Advanced Practice Registered Nursing Oklahoma Board of Nursing

Advanced Practice Registered Nursing Oklahoma Board of Nursing Update October 18, 2017

Today’s Educational Objectives � Advanced Practice Registered Nurses-CNPs will: ◦ define who regulates nursing practice in Oklahoma. ◦ Identify the difference between Board staff and Board member. ◦ summarize the 4 APRN roles and 6 populations served by APRNs. ◦ examine the Nursing Practice Act, Rules and Guidelines related to CNP practice. ◦ analyze the differences regarding the 12 approved certifications for nurse practitioners. ◦ identify statutes and rules related to prescriptive authority. ◦ choose appropriate APRN practice related to increase knowledge.

United States Nurses � Largest group of licensed health care professionals in the United States � More than 4. 5 million individuals hold a nursing licenses � More than 234, 000 Nurse Practitioners � Legal authority to practice comes from each state

Mission of the Oklahoma Board of Nursing � Safeguard the public’s health, safety and welfare through the regulation of nursing practice and nursing education. � Both Board Staff and Board Members work to uphold the mission.

Statutory Authority � Oklahoma Nursing Practice Act [59 O. S. § 567. 1, et seq] and Rules [OAC 485] • Laws regulating nursing practice • Requirements for Licensure • Grounds for Disciplinary action Can be viewed on the website

Board Staff � 28 paid employees work for the Oklahoma Board of Nursing (15 are licensed nurses) � Staff employees function in positions that work to ensure the safety and welfare of the public. ◦ Regulatory �Practice �Education �Licensing ◦ Peer ◦ Investigation

Board Members � 11 members-Appointed by the Governor, US citizens and residents of Oklahoma ◦ 9 licensed nurses-6 RNs, 3 LPNs (serve a 5 year term) � � � 2 2 1 1 1 nursing education Administration/management APRN Acute Care LTC ◦ 2 Public Members (serve a 4 year term) � Public members serve coterminously with the Governor. � Appointed from 8 geographical districts [567. 4. A]

Who Does the Oklahoma Board of Nursing Regulate? � Oklahoma Board of Nursing Regulates: ◦ Advanced Practice Registered Nurses (APRNs) ◦ Registered Nurses (RNs) ◦ Licensed Practical Nurses (LPNs) ◦ Advanced Unlicensed Assistants (AUAs) [567. 2. A. 1]

What is an APRN? � An APRN is a licensed Registered Nurse who has: ◦ Completed an APRN education program (after 1/1/2016 -accredited, graduate level) to acquire advanced clinical knowledge and skills focusing primarily on the direct care of individuals; ◦ Passed a national certification exam in an APRN specialty area/population focus; and ◦ Obtained a license from the OK Board of Nursing. [567. 3 a(5)]

HOW MANY APRNs in OK? � 3, 572 APRNs licensed in OK (FY 2017) � Compared to FY 2016, increase of 333 ◦ Four Roles for APRNs �Certified Registered Nurse Anesthetist (713 FY 2017) �Certified Nurse Midwife (65 FY 2017) �Clinical Nurse Specialist (277 FY 2017) �Certified Nurse Practitioner (2, 517 FY 2017) 335

Role of the APRN � APRNs practice within one of the 4 roles. ◦ CNP, CNS, CRNA, CNM � APRNs have advanced education, knowledge and skills to care for a specific population of patients: ◦ ◦ ◦ Family/Individual Across the Lifespan Adult/Gerontology Neonatal Pediatric Psychiatric/Mental Health Women’s Health/Gender Specific � The APRN is educationally prepared to assess, diagnose and manage patient care problems, which may include ordering tests and prescribing medications.

