWAYS√ ONLY an individual holding a current, valid Ohio
license may use the titles protected under Ohio law. Those titles include LPN, RN, and APRN. A nurse whose license has lapsed or is on inactive status may not use the licensure title.
√ AnindividualwithoutavalidOhioLicensetopracticenursing may not use any title that leads the public to believe the individual is a nurse.
√ Engagingintheunauthorizedpracticeofnursingisacriminal offense.
√ LicenseesmustnotifytheBoardofNursinginwritingwithin 30 days of a change of name or address. Failure to do so could mean the nurse will not receive renewal notices or other important information from the Board.
Definingnursingpractice–Scope of Practice
Because the unauthorized practice of nursing is a criminal offense, it is important for the law to define that practice so the public has notice of what is prohibited and nurses know what their license authorizes them to do. The definition section (4723.01 ORC) of the law regulating nursing practice contains what is commonly referred to as the nurse’s “scope of practice”. Each state defines nursing practice, but the definitions may vary from state to state. There is no national scope of practice. For that reason, it is important to be familiar with each state’s requirements. Generally, the RN’s scope is more consistent between states than are the scopes of practice for LPNs and APRNs.
Because RNs, LPNs, and APRNs frequently work together, it is important to be aware of the scopes of practice for each. It is also important to know that employers may restrict what nurses may do in their particular workplace but may not expand the legal scope of practice. That means, for example, Ohio
CONTINuINg eduCATION
Independent Study continued on page 12
restricts the activities LPNs may engage in with respect to intravenous (IV) therapy. An employer may adopt a policy that prohibits LPNs from administering any IV medications, but it may not adopt a policy that expands the LPNs’ authority in that regard beyond what is allowed by law.
Many nurses would like to have their practice more clearly defined, perhaps identifying in law specific tasks or activities that they may perform. While that may appear to be a way to eliminate or minimize scope of practice questions, it would not allow nurses to adapt to the ever-changing technology and other advances that characterize health care today. Revisions to scope of practice language must be enacted by the legislature, which can be a long process fraught with many pitfalls and often, significant opposition. For that reason, the definitions of practice for licensed nurses are purposefully non task-specific.
The current scope of practice for both RNs and LPNs in Ohio was defined in large part in 1988. Before that revision, nursing practice was defined as anything nurses learned in a nursing education program. The 1953 definition was severely limiting nursing practice so the changes made in 1988 were intended to allow more flexibility. At that time, however, some influential interest groups believed nurses were trying to infringe on the practice of medicine so much of the definitional language adopted by the legislature reflects compromises that allowed certain emerging concepts to become part of the law. For example, nursing diagnosis, health assessment, and nursing regimen were controversial concepts so they were defined using terminology that distinguishes the nurse’s role from that of the physician relative to these activities.
It is important that RNs understand the scope of practice for LPNs and the legal relationship between RNs and LPNs created by the scope language set out in the law. An RN may be directing the LPN’s practice; however, directing is NOT the same as delegating. The differences are subtle and will be discussed later in this study.
Scope of practice: RNsIn Ohio, the practice of nursing by RNs includes
five independent functions that a nurse may engage in without specific orders or directions to do so. These activities are inherent expectations of all RNs regardless of practice location or specialty. The independent functions include:
• Identifying patterns of human responses toactual or potential health problems amenable to a nursing regimen;
• Executing a nursing regimen through the selection, performance, management, and evaluation of nursing actions;
• Assessing health status for the purpose ofproviding nursing care;
• Providing health counseling and health teaching;and
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Page 12 Ohio Nurse June 2017
• Teaching, administering, supervising, delegating,and evaluating nursing practice
(Section 4723.01 (B) ORC) The law goes on to define “nursing regimen” as
preventative, restorative, and health promotion activities. (Section 4723.01(C) ORC). “Assessing health status” means the collection of data through nursing assessment techniques which may include interviews, observation, and physical evaluation for purposes of providing nursing care (Section 4723.01 (D) ORC). Note the repeated use of the word “nursing” throughout the scope of practice language to make clear the individual is not engaging in the practice of medicine. In fact, RNs and LPNs are explicitly prohibited from engaging in medical diagnosing, the prescription of medical measures and the practice of medicine or surgery or any of its branches. (Section 4723.151 ORC). The prohibition found in Section 4723.151 ORC does not apply to APRNs who are acting within their scope of practice.
