Oregon State Board of Nursing Oregons Nurse Practice

Oregon State Board of Nursing Oregon’s Nurse Practice Act: The Statutes and Rules that Govern Nursing Practice . O A presentation for Oregon Hospice & Palliative Care Association Professional Practices Exchanges September 26, 2016 By Gretchen Koch, MSN, RN, OSBN Policy Analyst

Following today’s presentation you will be able to: • Describe the different mechanisms of nursing regulation. • Identify the purpose of the Nurse Practice Act. • Locate the Nurse Practice Act. • Discuss the concept of context of care. • Identify how to apply Division 45’s scope of practice standards to your nursing practice. The following content is based upon application of Chapter 678 Oregon Revised Statutes (ORS), Chapter 851 Oregon Administrative Rules (OAR), and OSBN practice documents. The content provided is intended for general knowledge only and does not replace or supersede the laws and rules of Oregon’s Nurse Practice Act.

Regulation in Nursing Practice Adapted from American Nurses Association (2010)

1917 Standard of Practice For the treatment of shock in a patient, the following 3 drugs may be given on your own accord: 1. Whiskey by mouth, 2. Aromatic spirits of ammonia by mouth, or 3. Coffee & salt solution by rectum Foot, J. , 1917

Legal Regulation & OSBN The Oregon State Board of Nursing safeguards the public's health and wellbeing by providing guidance for, and regulation of, entry into the profession, nursing education and continuing safe practice.

Oregon Nurse Practice Act Chapter 678 Oregon Revised Statutes ORS 678. 150… (5) The Board shall determine qualifications of applicants for a license to practice nursing in this state… (6) The Board shall exercise general supervision over the practice of nursing in this state… (7) The Board shall determine scope of practice as delineated by the knowledge acquired through approved courses of education… www. oregon. gov/OSBN

Practice of Nursing ORS 678. 010 (8), the “Practice of nursing” means: diagnosing and treating human responses to actual or potential health problems through such services as identification thereof, health teaching, health counseling and providing care supportive to or restorative of life and well-being and including the performance of such additional services requiring education and training which are recognized by the nursing profession as proper to be performed by nurses licensed under ORS 678. 010 to 678. 410 and which are recognized by rules of the board… Oregon Revised Statutes 2015 Edition Chapter 678 Nurses; Nursing Home Administrators

Oregon’s Nurse Practice Act Chapter 851 Oregon Administrative Rules: • Interpret the broad language of ORS 678 • Help define safe and competent nursing practice • Have the effect of law ORS 678 Statues & Chapter 851 OARs www. oregon. gov/OSBN

• • • • 1 - Rules of Practice & Procedure 2 - Agency fees 10 - Administration Oregon Administrative Rules 21 - Educational Programs 31 – Licensure 45 – Scope and Standards RN & LPN 47 – Community-based RN Delegation 48 – Nursing Care by a Designated Care-Giver 50 – Nurse Practitioners 52 - Certified Registered Nurse Anesthetists 54 – Clinical Nurse Specialists 56 - Advanced Practice Registered Nurse Authority to Prescribe & Dispense 61 – Standards for Training Programs for CNA & CMA 62 – Standards for Certification CNA & CMA 63 – Standards & Authorized Duties for the CNA & CMA 70 – Fitness to Practice Related to Behavioral Health & Cognitive or Physical Impairment Chapter 851

Division 45: Standards & Scope of Practice 0030 Purpose & Definitions 0040 Scope of Practice Standards all Nurses 0050 Scope of Practice Standards for the LPN 0060 Scope of Practice Standards the RN 0070 Conduct Derogatory 0080 Criminal Hx/Denial/Revocation 0090 Duty to Report 0100 Imposition of Civil Penalties

Division 45: RN Standards & Scope of Practice Scope and standards of practice for the RN – page 6 Practices autonomously. Scope and standards of practice for the LPN – Page 4 Practices under the clinical direction and under the clinic supervision of the RN or licensed independent practitioner. Scope of Practice: The activities & processes that are permitted for the licensed individual Standards of Practice: The behaviors/actions that demonstrate a competent level of nursing for each scope of practice authority.

