The State of Wellness
The State of Wellness
The Oregon Nurse Practice Act: Key Takeaways for Everyday Practice
What is the Oregon Nurse Practice Act? Discover the essential rules and regulations that govern nursing practice in Oregon with our special guest, Dr. Sarah Wickenhagen, from the Oregon State Board of Nursing (OSBN). In this episode, we unpack the parameters that LPNs, RNs, and APRNs work within, plus the critical decision-making processes that nurses must master, especially in ambiguous situations.
The State of Wellness podcast is hosted by the Oregon Center for Nursing, the state's nonprofit nursing workforce center. Learn more at oregoncenterfornursing.org.
Welcome to the State of Wellness podcast, because nurses need a trusted place to share, collaborate and talk about what matters most to the Oregon nursing community and profession as a whole, Brought to you by the nonprofit Oregon Center for Nursing. Now here's your host, Janna Bitton, Executive Director for OCN.
Speaker 2:All right. Well, hello everyone and welcome to yet another fabulous episode of the State of Wellness. This is our podcast for Oregon nurses, brought to you by the Oregon Center for Nursing. My name is Jana Bitton. I'm the executive director for OCN. I'm going to be your host today, showing you around, showing you a little bit of the ropes, helping you learn a little bit more, doing a deep dive on the state of nursing in Oregon With me today. I'm excited to welcome back friend of the podcast, friend of the show, friend of OCN, dr Sarah Wickenhagen from the State Board of Nursing. Welcome. Thanks for being here. Yeah, pleasure. We keep bringing her back because it's so much fun.
Speaker 2:In the previous times that you've been here, we've talked a lot about the Board of Nursing. This is one of those things where everybody's like, oh, I already know about that. You dig a little deeper and you realize, nah, you don't know that much about it and that would be Oregon's nurse practice act. So let's, let's kind of like jump right in there. What the heck is Oregon's nurse practice act? This is for the people who, who absolutely have no idea, not the people who've been to nursing school and they did study it in nursing school. What is what's an Oregon nurse practice act? Why do we have that?
Speaker 3:Sure. So I'll just speak to Oregon initially and then I'll go out further. But in our state we have rules and regulation about the practice of nursing and we qualify that as a certain chapter out of the Oregon Constitution, or Oregon regulatory statute as some people call it. That is chapter six, seven, eight. It's super easy for me to remember. I'm really grateful that it's six, seven, eight. That is our little piece of Oregon regulatory statute that has to do with nursing and there are some specifics that are at that state level that say there's going to be a nursing board and you have to pass the test of some kind and these are the different types of nurses that we have in our state and these are the different types of licenses, and then from that you have the opportunity to write rule and that's what the nurse practice is. So that's where the Board of Nursing has its staff who work together with stakeholders, nurses in those areas, on a rules advisory committee, which we'll hopefully talk about. We're going to get to that, okay, we're going to get there.
Speaker 2:That's question three, but we might bump that up because they're already spoiler alert.
Speaker 3:Yeah, Go ahead, wow. So where we work together, uh, with the people that are involved in that particular area, because that's who should be involved in the that, that language writing, and people that are aware of you know current standards of practice, what federal laws are, what state laws are, because sometimes there are some connecting areas and we get those people around the table and we put pen to paper and we have those parameters and so that's sort of your I say your left and your right boundary of those particulars. So, for instance, we have several chapters of the Nurse Practice Act. Some of them have to do with the fees that you pay. Some of them have to do with the definitions that we have in the Nurse Practice Act. Certain chapters have to do with getting your license.
Speaker 2:Um, certain chapters- have to do with getting your license.
Speaker 3:There is a division 31 has to do with LPN and RN licensure. Then there's a chapter 21, which has to do with education, so all the different rules and regulations in the state around nurse education. So I could go on and on. There's there's lots of different chapters, but that's sort of the general spot. I guess I would be remiss if I didn't mention Division 45, which is around nursing practice for LPNs and RNs. And it also actually applies to advanced practice nurses as well and oftentimes that gets forgotten because there are other chapters that talk about advanced practice nursing.
Speaker 3:But all of us nurses in this state are held accountable to the parameters and setting in division 45. And again that has to do with nursing practice. So that's sort of a general sketch. Each state's a little bit different with their Nurse Practice Act. Some states don't have a Nurse Practice Act. Sometimes they fall under the Board of Medicine or a different health regulatory agency. But in Oregon we enjoy having our own board and having our own rules and having nurses sit on our board. So we're really lucky in our state to have that.
