Registered Nurse and Licensed Practical Nurse Practice
Q. Is it within ND law/rules for the LPN or RN to: 1) determine prescribed therapeutic regimen; 2) prescribe a drug to a client; or 3) dispense a drug to a client?
A. It is not within the LPN or RN scope of practice to: 1) plan or initiate a therapeutic regimen that involves ordering or prescribing drugs, devices, etc.; 2) prescribe drugs; or 3) dispense drugs. According to NPA 43-12.1-02 (6), prescriptive practice means assessing the need for drugs, immunizing agents, or devices and writing a prescription to be filled by a licensed pharmacist. Prescribing is included in the APRN standards with authority to prescribe (NDAC 54-05-03.1); however, is not included in the LPN or RN standards. The NDBON refers to the ND Board of Pharmacy statement titled, “Administrative Guidelines for Practitioner Dispensing in ND” and the ND Board of Pharmacy law 43-15-01 and 43-15-02 and NDAC 61-04-02-01. Available at https://www.nodakpharmacy.com
Q. Is it within ND law/rules for the APRN with prescriptive authority to assign or delegate prescribing to an LPN or RN?
A. According to NDAC 54-05-02-07, the nurse professional can assign to another only those nursing interventions that are included within that nurse’s scope of practice, education, experience, and competence. Prescribing practice is not within the LPN or RN standards or scope. Additionally, NDAC 54-02-07-01.1 includes inappropriate or inconsistent assigning or delegating interventions as potential grounds for discipline.
Q. Can I work on a nursing unit in a position other than as a licensed nurse?
A. If a nurse holds licensure in ND and chooses to work in a position other than nursing, and the job description does not include use of nursing knowledge, skill, and abilities, the individual is free to do so. However, the individual could not claim those hours for nursing practice hours for purposes of maintaining eligibility for licensure.
An individual who is applying for nurse licensure in ND or who is licensed as a nurse in another jurisdiction must be authorized to practice nursing, with a permit or work authorization, when hired to a position in a nursing unit, regardless of title, which may utilize nursing knowledge, unless the individual is licensed, registered or otherwise authorized to perform the work required in that position. For example, a nurse who is registered as a certified nursing assistant may serve in the role without having a license, permit or work authorization to practice nursing (October 25, 2018 Board motion).
Q. Can I complete any orientation (including classroom instruction and reading policy and procedures) prior to receiving a nursing license, permit or work authorization?
A. No. The ND Board of Nursing reaffirmed the position in 2018, as adopted and reaffirmed in 1987 and 1998, that orientation to a position that requires a nursing license, permit, or work authorization is considered nursing practice and therefore requires that the individual be properly licensed or authorized to practice for the position to which they are being oriented.
Q. Is it within the scope of practice of the licensed nurse to fill medication boxes for their clients when they do not have face to face contact with the client?
A. Pharmacists and pharmacy technicians dispense medication for clients while nurses administer medication to clients. The board of nursing supports the use of the medication boxes (or similar name) when utilizing the six rights of medication administration. RNs and LPNs may fill medication boxes for use by clients receiving health service in the community. The nurses would be filling the medication boxes from properly labeled bottles for a specific client to which they are providing care. Unlicensed assistive personnel may not fill a medication planner. This is an intervention that would not be delegated to an Unlicensed Assistive Person.
Q. Is it within the scope of practice of the licensed nurse to give out drug samples?
A. Giving out drug samples is considered dispensing. The dispensing of medication is outside of the scope of practice of the licensed nurse.
It is within the scope of practice of the licensed nurse to hand a patient pre-packaged pharmaceutical samples with the original label and packaging intact or a medication that a physician or pharmacist has appropriately repackaged and labeled from a bulk container and following the guidelines provided:
- Establish a policy and approved procedure to include the following points:
- An order must be written by the physician for the medication and if samples are going to be utilized the nurse may obtain the medications from the location in which they are stored. A procedure for signing out the sample must be in place in the organization.
- The physician or pharmacist should label the sample medication with the dose and instructions for administration.
- The instruction must be provided by physician/pharmacist on how to take the medication.
- Once that is completed and with the necessary components to meet the requirements for the state and federal regulations for dispensing, the nurse may provide the medication to the patient. Which is termed delivery or distribute, not dispensing.
NDCC CHAPTER 43-15 PHARMACISTS, Specifically, Subsection 43-15-01. Definitions.