APRN Certifications � Must pass an approved certification exam ◦ http: //nursing. ok. gov/prac-natlcert. pdf � 22 approved certification examinations for initial licensure: � 12 for CNP � 8 for CNS � 1 for CRNA � 1 for CNM

Changing and adding certifications � APRN adding an area of specialty and national certification must meet initial requirement for APRN licensure as identified in 59 O. S. § 567. 5 a and OAC 485: 10 -15 -4(a) � APRN who changes certifications within the same specialty must notify the Board within in 30 days � APRN who holds more than one certification and allows one to lapse must notify the Board within 30 days. APRN shall not work in the area of specialty upon expiration of certification. OAC 485: 10 -15 -4(b)

Titles and Credentials Used by APRNs � Effective November 1, 2011, each APRN must use the title “Advanced Practice Registered Nurse” or “APRN” and the role for the type of APRN license held (CNP, CNM, CNS, or CRNA). � Examples: � The “APRN-CNP” or “APRN, CNP” APRN may choose whether to use additional certification or education credentials. “APRN, CNP, FNP-BC”

Determining the Scope of Practice for the APRN � APRN should confirm practice includes: ◦ education and preparation for one of the 4 roles ◦ certification for role and area of specialty ◦ population delineated by specialty � 59 O. S. §§ 567. 3 a (5) (6) (7) (8) (9) (10) �OAC 485: 10 -15 -6 (b) Scope of Practice for CNP � Decision Making Model for Scope of Practice Decisions, # P-10

Decision-Making Model � The “Decision-Making Model” is a tool that can be used to help licensed nurses determine their scope of practice. � Application of the guideline is accomplished through answering seven questions. � Can be located on the OBN website @ ◦ http: //nursing. ok. gov//prac-decmak. pdf

Oklahoma Statutes � Go to www. oscn. net � Click on “Legal research” � Click on “Oklahoma statutes citationized” � Locate Title 59 and expand � Locate the Oklahoma Nursing Practice Act ◦ 59 O. S. § 567. 1, et seq

Oklahoma Rules � Go to http: //www. oar. state. ok. us � Click on view code � Locate Title 485 ◦ Oklahoma Board of Nursing Rules �[OAC: 485. ]

Other Statutes can help with determining Scope of Practice � OK Allopathic Medical and Surgical Licensure and Supervision Act: 59 O. S. §§ 480 -518 � OK Osteopathic Medicine Act: 59 O. S. §§ 620 -645 � OK Pharmacy Act: 59 O. S. §§ 353 -360 � OK Physical Therapy Practice Act: 59 O. S. § 887. 1, et seq � Public Health and Safety: 63 O. S. § 1 -101, et seq � Uniform CDS Act: 63 O. S. § 2 -101, et seq

And Rules � OK Allopathic Medical and Surgical Licensure and Supervision [OAC Title 435] � OK Osteopathic Medicine [OAC Title 510] � OK State Board of Pharmacy [OAC Title 535] � OK State Department of Health [OAC Title 510] � OK State Bureau of Narcotic and Dangerous Drugs Control [OAC Title 475]

Application Process for APRN � Must hold a current Oklahoma RN license � Submit an official transcript verifying completion of an accredited graduate level APRN education program in one of the 4 roles and a specialty area in at least one of the 6 population foci � Submit evidence of current national certification recognized by the Board � Submit complete application and required fee [OAC 485: 10 -15 -4(a)]

License Verification � APRN license can be verified on the OBN website. � There are three screens ◦ First screen: Type in the name and select RN ◦ Second screen: Verification of initial licensure and disciplinary action since 2009 ◦ Third screen: Verification of APRN licensure, role, certification, prescriptive authority and supervising physician

Can all APRNs write orders for medications and medical supplies? � � No – the APRN must hold a separate prescriptive authority recognition. CNPs, CNSs, and CNMs are eligible for prescriptive authority recognition. (must utilize the Exclusionary formulary) CRNAs are eligible for authority to select, order, obtain, and administer drugs. (must utilize the Inclusionary Formulary) Prescriptive authority can be identified on the website under license verification.