Speaker 2:Not every state has that this brings up an interesting question, because I'm going to guess that the human body is not different from one state to the next and yet it sounds like we have laws that are different, like this is basically the Nurse Practice Act is a law that we have to follow. So if, why is it? Why is it different? Why do some states have Nurse Practice Acts, some states don't? Why is it? Why is it different? And why did Oregon go the route of the Nurse Practice Act?
Speaker 3:And why did Oregon go the route of the Nurse Practice Act? So it all is a state's rights issue. So if you look at other types of rules and regulations that other states have, a lot of it has to do with politics, a lot of it has to do with how that state was set up at that time and who the governor was, who was in their legislature, and so there are some very specific parameters that we speak to here in Oregon that would potentially be very different in other states. And on that same vein, in Oregon we enjoy a large scope of practice, so we have a lot of ability to work at the highest level. So, for instance, I'm always thinking about advanced practice nursing because I'm one myself, but we can practice independently here.
Speaker 3:And if you go to other states in the country for instance, I was on a phone call this morning with the great state of Alabama, for instance I was on a phone call this morning with the great state of Alabama and they were talking about how they have to have a physician who supervises their practice. They have to have a practice agreement and there are very specific parameters that only they can do in that state. And that is also the case with other levels of licensure in other states, and that's also the case when it comes to other types of laws. I'm sure everyone's been paying attention to the news and so there are which news? I would say? The national news about how, in this past legislative session, in different states they've had the same issue come before them, but they've come up with different parameters about how their state is going to operate based on a certain topic.
Speaker 2:All right. Well, let's go back to the spoiler alert that you gave before, which is a rules advisory committee or a RAC R-A-C a RAC. So what does the rules advisory committee do in relation to the Nurse Practice Act?
Speaker 3:I believe the state acted wisely and recommended that the health licensing agencies and these other agencies of the state. When it comes to writing rules, it's of a tremendous benefit to have certain people sitting around the table who can give input before it's adopted, and you always want to have the right people at the table. So, for instance, we just did a rules advisory committee on division 47, which has to do with community-based care and delegation, and so we wanted people that had that expert set of eyes, and those experts were nurses. Those experts were school nurses, were nurses. Those experts were school nurses, they were employers, they were schools, and so there was a lot of different people that needed to be there and think about.
Speaker 3:Well, don't forget about this, in school nursing, we have this particular situation where we're not there for three months of the summer, so is this particular part of the rule going to apply to us? Is it going to work for us? For instance, there's a situation in hospice that has this requirement that's also a federal requirement. Is this also going to work for that? So it's important to have the right people at the table when you go down this path to make sure that we incorporate it.
Speaker 3:It's not a requirement, but it's highly advised and I have been in this job for a while and I've done rules without a rules advisory committee and I've done them with, and I definitely think it's been a tremendous benefit to do them with you sort of work out the kinks that could potentially be there. You have a good opportunity to get good education and information out to folks, and so, because those stakeholders are partnering with you right, they're helping direct the path. They also understand, though, that at the end of the day, it's the board that makes the final decision right. This is advisory information and opinion and data that we're looking at, but at the end of the day, it's the board that makes the deciding vote, and it has to go through the rulemaking process, and there are there are a few steps in that as well, but that's sort of my breakdown on the rules advisory committee it.
Speaker 2:It does make sense, like I was. I was just at a meeting recently where they were saying isn't it crazy how there are so many people that want to pass legislation related to nurses and they don't ask nurses if that's going to work for them? I mean, it's it's 2023 and that's happening all the time right now. So it is a little bit like okay, good At least at the board of nursing.
Speaker 2:They're asking nurses like this is going to directly affect you. It gives you an opportunity to to have your say when you go around the state and do the job and the work that you do. What is your? What are the most common questions that you get from people about the Nurse Practice Act?
Speaker 3:I mentioned, I think, on another podcast that we have a Dear Abby of sorts where folks can ask us questions on a regular basis, and a lot of those questions are around scope of practice. So I'm in this situation and I want to know can I do this or not?
Speaker 3:I would like to say that it's intuitive, but always my answer is basically well, it depends, because the nurse practice act is a living document, right, and we can't have everything in the nurse practice Act that a nurse can or cannot do. We don't have a list in there that says an RN can do only this, an LPN can do only this, a CRNA can do this. We don't do that.