Division 45: Standards & Scope of Practice 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Client Advocacy Ethics, Professional Accountability, Competence Environment of Care Nursing Technology Assign and Supervise Care Accept and Implement Orders Nursing Practice Implementation Collaboration w/Interdisciplinary Team Leadership Quality of Care Health Promotion Cultural Sensitivity Delegate and Supervise the Practice of Nursing

Division 45: Standards & Scope of Practice Standards related to the licensed nurse’s responsibilities for ethics, including professional accountability and competence. The licensed nurse: (a) Has knowledge of the statutes and regulations governing nursing, and practices within the legal boundaries of licensed nursing practice; (b) Accepts responsibility for individual nursing actions and maintains competence in one's area of practice. 851 – 045 – 0040 (3) (a) & (b) Chapter Division Rule Section Subsections Number Page 3

Individual Scope of Practice The licensee’s recognized nursing knowledge, skills, and abilities that fall within the broader scope of practice boundaries allowed by statute. Individual scope of practice is influenced by things such as practice experience, professional development, continuing education, and nursing practice specialty certification.

Division 45: Standards & Scope of Practice Standards related to the licensed nurse’s responsibilities for ethics, including professional accountability and competence. The licensed nurse: (d) Accepts only nursing assignments for which one is educationally prepared and has the current knowledge, skills and ability to safely perform. (f) Maintains documentation of the method by which competency was gained, and evidence that it has been maintained. 851 – 045 – 0040 (3) (d) & (f) Chapter Division Rule Section Subsections Number Page 3

Division 45: Standards & Scope of Practice 851 -045 -0040(5) Standards related to the licensed nurse’s responsibilities to assign and supervise care. The RN may: • Assign to the RN, nursing interventions that fall within RN scope of practice, that the licensee receiving the assignment has the competencies to perform safely, and is authorized to perform within the setting. • Assign to the LPN, nursing interventions that fall within LPN scope of practice, that the licensee receiving the assignment has the competencies to perform safely, and is authorized to perform within the setting. • Assign to the CNA and/or CMA authorized duties identified within Chapter 851 Division 63, that the certificate holder has the competencies to perform safely, and is authorized to perform in the setting. • The RN may assign to the UAP work the UAP has the competencies to perform safely, and is authorized to perform within the setting. Page 4

Division 45: Standards & Scope of Practice 851 -045 -0040(5) Standards related to the licensed nurse’s responsibilities to assign and supervise care. The LPN may, under the clinical direction and under the clinic supervision of the RN or licensed independent practitioner: • Assign to the LPN, nursing interventions that fall within LPN scope of practice, that the licensee receiving the assignment has the competencies to perform safely, and is authorized to perform within the setting. • Assign to the CNA and/or CMA authorized duties identified within Chapter 851 Division 63, that the certificate holder has the competencies to perform safely, and is authorized to perform in the setting. • Assign to the UAP work the UAP has the competencies to perform safely, and is authorized to perform within the setting. Page 4

Division 45: Standards & Scope of Practice Standards related to the Registered Nurse’s responsibility for nursing practice implementation. Applying nursing knowledge, critical thinking and clinical judgment effectively in the synthesis of biological, psychological, social, sexual, economic, cultural and spiritual aspects of the client’s condition or needs, the Registered Nurse shall: • Conduct and document assessments of the health status of clients. • Establish and document nursing diagnostic statements and/or reasoned conclusions which serve as the basis for the plan of care. • Develop and coordinate a plan of nursing care. • Implement the plan of care. • Evaluate client responses to nursing Pages 6 & 7 interventions and progress toward desired outcomes.

Division 45: Standards & Scope of Practice • Delegate – The RN delegates: • Only nursing procedures within scope of RN practice • Only as appropriate for the context of care • Only to the UAP • Only as a function of the plan of care • The RN does not delegate to an RN or LPN. The other licensee already has the scope of practice authority to engage in the activity. The RN would assign the activity to an RN or LPN. • The RN does not delegate to the person working as a CNA or CMA. When working as a CNA/CMA, the certificate holder must adhere to Division 63 authorized duties and not exceed the duties listed. * The RN would assign Division 63 authorized duties to the CNA/CMA.