The only dependent component of RN practice is administering medications, treatments, and executing certain medical regimens. These activities must be authorized (ordered) by individuals authorized to practice in Ohio who are acting within their professional practice. (Section 4723.01 (B)(5) ORC). In other words, a registered nurse may not administer medication without a valid order from an authorized individual to do so. RNs may not prescribe, which means a medication order must be specific with respect to dosage, indications for administering the drug, time, and route of administration. Failure to heed this limitation could result in a charge of practicing medicine without a license.
Scope of practice: LPNsThe scope of practice for LPNs includes no
independent functions or activities. An LPN must practice under the direction of a registered nurse, physician, physician assistant, dentist, podiatrist, optometrist, or chiropractor. (Section 4723.01 (F) ORC). “Direction” does not mean over-the-shoulder supervision. Rather, there must be someone who is communicating or has communicated a plan of care to the LPN. (Rule 4723-4-02 (B)(6) OAC). The LPN contributes to the development of the plan of care but cannot independently develop or revise it.
Nursing care provided by LPNs includes:• Observation, patient teaching, and care in a
diversity of health care settings;• Contributionstotheplanning,implementation,and
evaluation of nursing;• Administering medications and treatments
authorized (ordered) by an individual who is authorized to practice in Ohio who is acting within their professional practice provided the LPN has successfully completed a course in basic pharmacology either in a pre-licensure education program approved by the Board or a post licensure basic pharmacology course approved by the Board (Section 4723.17 ORC);
• Administeringtoanadult appropriately authorized IV therapy within the requirements set forth in Section 4723.18 ORC (described more fully below);
• Delegating nursing tasks as directed by aregistered nurse. Note: if the LPN is being directed by a non-nurse, the LPN may not delegate nursing tasks; and
• TeachingnursingtaskstoLPNsandindividualstowhom the LPN is authorized to delegate nursing tasks.
(Section 4723.01 (F) ORC)
The Board through its rules specifies that RNs and LPNs apply the nursing process when engaging in practice. The process is cyclical and the nurse’s action should respond to the patient’s changing care needs. An RN is expected to use clinical judgment in establishing and revising the patient’s nursing plan of care (Rule 4723-4-07 OAC) while LPNs contribute to the care plan, they may not act independently to develop or change it.
LPNs and IV therapyLPNs in Ohio have very specific requirements
and limitations they must adhere to with respect to IV therapy. In order to be authorized to engage in any of the allowable activities the LPN must have completed a course in IV therapy that includes 40 hours of training approved by the Board. The curriculum must include the anatomy and physiology of the cardiovascular system, signs and symptoms of local and systemic complications in administering IV fluids and antibiotic additives and guidelines for management of these complications. The course must also include a testing component.
When the LPN is providing IV therapy at the direction of an RN the RN must be readily available at the site where the IV therapy will be done, and the RN must personally perform an on-site assessment of the patient who will receive the IV therapy. LPNs may provide IV therapy only to an adult.
(Section 4723.18 ORC).
LPNs may NOT do the following with respect to IV therapy:
• Initiateormaintainbloodorbloodproducts;• Initiate or maintain solutions for total parenteral
nutrition;• Initiateormaintaincancertherapeuticmedications
including but not limited to chemotherapy and anti-neoplastic agents;
• Initiateormaintain solutionsadministered throughany central venous line or arterial line or any other line that does not terminate in a peripheral vein, o except that a licensed practical nurse may
maintain the following solutions—dextrose 5%, normal saline, lactated ringers, sodium chloride .45%, sodium chloride 0.2 %, sterile water;
• Administeranynewinvestigationalorexperimentaldrug;
• Initiateintravenoustherapyinanyvein,exceptinavein of the hand, forearm, or antecubital fossa;
• Discontinueacentralvenous,arterial,oranyotherline that does not terminate in a peripheral vein;
• Initiateordiscontinueaperipherallyinsertedcentralcatheter;
• Mix, prepare, or reconstitute any medication forintravenous therapy,o except an antibiotic additive;
• Administer medication via the intravenous route,including all of the following activities:o Adding medication to an intravenous solution or
to an existing infusion, § except the following:
• Initiatean intravenous infusioncontainingone or more of the following elements: dextrose 5%, normal saline, lactated ringers, sodium chloride .45%, sodium chloride 0.2 %, sterile water;
• Hang subsequent containers of theintravenous solutions specified above
that contain vitamins or electrolytes, if a registered nurse initiated the infusion of that same intravenous solution;
• Initiateormaintainanintravenousinfusioncontaining an antibiotic additive;
o Injecting medication via a direct intravenous route, § except heparin or normal saline to flush an
intermittent infusion device or heparin lock including, but not limited to, bolus or push;
• Changetubingonanylineincluding,butnotlimitedto, an arterial line or a central venous line, o except tubing on an intravenous line that
terminates in a peripheral vein; and• Programorsetanyfunctionofapatientcontrolled
infusion pump.(Section 4723.18 ORC).