Speaker 3:Yeah, we speak to general generalities and you want us to trust me, because when we start getting very specific, then that paints people into again that corner right which I talked about with division 47, we want it to be broad enough to give you sort of the left and right boundary, but we also want you to have the opportunity to make those decisions in the context of care or the environment of care or the setting that you're working in Exactly. We try to also point people to the scope of practice decision-making tree, so we'll provide that link to you all. But it basically walks you through. Is there a federal law against this? Is there a state law against this? Do you feel like you have the knowledge, skills and ability to perform such a task? So, for instance, I had someone asked me this the other day and so I'll just I'll put it out here. I had a nurse practitioner ask me if they could perform liposuction and the answer is it depends.
Speaker 3:It depends Some of the things that we talk about in that decision tree and then also in the advice that I gave this person is it's complicated because in that particular case we have different boards that have regulatory authority in this case. So if it's considered cosmetics, that's the aesthetic board, right Right? If it's considered surgery, that's the board of medicine. If you're considering giving anesthesia in an outpatient setting, then that has to do with the Oregon Health Authority. So already we've crossed all these places that it isn't easy to say whether or not you can or cannot do that. And then sort of, for me you can go through the whole, the whole decision tree and for me, it's the gut check.
Speaker 3:Right, right, it's the. Are the hairs on the back of my neck standing up and do? I feel like I should do this? And for me, I'm going to tell you right now I have zero desire to do liposuction. So this nurse practitioner might be the most skilled nurse practitioner I've ever heard of in an organ. That's incredibly possible right.
Speaker 3:They may have all the parameters for this practice to occur that meet all those requirements, that they're set up for anesthesia, that they're doing it in a surgery center, that there's a collaborating person that's performing the procedure, but they're the clinic manager who knows Like there could be parameters where this could be a time and place that it could occur. But then I also take pause with and this is what I told the nurse practitioner sort of at the end of the day, and my bottom line is if something goes sideways and something occurs, are you ready to be responsible for this, for that patient's life, for the results If this does go wrong? Do you know? Do you have a plan of action? Do you have malpractice? You know how many other nurse practitioners are doing liposuction? I don't know very many, yeah, so I take pause with that, right? So I also said you know I need you to use your own head to do some critical thinking about whether or not this is something that you want to consider.
Speaker 2:So the questions that you get sometimes like, seriously, as you're talking about this, I'm starting to imagine that OSBN could get some swag going, where there are little pins that you could put on your lanyard and one could say it depends, and the other one says it's complicated and anytime somebody asks you a question you could be like, oh, you get the it depends question Not so I yes, no, there's not a lot of yes no's in there, but there are some.
Speaker 2:it depends and it's complicated, but I digress. Um, when people ask you questions, it sounds like the answers are never really cut and dry, like even though we have this document that really is trying to quantify how we are going to make sure that nurses practice safely and that the people who live in Oregon can count on nurses are going to be trained in a certain way so that they can they can be, they can provide really high quality care, it still seems like when you get questions about it, it's it's. It's never a cut and dry answer. Why do you think that is?
Speaker 3:Well, because I think there's so many players right, there's so many people at the table. So, for instance, things that I didn't say that are also part of that scope tree are who do you work for, right? So your employer may have you know policies and procedures in place that disallow X that only are. We're not going to do that. Or you may or may not be credentialed with a insurer that will pay for that. So, again, there are all these other factors that come into consideration, but I will say, when I can say yes or no, I do, and I say, based on my years of experience, or based on this being a very well-known issue, that this is something that, uh, has been well vetted and is easily understood, that, um, you know, an RN can delegate this you know so, or you can have standing orders, absolutely.
Speaker 3:If you would like an example of best practice, look here. So when I can point someone to those things, I most certainly do, and I do with due diligence, as long as and also the rest of the other policy analysts on the team, I think that we all try very hard to give them a direct answer if we can. But scope of practice is probably the number one thing. Sometimes we'll get ethical dilemmas where people just they just want advice, and you know, sometimes we'll then. Or they'll want business advice right, they want, they want to. They're an RN and they want to open up their own shingle and do some type of practice, and so we a lot of times we'll wrap them to the right information source.