6. “Deliver” or “delivery” means the actual, constructive, or attempted transfer of a drug or device from one person to another, whether or not for a consideration.
8. “Dispense” or “dispensing” means the preparation and delivery of a prescription drug, pursuant to a lawful order of a practitioner or a nurse licensed under chapter 43-12.1 who is authorized by the practitioner to orally transmit the order that has been reduced to writing in the patient’s record, in a suitable container appropriately labeled for subsequent administration to or use by a patient or other individual entitled to receive the prescription drug.
9. “Distribute” means the delivery of a drug other than by dispensing or administering.
- Lastly, it is incumbent, upon the nurse to be educated and competent regarding the medication to include but not limited to indications, contraindications, and side effects, that is being delivered to the patient.
Q. What is the role and responsibility of the licensed nurse for medication reconciliation?
A. The process for reconciliation of medication is the responsibility of the prescriber. The prescriber may include a physician or an advanced practice registered nurse with prescriptive authority. It is important to remember that a licensed nurse is not authorized or approved to sign orders that must be reconciled with patient medication. Medication reconciliation is a formal process for creating the most complete and accurate list possible of a patient’s current medications and comparing the list to those in the patient record or medication orders. The purpose of reconciliation is to avoid errors that include but are not limited to transcription, omissions, duplication, dosing errors, or drug interactions.
Taking a medication history on admission has always been part of the nursing assessment, but the nurse is practicing beyond the scope of practice if she reconciles these medications without the prescriber’s signature either in the computer or in the chart. There are many variations to this new practice and nurses need to be aware of what the medication reconciliation process is and what it is not, according to the regulatory requirement of their practice.
The suggested nursing procedure for admission medication reconciliation is the following:
- Follow the policies and procedures relative to the electronic system utilized by the organization.
- Collect and verify the patient’s complete medication history.
- Clarify that the medications and dosages taken by the patient are correct and enter the information into the patient’s record.
- Notify provider of updated list.
- Licensed prescriber reviews the medications list and reconciles.
JC Chapter: National Patient Safety Goals Standard: NPSG .03.06.01 Maintain & Communicate Accurate Patient Medication. Goal 3, Improve the Safety of Using Medications.
Q. Can nurses or other non-pharmacy personnel re-label or repackage medications?
A. The re-labeling or re-packaging of medications is the sole purview of the pharmacy profession. The proper labeling, storage and cautionary information required, is the expertise of pharmacy. Registered Pharmacy Technicians can perform some of these duties, when the final product is checked by a pharmacist.
APRNs are allowed to dispense and label medications for dispensing, when serving their own patients, within their own practice. That practitioner is then solely responsible for what occurs in their office and with the dispensing to their patients. (Board of Pharmacy, July 2005).
Also refer to Procedures for Residents/Patients Going on Pass from Long-Term-Care, including Basic Care and Assisted Living Facilities
Q. Can licensed nurses renew/refill prescriptions if there are protocols?
A. In ND, the RN (registered nurse) may renew/refill a prescription without consulting the prescriber by utilizing a protocol. Only the licensed health care practitioner (HCP) with prescriptive authority has the independent legal authority to prescribe medication. A protocol may be written maintenance prescriptions intended for continuation until their next scheduled visit. For example, the registered nurse receives a refill/renewal request from the pharmacist to the clinic. The registered nurse has no contact with the client but will consult the chart, assess the client’s condition for stability and communicate the HCP’s wish for the continuation prescription, effective through the next scheduled visit.
In ND, for the LPN (practical nurse), there must be an order written for a renewal, refill, or extension of a client prescription that allows the LPN to implement that client order.
Q. What is the scope of practice for the graduate nurse?
A. The graduate nurse:
- Must practice under the supervision of a registered nurse while the “Work Authorization” to practice is valid.
- Must practice utilizing standards of practice for registered nurses or practical nurses which includes appropriate assignment of components of the nursing care plan. Therefore, assignment by the registered nurse to the graduate nurse of those skills acquired while in the nursing program is appropriate.
- Shall NOT be assigned to function in clinical leadership roles where on-unit supervision is not available.
- Shall NOT be employed in administrative positions that require licensed personnel according to the standards of the external regulating agency.
Guidelines for Employment of Graduate Nurses before Licensure
Q. Who should I contact regarding practice issues when I am a multi-state licensed North Dakota nurse practicing in a participating Compact State? Whose jurisdiction am I under?