Requirements for Prescriptive Authority Recognition (CNP, CNM, CNS) � � � Submits a completed application for each type of recognition and fee Licensed as an RN and APRN Holds a graduate degree from an APRN accredited education program Has completed 3 academic semester credit hours or 45 contact hours of education within the last three years, targeting APRNs and other prescribers, in pharmacotherapeutics, clinical applications, and the use of pharmacological agents Submits an agreement with a supervising OK-licensed physician [59 O. S. § 567. 4 a and OAC 485: 10 -16 -3]

Physician Supervision Agreement for Prescriptive Authority � Form RS-20 located on the OBN website @ http: //nursing. ok. gov/pa-1. pdf � Requirements: ◦ ◦ OK licensed MD or DO with unrestricted license Must have a current permit with OBNDD and DEA Cannot be a resident or intern Form must be notarized Changes to the written statement shall be filed with the Board within thirty (30) days of the change and shall be effective on filing. [59 O. S. § 567. 4 a. 1]

Requirements for the Supervising Physician � Rules established by the Oklahoma Board of Medical Licensure and Supervision [435: 10 -13 -2] or the Oklahoma Board of Osteopathic Examiners [510: 10 -4 -3] � Full and unrestricted licensure with DEA and OBNDD permits � Active(MD) clinical practice w/patient contact at least 20 hours per week � Trained and fully qualified in the APRN specialty � May supervise no more than 2 FTE APRNs, or 4 PTE APRNs

Responsibilities of the Supervising Physician � “Supervision of an Advanced Practice Registered Nurse with prescriptive authority means overseeing and accepting responsibility for the ordering and transmission by a Certified Nurse Practitioner, a Clinical Nurse Specialist, or a Certified Nurse-Midwife of written, telephonic, electronic or oral prescriptions for drugs and other medical supplies, subject to a defined formulary” [59 O. S. § 567. 4 a]. � “The supervising physician should regularly and routinely review the prescriptive practices and patterns of the advanced practice nurse with prescriptive authority” [OAC 435: 10 -13 -2] or [510: 10 -4 -2].

Controlled Dangerous Drugs � APRNs (CNP, CNM, CNS) may not order or prescribe schedule I or II controlled dangerous drugs. ◦ [63 O. S. § 2 -312. C] � Must comply with state and Federal Drug Enforcement Administration (DEA) requirements prior to prescribing controlled and dangerous drugs. ◦ Apply for OBNDD permit (state) ◦ Apply for DEA permit (federal) � No more than 30 -day supply for schedule III-V drugs shall by prescribed by the APRN with Rx authority. [OAC 485: 10 -16 -5. (c)]

Prescription Monitoring Program (PMP) � The PMP application provides continuity between health care practitioners, pharmacies, and state law enforcement to help prevent prescription fraud and drug abuse in Oklahoma. � APRNs with prescriptive authority who prescribe narcotics shall obtain registration with OBNDD. � APRNs shall access to the PMP for the purposes of patient treatment and for the determination in prescribing or screening new patients. � 63 O. S. § 2 -309 D(G)

Exclusionary Formulary � For CNP, CNM, CNS with prescriptive authority � Lists drugs that shall not be prescribed or ordered � Reviewed annually by the Formulary Advisory Council and submitted to the Board for approval � The Board may accept or reject the Formulary. They cannot make changes. [59 O. S. § 567. 4 a. 9. (a)]

Requirements for Authority to Select, Order, Obtain, and Administer Drugs (CRNA) � Licensed as an RN and APRN-CRNA � Has completed 15 units of continuing education in advanced pharmacology related to the administration of anesthesia as recognized by the American Association of Nurse Anesthetists, or within an approved nurse anesthetist education program within the past two years � The CRNA with authority to order, select, obtain and administer drugs can write orders, they do not write prescriptions to be filled by pharmacists. � CRNAs administer anesthesia under the supervision of a OK-licensed physician, podiatric physician, or dentist. They do not have a supervising agreement.

Inclusionary Formulary � For CRNAs with prescriptive authority (select, obtain, order, administer) � List drugs that may be ordered � Reviewed annually by the CRNA Formulary Council and submitted to the Board for approval � The Board may accept or reject the Formulary. The cannot make changes. [59 O. S. § 567. 4 b]

RX Authority and the 4 APRN roles CNS CNM CNP Independent practice except RX/authority writes orders and prescriptions Exclusionary Formulary 59 O. S. § 567. 4 a CRNA Supervised practice Writes orders Inclusionary Formulary 59 O. S. § 567. 4 b