Speaker 3:So sometimes it isn't the board of nursing, sometimes it's the Oregon Nurses Association or sometimes it's a different board board. So when we can put them in touch with the right people, we do that. You know, again, we we sort of have this debate every day at at the board about what explicitly needs to be here and I kind of think of it like the syllabus, you know, like a syllabus in like a class or something exactly like, like it's. It's your syllabus. It's not going to have everything in there, um, but if there are things that are explicitly prohibited, it'll be there.
Speaker 2:That's going to be in there.
Speaker 2:So that kind of brings me back to the last time we talked, when we were talking about discipline, because I think that there are a lot of people that are under the impression we can, kind of we can, we can revisit this, that there are a lot of people that are under the impression we can, kind of we can revisit this, but there's a lot of people that are under the impression that if they cannot live up to the letter of the law that is contained within the Nurse Practice Act, they're going to be subject to some kind of a complaint. And I think, as we learned last time, that depends and it's not necessarily the case, and it certainly isn't the case that that's going to happen as often as people think it is. But it seems like when the Nurse Practice Act is also synonymous with discipline. Can you talk about that a little?
Speaker 3:bit Sure. So I one time at a conference sort of explained this as how when people swim in the ocean, they're always afraid of getting bit by a shark. Yeah, right, but how many people actually get shark bites? Right? Not very many. It's sort of like that. And so to me I think I ended the last time I said it with please keep swimming are danger points.
Speaker 3:There are things that can be complicated and can get a nurse into trouble, and so in those situations we want again sort of that nurse to use those the critical thinking and good decision-making and consider all the things and not be in a rush to do something Right. So take pause again. It sounds silly, but like, are the hairs on the back of your neck standing up? Yeah, you have a gut. Check on this. Do you feel like this is something you've done a hundred times and you know how to do it and you feel good about doing it? Or is this the first time you're doing something and you're doing it with a different person and maybe you don't have all the things that you're used to doing? Then you probably shouldn't do it.
Speaker 3:Yeah, right, um, and so those are sort of again the critical thinking, the judgment, um the thought process that we want nurses to develop in in school, in practicum, um as they work, um wherever they work for a few years and they become experts in those areas, right, and if you're not an expert in an area and it's not something that you've done before or was part of your education, take pause, because that may be something you shouldn't do, yeah, and so I think that's where we see people fall down. I will also say, you know, there's just some interesting data out there too, that you know. A lot of times it isn't new nurses that get into trouble, it's not new nurses.
Speaker 2:That actually was bringing me to something that I was just like what? What happens when you're a nurse and your employer who? Who doesn't know anything about the Nurse Practice Act? They employ nurses but they haven't. Necessarily you can't guarantee that they've read the Nurse Practice Act, and they certainly didn't have an entire semester going over the Nurse Practice Act when they were in nursing school but they ask you to do something that violates the Nurse Practice Act. What happens then?
Speaker 3:Well, that's where that nurse needs to say we're going to have to take a pause here. That isn't something that I'm able to do, and I can't accept any assignment that I'm not prepared to.
Speaker 2:Can the nurse recommend the employer call the Board of Nursing to verify that that's a violation, or are you more of like? I mean, that seems like more than a dear Abby kind of, a kind of a question, or maybe it is, I don't know.
Speaker 3:Well, I had something like that recently actually, where it had to do with like the triage process and there was a nurse who felt uncomfortable in a triage situation with how much information she was giving a client before they actually became a client.
Speaker 1:So, right.
Speaker 3:They were just like at the beginning of whatever medical procedure they were going to have or how they were connected with this particular clinic. And so she was saying I know better that I should also be saying X, y and Z, but my employer told me A, b and C, and so I don't like it, help me, right? So then I wrote back to this person and said thank you for the courage to write us and to reach out to us. You're right. Once you have a relationship with a patient, you've established this hierarchy that you are the nurse. You're responsible at the full level to give them the greatest care that you can give them. You can't give anyone halfway care because they haven't seen a doctor yet. That's not how it works, right? So, um. So I explained it that way, um, and then she was like great thanks. And then that person's manager wrote me and said hey, I got your email from Jane Doe, help me understand this. And so that was great, right? Well, I can say no problem.
Speaker 3:Again, I want to emphasize that we only have control over individual nursing in the state. We don't have influence over employee settings. But my recommendation in the future would be this and also to obviously look at existing literature, look at other health systems that do triage all the time. You know there have been books written on this. You don't need to reinvent the wheel here. You know there's nurse call lines, there's all kinds of things that I think will help you all out, and so that's a. That's a win right, that's a success story out.