To summarize that can be very confusing language, LPNs who have completed the required IV therapy course may do the following for an adult patient:
• Change tubing on an IV line that terminates in aperipheral vein;
• Inject IV heparin or normal saline to flush anintermittent infusion device or heparin lock including bolus or push;
• Initiate an IV infusion containing one or more ofthe following dextrose 5%, normal saline, lactated ringers, sodium chloride .45%, sodium chloride 0.2%, and sterile water;
• Hang subsequent containers of the above IVsolutions that contain vitamins or electrolytes if an RN initiated the infusion of that same IV solution;
• Initiate or maintain an IV infusion containing anantibiotic additive;
• Use only the veins of the hand, forearm, orantecubital fossa when performing IV therapy;
• Maintain an IV administered through any centralvenous or arterial line of the following solutions dextrose 5%, normal saline, lactated ringers, sodium chloride .45%, sodium chloride 0.2%, and sterile water.
“Maintain” is defined as administering or regulating an IV according to the prescribed flow rate (Rule 4723-17-01 (E) OAC). An “adult” is defined as anyone who is 18 years of age or older. (Rule 4723-17-01 (A) OAC).
LPNs who have NOT successfully completed the required IV therapy course may do the following regardless of the patient’s age:
• Verify the type of peripheral intravenous solutionbeing administered;
• Examine a peripheral infusion site and theextremity for possible infiltration;
• Regulate a peripheral intravenous infusionaccording to the prescribed flow rate;
• Discontinueaperipheral intravenousdeviceat theappropriate time; and
• Perform routinedressingchangesat the insertionsite of a peripheral venous or arterial infusion, peripherally inserted central catheter infusion, or central venous pressure subclavian infusion. (Section 4723.181 ORC).
CONTINuINg eduCATIONIndependent Study continued from page 11
June 2017 Ohio Nurse Page 13
Scope of practice: APRN’s With the passage of HB 216 by the legislature in
late 2016, several significant changes were enacted that affect the APRN scope of practice. While the law continues to define APRNs as including CRNAs, CNPs, CNMs and CNSs, nurse anesthetists have significant differences from other APRNs with respect to their authorized activities. Most notably, CRNAs do NOT have prescriptive authority and practice with physician supervision. All other APRNs have prescriptive authority and practice in collaboration with a physician pursuant to a standard care arrangement.
The legislation also eliminated the requirement that newly licensed APRN prescribers complete an externship before obtaining a certificate to prescribe (CTP). As April 4, 2017 the Board will issue an APRN license (rather than a certificate of authority or COA) that includes prescriptive authority.
The scope of practice for all APRN specialty designations recognizes that advance practice requires knowledge and skill gained from advanced formal education, training, and clinical experience. (Section 4723.01(P) ORC). Specific scope of practice language for each APRN designation can be found in Section 4723.43 ORC.
• PracticeasaCNMincludes:o Management of preventive services and
primary care services to women antepartally, intrapartally, postpartally, and gynecologically;
o Performing episiotomies and repairing vaginal tears.
o A CNM may not perform version, deliver breach or facial presentations, use forceps, do any obstetrical operation or treat an abnormal condition except in an emergency. (Section 4723.43 (A) ORC).
• PracticeasaCRNAincludes:o Administering anesthesia induction,
maintenance, and emersion in the immediate presence of a physician, dentist, or podiatrist;
o Pre-anesthesia preparation and evaluation, post anesthesia care and clinical support functions under the supervision of a physician, dentist or podiatrist.
o The CRNA who is supervised by a dentist or podiatrist may perform only the anesthesia procedures the dentist is authorized to perform and may not administer general anesthesia in a podiatrist’s office. (Section 4723.43(B) ORC).
• PracticeasaCNPincludes:o Prevention and primary care services;o Services for acute illnesses; ando Evaluation and promotion of patient wellness.o If collaborating with a podiatrist, the CNP is
limited to procedures the podiatrist is authorized to perform. (Section 4723.43 (C) ORC).