INVESTIGATIONS AND DISCIPLINE � When safety is breach through a violation of the Oklahoma Nursing Practice Act, violations are investigated by the Board. � If there is cause, a hearing is conducted and the Board may take disciplinary action on the license: ◦ Deny, revoke, or suspend a license ◦ Assess an administrative penalty ◦ Otherwise discipline a licensee

Statutory Authority for Disciplinary Action � Oklahoma Nursing Practice Act � Oklahoma Board of Nursing Rules ◦ 59 O. S. § 567. 8 ◦ OAC 485: 10 -11 -1

Common Questions 1. 2. 3. 4. 5. 6. 7. 8. Scope of Practice Prescriptive Authority Physician supervision Delegation Work environment Title Abandonment Hospital privileges

APRNs working with Medical Assistants � Medical Assistants are not regulated in Oklahoma. Guideline: Delegation of Nursing Functions to Unlicensed Persons, #P-02 � OBN ◦ AG Opinion 2015 -76 A � Licensed nurses may delegate selected nursing duties to individuals qualified, competent and legally able to perform such duties. [OAC 485: 10 -1 -2]

What is Abandonment? � Abandonment may occur when a licensed nurse fails to provide adequate patient care until the responsibility for care of the patient is assumed by another nurse or licensed provider. Patient safety is the key factor in determining nurse responsibility. � Situations considered by the Board not to constitute abandonment include, but not limited to: ◦ Resigning from a position and not fulfilling the remaining work scheduled ◦ Ending the employer-employee relationship without providing the employer with a period of time to obtain replacement staff for that specific position

Continued: � The Abandonment Statement, #P-11, does address implications for the APRN ◦ The legitimate discharge of a patient from practice, when the advanced practice registered nurse is the patient’s primary or specialty provider, does not constitute patient abandonment. However, a patient who is receiving acute or immediate care should not be discharged until transferred to another appropriate licensed health care provider.

DNP: Use of the word “doctor” � If the term “doctor” is used by a licensed nurse holding appropriate educational credentials, such usage must be in accordance with 59 O. S. § 725. 1, et seq. and OAC 485: 10 -13 -1. (e) � DNP is not one of the 9 classes of persons in 59 O. S. § 725. 2; however, there is additional language. � “Any other person using the term doctor, or any abbreviation thereof, shall designate the authority under which the title is used or the college or honorary degree that gives rise to the use of the title. ” [59 O. S. § 725. 2 B. ]

Licensed Independent Practitioner � “Licensed independent practitioner” may include advanced practice registered nurses with prescriptive authority. ◦ [OAC 310: 667 -1 -2] � APRN has completed an education program in one of the four APRN roles, CNP, CNS, CNM and CRNA ◦ [59 O. S. § 567. 3 a (5)] � CNP, CNS or CNM shall be eligible, in accordance with the scope of practice of the CNP, CNS or CNM, to obtain recognition as authorized by the Board to prescribe, as defined by the Board and subject to the medical direction of a supervising physician. ◦ [59 O. S. §§ 567. 3 a (6) (7) (8)]

Credentialing � Hospitals using non-physician practitioners, such as PAs, APRNs (CNP), CNMs, CRNAs, psychologists, or other practitioners, shall clearly define the role, limitation and mechanism of supervision in their job description, contract, or bylaws , as appropriate, to insure compliance with state law and good-practice standards for each practitioner. ◦ Oklahoma State Department of Health Rules: OAC 310: 6675 -2 � Staff of the hospital (APRNs) shall be licensed or registered in accordance with applicable state laws and shall provide care according to the requirements of their respective practice Acts. [OAC 310: 667 -5 -1]

New Enhanced Nurse Licensure Compact (e. NLC) � Effective date for the e. NLC, July 20, 2017 � Implementation date for the e. NLC, January 19, 2018 � RNs and LPNs can apply for a multistate license in their home state. � Must meet Uniform licensure requirements � Letters will be sent to Oklahoma licensed nurses, employers and schools in October. � e. NLC does not apply to APRNs

For more information contact: Gina Stafford, BSN, RN Associate Director for Nursing Practice Oklahoma Board of Nursing (405) 962 -1840

QUESTIONS?