Speaker 2:And so that's a that's a win, right? That's a success story. I hope that answered your question. No, that does. What I was I was thinking is that the story, just that story just also reminds me of that.
Speaker 2:Nurses are not necessarily out on their own. If they're in a situation where they're in an employer, there was an employer and this is because of the Nurse Practice Act. Right, the Nurse Practice Act is because the Board of Nursing is in charge of individual nurses and their individual practice and the Nurse Practice Act defines that in such a way so that individual nurse that gives them some ability to be able to push back to an employer that might have a policy or some kind of a procedure that's going to go against the nurse practice act, because then they're asking the nurse, the individual nurse, to violate her, his license, and then that's. Then you get in and you know, then go back to the other episode that we did about discipline and then all of a sudden you episode that we did about discipline and then all of a sudden you get into that whole cycle.
Speaker 2:So I don't know, I guess that's one thing that I do want to make sure that is known is that nurses aren't an island in and of themselves when you don't get your license, and then you're completely an island. And if you're feeling like you're an island, that's time to get connected into the nursing community. That's the hairs on the back of your neck needing to start popping up, because if you feel like an island and you feel like you're being asked to do something that you're not comfortable doing, you have no one to talk. To get connected into the community and I don't know. That's just kind of what I was thinking.
Speaker 3:Absolutely. I think that that is a great way of explaining it, and I have also said something similar to like phone a friend. Nursing relationships are really important, so I still, today, talk to people that were in my nurse practitioner class. I have students who reach out to me, you know, via text hey, I have this interesting patient. What do you think? You know, colleagues, all the time I'm going to bounce this off of you, as we all do in different roles outside of nursing, right? So, yeah, we're all here for each other and we don't ever want to put someone in a position where they feel like they're cornered and they have to do something. Right, that's scary and not what anyone wants, and so we want there to be resources, we want people to take time and to be thoughtful before patient harm occurs. Right, right, exactly. We want good news stories.
Speaker 2:Exactly as I have learned, 100% of all nurses in the state of Oregon are human beings and because of that they have, you know, you need to be able to connect with each other, um, and you're not completely out there on your own. And well, that was one thing that I was thinking too, is that the nurse practice act. Is that part of the reason why it's not? It's not so prescriptive, it's not quite, it's not so detailed, because then, all of a sudden, you are going to feel you are going to be an Island in and of yourself, and we don't want that. We want you to be able to use all the human judgment and the human you know, self-reflection, and and and critical thinking, and all the things that you have, so that you can be an amazing nurse. All right, well, any last words, dr Sarah Wickenhagen.
Speaker 3:I don't think so. I've just really enjoyed the opportunity and just again want to say uh, I'm your friend that you can phone, so don't hesitate to reach out to me.
Speaker 2:We're all going to be. Yeah, it's going to be. You want to be a millionaire? Yeah, well, thank you. I really appreciate you being here again. I appreciate you talking to us again. Um, that is really it for today. So, dr Wiggenhagen, thank you for being here again. I appreciate you talking to us again. That is really it for today. So, dr Wickenhagen, thank you for being here. Thank you for helping us understand a little bit more about the Nurse Practice Act. And if you want to get more information about the Nurse Practice Act, we're going to have some links in the show notes. We'll have another link to that Dear Abby email that you can reach out to.
Speaker 2:If you want to do a question, you can do an anonymous question. You don't have to identify yourself, or you can identify yourself. It's all good, whatever works for you, I think I it sounds to me like there's just people here that are available to answer your questions. So you have been listening to yet another amazing episode of the state of wellness. This is our podcast for Oregon nurses. Don't forget to subscribe wherever you get your favorite podcasts so that you can find out when our next one is and you can find all the notes, all these show notes. You can find them at our website at Oregon center for nursingorg Also, if you have a really fabulous idea a great idea for another podcast.
Speaker 2:we want to hear about it. So you know, drop us a note. We like to hear from people, we like to be connected into the nursing community so that we're not quite an island either. And until next time, stay well.
Speaker 1:Thank you for joining us on the State of Wellness podcast, and if you need more information, show notes, past episodes or resources, go to OregonCenterForNursingorg and subscribe wherever you listen to your favorite podcasts so you never miss a future episode.