• PracticeasaCNSincludes:o Providing and managing care of individuals and
groups with complex health care problems;o Providing health care services that promote and
manage health care.
o If collaborating with a podiatrist, the CNS is limited to procedures the podiatrist is authorized to perform. (Section 4723.43 (D) ORC).
Protecting the public in an evolving health care system
Nursing care is not static. As technology evolves, care that may have once been considered the practice of medicine may be seen as appropriately within a nurse’s scope. The Board recognizes the inevitability of change, and through its rules establishes factors that must be considered before a nurse provides care that is beyond basic preparation. The nurse must:
• Obtain education from a recognized body ofknowledge;
• Demonstrate the knowledge, skills, and ability toprovide the care; and
• Document completion of both the requirededucation and demonstration of skills needed to safely provide the care.
The care in question must not be prohibited by any other law or rule and there must be an appropriate order to perform the tasks associated with the care. (Rules 4723-4-03 and 4723-4-04 OAC). An order does not, however, authorize a nurse to act outside his/her legal scope of practice. That means an RN or LPN may not perform a surgical procedure or diagnose a medical condition even if a physician orders him/her to do so.
Because the Board’s focus is solely on public safety, it is concerned about the competency of the individuals it licenses both initially and on an ongoing basis. In addition to knowing their scope of practice, nurses are expected to be competent practitioners of nursing. Competent practice includes maintaining current knowledge of duties, responsibilities and accountability as well as consistent performance of all aspects of care. This expectation is particularly important when a nurse is considering whether to engage in or perform a specific task, procedure, or activity. The nurse must have both the knowledge needed to consistently perform the task, procedure, or activity safely and be able to recognize complications should they arise. The nurse must also have the ability to refer or consult and provide appropriate intervention to address the complications. (Rules 4723-4-03 (C) & 4723-4-04 (C)
CONTINuINg eduCATIONOAC. Often it is the latter factor, dealing appropriately with complications, that is the most crucial issue to be considered when determining whether to engage in a particular activity.
TAKEAWAYS:√ There is no national scope of practice for nurses.
Each state defines nursing practice and those definitions are the scope of a nurse’s practice when he/she is practicing in that state.
√ RNShave5independentactivitiestheyareallowedtoengage in without need for a specific order to do so. Administering medications and performing medical treatments, however, are dependent functions and require a valid order for both RNs and LPNs.
√ LPNalwaysmustworkatthedirectionofaphysician,dentist, optometrist, podiatrist, chiropractor, registered nurse, or a physician assistant.
√ APRNs (other than CRNAs) working pursuant tothe scope of practice for their particular specialty designation may diagnose and prescribe. CRNAs do not have prescriptive authority in Ohio.
√ Simplybecausea taskoractivity iswithinanurse’slegal scope of practice is not enough. The nurse must also have the knowledge, skills and ability to safely perform the task in the clinical setting in which it will be performed. Safe practice means knowing how to do the task correctly and having the means to recognize complications when they arise and appropriately respond to those complications.
Delegation and Direction
DelegationThe scope of practice for nurses recognizes that
delegation of certain aspects of nursing care is an independent function for RNs, and LPNs may delegate nursing tasks but only at the direction of an RN. The Board adopted a series of rules setting out standards nurses must use when delegating these activities. (Chapter 4723-13 OAC). Delegation is defined as the “transfer of responsibility for performance of a selected nursing task from a licensed nurse authorized to perform the task to an individual who is not so authorized.” (Rule 4723-13-01(B) OAC). A nursing task is defined as those activities that constitute the practice of nursing including assistance with activities of daily living that are performed to maintain or improve the patient’s well-being when the patient is unable to perform that activity for him or herself. (Rule 4723-13-01(I) OAC). While nurses may delegate a task, that action does not absolve them of responsibility with respect to the patient’s overall care needs. The nurse must make sure the task is performed as delegated and take action if it is not in order to make certain the patient’s safety is maintained and care needs are met.