Standard of Practice 1917 Nursing & Dietetics How to cream oysters for one person: One-half cup thin cream or rich milk, 1 tsp butter, 8 oysters, 1 T flour, ¼ t salt. Wet the flour with a little cold milk; scald the cream, add the flour and cook well. Just before serving add the drained oysters and cook until they grow plump and the edges curl, add the salt and butter. Serve on rounds of toast. Bonne santé & bon appétit! Foot, J. , 1917

Conduct Derogatory Categories 1. 2. 3. 4. 5. Client safety & integrity Federal or state statute/rule violations Communication Impaired function Achieving & maintaining clinical competency 6. Licensure violations 7. Relationship with the Board 8. Client's family 851 -045 -0070 9. Co‑workers 10. Advanced Practice Nursing

Duty To Report 851 -045 -0090 A licensed nurse who has knowledge or concern that a licensee’s behavior and/or practice fails to meet essential standards of acceptable and prevailing nursing practice and presents a potential for, or actual danger to the public health, safety and welfare, has a responsibility to make a report to the Board of Nursing. A nurse MUST always report the 11 things identified in 851 -045 -0090(6) Access & read: Page 14 of Division 45 Handout

When the activity it is not a must report activity… • The decision to report is based on: • Past practice history, • A pattern of substandard practice, • The magnitude of occurrence for actual/potential harm to public. • When in doubt, make a report! 851 -045 -0090

Licensee’s Duty to Report ØORS Chapter 676 Health Professions Generally ØORS Chapter 124 Abuse Prevention and Reporting; Civil Action for Abuse ØORS Chapter 146 Investigations of Deaths, Injuries & Missing Persons …and rules applicable to the context of care! Oregon State Board of Nursing: December 16, 2015 ØORS Chapter 419 b Reporting Of Child Abuse

Reporting questionable practice, even when done appropriately, may present substantial risk to the nurse; however, such risk does not eliminate the obligation to address threats to patient safety. Provision 3. 5 Code of Ethics for Nurses (ANA, 2015)

Summary/Query/Discussion 1. Client Advocacy 2. Ethics, Professional Accountability, Competence 3. Environment of Care 4. Nursing Technology 5. Assign and Supervise Care 6. Accept and Implement Orders 7. Nursing Practice Implementation 8. Collaboration w/Interdisciplinary Team 9. Leadership 10. Quality of Care 11. Health Promotion 12. Cultural Sensitivity 13. Delegate and Supervise the Practice of Nursing

• American Nurses Association (2015). Code of ethics for nurses with interpretive statements. Silver Spring, Maryland: Author. • American Nurses Association (2015). Scope and standards of practice (3 rd. ed. ). Silver Spring, Maryland: Author. • American Nurses Association (2015). Guide to nursing’s social policy statement: Understanding the profession from social contract to social covenant. Silver Spring, Maryland: Author. • American Nurses Association (2010). Nursing’s social policy statement: The essence of the profession. Silver Spring, Maryland: Author. • American Nurses Association and National Council of State Boards on Nursing. (2008). Joint statement of delegation. • Foote, J. (1917). State Board questions and answers for nurses. Lippincott: Philadelphia, PA.

• La. Charity, L. A. Kumagai, C. K. , & Bartz, B. (2011). Prioritization, delegation, and assignment Practice exercises nd for the NCLEX® examination (2 ed. ). Mosby: St. Louis. • Motacki, K. , & Burke, K. (2011). Nursing delegation and management of patient care. Mosby: St. Louis. • Oregon Secretary of State (2015). Oregon Revised Statute 678. 036 – Nurses; Nursing Home Administrators. • Oregon Secretary of State (2012, August 1). Oregon Administrative Rules Chapter 851 Division 45: Standards and Scope of Practice for the Licensed Practical Nurse and Registered Nurse. • Oregon Secretary of State (2004, February 26). Oregon Administrative Rules Chapter 851 Division 47: Standards for Community Based Care Registered Nurse Delegation. • Oregon State Board of Nursing (2016). Oregon State Board of Nursing Scope of Practice Decision Making Guideline for All Licensed Nurses. Oregon State Board of Nursing.