LPNs who complete the required IV therapy course may for adults only:
LPNs who have not completed the IV therapy course may regardless of the patient’s age:
Change tubing on an IV line that terminates in a peripheral vein
Verify the type of peripheral IV solution being administered
Inject IV heparin or normal saline to flush an intermittent infusion device or heparin lock including bolus or push
Examine a peripheral IV site and the extremity for possible infiltration
Initiate an IV infusion containing one or more of the following: dextrose 5%, normal saline, lactated ringers, sodium chloride .45%, sodium chloride 0.2%, and sterile water
Regulate a peripheral IV infusion according to the prescribed flow rate
Hang subsequent containers of the above IV solutions that contain vitamins or electrolytes if an RN initiated an IV of the same solution
Discontinue a peripheral IV device at the appropriate time
Initiate or maintain an IV infusion containing an antibiotic additive
Perform routine dressing changes at the insertion site of a peripheral venous or arterial infusion, peripherally inserted central catheter infusion, or central venous pressure subclavian infusion
Use only the veins of the hand, forearm, or antecubital fossa when performing IV therapyMaintain an IV administered through any central venous or arterial line of the following solutions: dextrose 5%, normal saline, lactated ringers, sodium chloride .45%, sodium chloride 0.2%, and sterile water.
TAKEAWAYS–LPNsandIVTherapy
Independent Study continued on page 14
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The rules addressing delegation do not include a list of activities or tasks that can always be delegated because no task is always delegable. Whether to delegate a task is left to the nurse’s clinical judgment based on the complexity of the task, the patient’s health status, the skill of the unlicensed person who will perform the task, and the availability of necessary resources and supervision. (Rule 4723-13-05 OAC). For a task to be delegable certain criteria must be met. Those criteria include:
• The task requires no judgment based on nursingknowledge and expertise;
• Theresultsofthetaskarereasonablypredictable;• The task can be performed safely according
to exact unchanging directions with no need to alter the standard procedures for performing the task;
• Performance does not require repeated nursingassessments; and
• The consequences of incorrectly performing thetask are minimal and not life threatening.
Rule 4723-13-05 (D)(6) OAC.
Given the stringent criteria for defining a delegable task, the administration of medication is not generally considered delegable. There are exceptions, however, that allow delegation to occur. Nurses may delegate:
• Over-the-counter topical medications applied tointact skin to improve a skin condition or provide a barrier; and
• Over-the-counter eye drops, ear drops,suppositories, foot soak treatments and enemas.
Rule 4723-13-05 (C) OAC
An APRN may delegate medication administration to an unlicensed person if:
• ThedrugisonetheAPRNmayprescribe;and• The drug is not to be administered in a hospital
inpatient care unit, a hospital emergency department, a free-standing emergency department, or an ambulatory surgical facility.
Section 4723.489 ORC
Ohio law explicitly authorizes unlicensed assistive personnel to administer medications in certain specific settings, for example public schools. If a school district has established a policy that authorizes unlicensed individuals to administer medications, no nurse delegation is needed. (Section 3313. 713 ORC). Within specific developmental disability care sites the law allows certain medications to be administered without delegation while others require nurse delegation. (Sections 5123.4 et. seq. ORC and Rules 5123:2-6-01 to 5123: -6-07 OAC). If delegation is required, the nurse must act in accordance with the requirements and limitations set out in Chapter 4723-13 OAC. (Rule 4723-13-02 OAC).
Additionally, Ohio law recognizes “assistance with self administration of medications” when the activity occurs in a facility where the substantial purpose of the setting is not the provision of health care. An unlicensed person acting without delegation may:
• Remindtheindividualwhentotakethemedication& observe to ensure the medication is taken according to directions on the container;
• Bring the medication in its container to theindividual, and if the individual is physically unable to do so, open the container; and
• Remove the oral or topical medication from thecontainer and if the individual is physically impaired place a dose of medication in another container and place that container to the mouth of the individual. (Rule 4723-13-02 OAC)
When a licensed nurse delegates a task, the nurse must supervise the performance of the task. Supervision does not mean over-the-shoulder observation. Rather it means initial and ongoing procedural guidance and evaluation. Adequate communication regarding the nurse’s expectations is critical to successful, safe delegation.
If the substantial purpose of the setting in which the delegation is occurring is the provision of health care services, the supervision must be on-site. However, if the purpose of the setting is other than the provision of health care, the supervision may be indirect, but the nurse must always be accessible electronically. When not required to be on site, several factors must be considered by the nurse when making a decision regarding delegation. Those factors include:
• The number of individuals needing nursing careand their health status;
• The types and number of nursing tasks beingdelegated; and
• The continuity, dependability, and reliability of theunlicensed individual.
If the license nurse is responsible for more than one site, the distance and accessibility of each setting and any unusual problems that may be encountered must also be considered, as must the availability of emergency aid if needed.
Rule 4723-13-07 OAC.
DirectionLPNs work at the direction of RNs, which means the
RN communicates a plan of care to the LPN. (Rule 4723-4-01 (B) (6) OAC). When directing an LPN the RN must assess:
• Theconditionofthepatient,includingthepatient’sstability;
• Thetypeofcarethepatientrequires;• Thecomplexityandfrequencyofthenursingcare
needed; and• The training, skill, and ability of the LPN being
directed.Rule 4723-4-03 (K) OAC
TAKEAWAYS√ Thescopeofpracticerecognizesthatdelegationisan
independent function for RNs. √ LPNsmaydelegatetoanunlicensedpersonandmust
delegate according to standards established by the Board. A physician, dentist, podiatrist, chiropractor, optometrist, and physician assistant may not direct the LPN to delegate nursing care. Only the RN may do so.
√ The delegating nurse remains responsible for theoverall outcome when a task is performed by an unlicensed person.
√ Medicationadministrationisnot,typically,adelegabletask for RNs and LPNs; however, APRNs may delegate the administration of mediations in certain non-hospital settings.
Maintaining a license
Consistent with its obligation to protect the public from unsafe nursing practice, the law authorizes the Board to establish criteria, including continuing education requirements, licensees must meet to renew a license. The Board also is authorized to revoke, suspend, or restrict a license should it find a licensee has engaged in activities that constitute a violation of certain provisions
of law set out in Section 4723.28 ORC. These activities are intended to help the Board ensure the ongoing competency and safe practice of its licensees.
Continuing education In order to be eligible to renew a nursing license in
Ohio (EXCEPT the first renewal following initial licensure by examination) the licensee must complete 24 hours of continuing nursing education (CE), one hour of which must be directly related to the laws and rules pertaining to the practice of nursing in Ohio, so-called Category A continuing education. (Section 4723.24 ORC). Effective April 4, 2017 APRNs must obtain an additional 24 hours of continuing education to renew an APRN license and 12 of those hours must include advanced pharmacology. (Section 4723.24 ORC). If a nurse completes more than the required 24 (or 48) hours during a renewal cycle those additional hours may NOT be applied to future renewal periods. Continuing education requirements are described in more detail in Board rules found in Chapter 4723-14 (OAC). A licensee may also use a one-time only waiver to renew a license without obtaining the requisite continuing education. The waiver request must be submitted in writing and once requested it may not be withdrawn. Once that waiver option is used it may never be used again. (Rule 4723-14-03 (G) OAC).
Ohio accepts, for continuing education purposes, both independent studies as well as faculty-directed activities. In fact, nurses may rely on independent studies to satisfy all hours of the CE requirement if they choose to do so. Regardless of the format of the study or activity, the nurse must maintain documentation or verification of completion of the CE that is issued by the CE provider. The nurse must retain this documentation for six years or three renewal cycles.
As part of the renewal process, the nurse will be asked to attest to having met the CE requirement, and the Board may ask the nurse to verify that the attestation is accurate. When this CE audit is conducted, the nurse must provide the requested documentation—the relevant CE certificates. Failure to do so before November 1st will result in a lapsed license. (Rule 4723-14-03 OAC). If a license is lapsed or on inactive status for more than two years, the nurse must complete 24 hours of prescribed CE that includes the following content:
• Twocontacthoursonscopeofpractice,standardsof safe practice, and delegation;
• Sixcontacthoursaddressing thenursingprocessand critical thinking, clinical reasoning, or nursing judgment related to patient care;
• Six contact hours in pharmacology, drugclassification, medication errors, and patient safety;
• Two contact hours related to clinical ororganizational ethics; and
• Eightcontacthoursrelatedtothenurse’sparticularpractice.
Rule 4723-14-03 OAC.
Individuals taking college courses may apply the credit hours earned in those courses to satisfy the CE requirement. One credit hour earned in an academic semester is equivalent to 15 contact hours of CE; one credit hour earned in a quarter system is equivalent to 10 contact hours; and one credit hour earned in a trimester system is equivalent to 12 contact hours. (Rule 4723-14-04 OAC). However, if the college course work does not include the content required to meet the Category A law and rules requirement, the nurse would need to obtain that hour through an approved continuing education program designated as a Category A presentation.
Although Ohio is fairly generous in its determination of what constitutes acceptable continuing nursing education, there are specific exceptions to that flexibility. The following activities cannot be used to satisfy the 24 hours of CE required for license renewal:
CONTINuINg eduCATIONIndependent Study continued from page 13
June 2017 Ohio Nurse Page 15
• Repetitionofanactivitywith identical contentandoutcomes within a single reporting period;
• Self-directed learning such as reading texts orjournal articles not approved as an independent study;
• Participationinclinicalpracticeorresearch;• Personaldevelopmentactivities;• Professional meetings or conventions except for
portions designated as CE• Communityserviceorvolunteerpractice;• Membershipinprofessionalorganizations;and• CEorderedbytheBoardasaresultofdisciplinary
action. Rule 4723-14-05 (OAC).
Taking disciplinary action to protect the publicThe Board may take disciplinary action when a
nurse (or other individual under the Board’s jurisdiction) violates specific provisions found in Section 4723.28 ORC. If an action or inaction is not included in that section of law, the Board cannot act. That same section of law also defines the processes the Board must use when it proposes to take the allowed action. The Board must provide the accused individual due process, which includes notice of the allegations and an opportunity for the accused individual to tell his/her side of the story. Just like other judicial or quasi-judicial proceedings, the Board must prove the charges, in other words, the nurse is “innocent until proven otherwise”, but the Board’s burden of proof is comparatively light; a preponderance of the evidence standard, rather than the beyond a reasonable doubt standard that is typically seen in criminal cases.
The Board relies generally on its complaint process as the basis for its disciplinary activities. In other words, the Board does not typically initiate an investigation unless it has received information in the form of a complaint that describes what the regulated individual did or did not do that would be considered a violation of Section 4723.28 ORC. All complaints are confidential and must be investigated by Board staff, who are trained investigators. Nurses have the right to have an attorney represent them in these proceedings with the processes for doing so set out in Chapter 4723-16 of the Ohio Administrative Code. Once an investigation has been completed by Board staff, a decision is made as to whether the charges constitute a violation of Section 4723.28 ORC and whether there is sufficient evidence to support the allegation. Board members then decide whether to proceed to adjudicate the case. At this point the case becomes public information, and the nurse is notified regarding his/her right to request a formal hearing.
Because felonies and certain misdemeanor criminal convictions, a plea of no contest to, or treatment in lieu of conviction are the grounds for Board action under Section 4723.28, county prosecutors are required by law to report these judicial outcomes to the Board. In addition, employers are required to report to the Board any current or former employees whose conduct would be grounds for disciplinary action under the law. (Section 4723.34 ORC) Individual nurses, however, are not mandated by law to report to the Board. Any person who reports to the Board in good faith is immune from liability and other adverse actions. (Section 4723. 341 ORC).
In addition to convictions or adjudicatory action related to felonies, misdemeanors in the course of practice and crimes involving moral turpitude, Section 4723.28 ORC includes in part the following as grounds for the Board to take disciplinary action:
• Impairment in the ability to practice according toacceptable prevailing standards of safe care due to:o Use of drugs, alcohol, or other chemical
substances;o Habitual or excessive use of controlled
substances or other habit forming drugs, alcohol, or other chemical substances;
o Physical or mental disability;• Failure to practice in accordancewith acceptable
and prevailing standards of safe nursing care. (Those standards are found in Chapter 4723-4 OAC and address both competency and patient safety considerations);
• Engaging in activities that exceed one’s scope ofpractice;
• Aiding and abetting in the unlicensed practice ofnursing;
• Taking into the body any dangerous drug not inaccordance with a legal valid prescription;
• Selling, giving away, or administering drugs forother than legitimate therapeutic purposes;
• Failuretouseuniversalandstandardprecautions;• Assaultingorcausingharmtoapatientordepriving
a patient of the means to summon assistance;
• Failure to establish and maintain professionalboundaries;
• Engaginginsexualcontactorverbalbehaviorthatis sexually demeaning with a patient;
• Misappropriationofanythingofvalueinthecourseof practice; and
• Actiontakenbyanotherregulatoryboard.
(It is important to note that this is only a partial list of grounds for Board disciplinary action).
TAKEAWAYS√ TheBoardcantakeactionthatcouldrevoke,suspend,
restrict or otherwise limit a nurse’s license to practice nursing.
√ A nurse has a right to be notified of the chargesagainst him/her and to have an opportunity to offer a defense-due process rights. The nurse may also be represented by legal counsel.
√ The Board, typically, learns of alleged violations ofSection 4723.28 ORC from complains filed with the Board. All complaints are confidential until the Board completes its investigation and believes it has reason to believe it can prove the charge. At that point, the case becomes public information.
Acceptable Standards of Safe & Effective Nursing Practice
Acceptable standards include (in part):• Timely implementation of an authorized
practitioner’s order unless the nurse believes the order is inaccurate, not properly authorized, not current or valid, harmful or potentially harmful, or contradicted. o If a nurse believes an order is not
appropriate, he/she must clarify the order. o If after clarification the nurse determines not
to implement the order, that determination must be documented accurately and in a timely manner and the nurse must act to assure the patient’s safety.
• Maintainingpatientconfidentiality.• Displaying title or licensure initials when
providing direct patient care, including when practicing via telecommunication.
• Documenting accurately, timely, andcompletely nursing assessments or observations, the care provided by the nurse, and the patient’s response to that care.
• Accuratelyandinatimelymanner,reportingerrors or deviations from a current valid order.
• Providingasafeenvironment.• Providing privacy during examination and
treatment.• Treatingeachpatientwithcourtesy,respect,
and with full recognition of the patient’s dignity and individuality.
• Establishing & maintaining professionalboundaries with a patient.
• Not falsifying any patient records or otherdocuments prepared or utilized in the course of or in conjunction with nursing practice.
• Notengaging inphysical, verbal,mental,oremotional abuse.
• Not misappropriating a patient’s propertyor seeking or obtaining personal gain at the patient’s expense.
• Notbecoming inappropriately involved inapatient’s personal relationships or financial matters.
• Not engaging in sexual conduct with apatient or verbal behavior that is seductive or sexually demeaning to a patient.
Rule 4723-4-06 OAC.
Nurses are responsible for knowing when changes occur to the laws and rules governing their practice. One way to stay informed is by going to the Board’s web page (www.nursing.ohio.gov) and subscribing to e-news.
ConclusionLicensed nurses by virtue of holding a current
valid license are allowed to touch people physically and emotionally in ways others may not. That authority is a privilege and carries with it an obligation to engage in nursing practice safely and
in accordance with all relevant laws and rules. The Board of Nursing is charged with protecting the public from the unsafe practice of nursing. That responsibility includes the adoption of rules that enable the Board to enforce the law effectively. Nurses must know both the law and the rules governing their practice and keep up with changes as they occur. The Board’s web site (www.nursing.ohio.gov) has many resources licensees may find useful in helping them decipher some of the more complex aspects of nursing practice including the regulations they must follow. In addition, professional associations such as the Ohio Nurses Association and the Ohio Association of Advanced Practice Nurses are excellent resources for nurses who may have questions or concerns. Safe practice is a goal for everyone, regulators and nurses alike. Knowing the rules and practicing in accordance with them is an important component of safe practice, especially in today’s complex health care environment.
CONTINuINg eduCATION
RN Case Managers
Gem City Home Care is an Evolution Health company that is committed to transforming the delivery of care.
We are looking for RN Case Managers to join our inter-professional care team in the Ohio area. You will provide direct patient care, including IV therapy and wound care, and develop, implement and evaluate individualized patient care plans.
We offer competitive pay, flexible scheduling, 401K, medical/dental/vision and paid time off.
To apply for this great opportunity and/or learn more about our organization, please go to https://www.evolution.net
Contact Patricia Pauly, Clinical Recruiter at 937-510-6465 or [email protected]
Page 16 Ohio Nurse June 2017
OB RN – We have positions available in the Family Birth Center for 12 hour shifts (7p-7a), 72 hours per pay, every 3rd weekend and PRN positions with 12 hour shifts. Previous OB RN experience is required.
ICCU RN – We have FT, PT and PRN positions available in our ICCU for 8 hour and 12 hour shifts (varied times). The position requires conscious sedation and cardiac classes.
ER RN – We have positions available in our Emergency Department for 12 hour shifts (7p-7a), 72 hours per pay and 48 hours per pay. Previous ED RN experience is required, in addition to current BCLS certification.
Please visit our website for further details.
Benefits to working at Mary Rutan Hospital:• $1000 sign-on bonus • Low nurse to patient ratios • 12 hour shifts• Part-time and full-time positions available • RN to BSN paid at 100%
Current employees not eligible for sign-on bonus