A. When you are practicing nursing in another Compact State you must abide by the Nurse Practices Act and Rules and Regulations of that state. You are under the jurisdiction of the regulatory board in the state in which you practice nursing and should contact the appropriate state board.
Q. Can an employer require a licensed nurse to work longer than scheduled, or to work overtime? How many consecutive hours or shifts can a licensed nurse work?
A. The North Dakota Board of Nursing has no jurisdiction over work-place issues, such as schedules or number of hours worked, either consecutively, in a given time period or “on call”. These situations are examples of employer-employee or contract issues. The refusal by a nurse to work mandatory overtime does not constitute patient abandonment and is not a violation of the NPA or Rules.
The NPA and Administrative Rules do emphasize the licensed nurse’s responsibility to the client in providing safe and effective nursing care. In relation to overtime and or consecutive hours worked, each nurse must realistically evaluate his/her abilities to determine the number of hours in which he/she can safely provide nursing care. Only the individual nurse is aware of his/her physical, mental and or emotional fatigue and needs to communicate that condition to employer on a case by case basis. Nurses working too many hours may exhibit impaired judgment and inappropriate decision making.
Q. How do nurse staffing requirements differ for Critical Access Hospitals (CAHs), compared to general acute care hospitals?
A. CAHs have more flexibility regarding staffing levels for nurses. NDCC 33-07-01.1-16(2b) states “a registered nurse must provide or assign to other personnel the nursing care of each patient, including patients at a skilled nursing facility level of care in a swingbed. The care must be provided in accordance with the patient’s needs and the specialized qualification and competence of the staff available. When a registered nurse is not on duty, the nurse executive or another registered nurse designated as the nurse executive’s alternate must be on call and available within twenty minutes at all times. It there are no patients in the facility, staffing must include at least one licensed nurse with a RN on call and available within 20 minutes. As in any health care setting it is incumbent on the practitioner to function within their role and scope. NDAC Article 54-05 Standards of Practice outlines the role and scope for the RN & LPN.
Q. Can an LPN or RN work in a position that is below the level of his/her licensure?
A. There are no laws or ND Board of Nursing rules that prohibit a licensed nurse from working in a position that is below his/her licensure. For further clarification please view the Board Guidelines - Students and Licensed Nurse Practice Parameters.
Registered Nurse Practice
Q. Must an RN sign behind or "co-sign" nursing interventions performed by an LPN?
A. In general, the Board does not recommend a nurse co-sign anything unless he/she has directly witnessed an act (such as narcotic wastage) or has gone behind another nurse and personally performed the same assessment with the same findings. Also, NDAC (Rules) do not require co-signatures. You must, however follow facility policy if it requires a co-signature. As discussed in the previous question, each licensed nurse is responsible for accepting assignments that are within the educational preparation, experience, knowledge, and ability of the individual nurse. Both LPNs and RNs are required to document the nursing care they render; each is held accountable for doing it accurately and completely.
The question of an RN co-signing after an LPN most often arises in situations when an attempt is made to expand the LPNs scope of practice by holding the RN responsible for expanded tasks performed by the LPN. The RN co-signing for something that is beyond the LPNs scope of practice does not legitimize the LPNs actions. A nurse never functions "under the license" of another nurse or licensed practitioner. Therefore, if a patient requires an initial comprehensive assessment performed by an RN, the assignment may not be given to an LPN. If such an assignment is inadvertently given to an LPN, he/she is responsible for notifying the nurse who made the assignment that it is beyond the scope of practice to perform the assigned task. Each nurse has a duty to maintain client safety that includes communication with appropriate personnel.
Q. What is the role of the RN in management and/or administration of medications via epidural or intrathecal catheter routes?
A. As with all areas of nursing practice, the RN must apply the Nurse Practices Act and administrative rules to the specific practice settings. RNs and facilities should consider evidence-based practice guidelines put forth by professional specialty organizations(s):
The ND Board of Nursing endorses the Association of Women’s Health Obstetric and Neonatal Nurses (AWHONN) clinical position statement on “Role of the Registered Nurse in the Care of the Pregnant Woman Receiving Analgesia and Anesthesia by Catheter Techniques.” (1/18/18)
The ND Board of Nursing endorses the American Association of Nurse Anesthetists (AANA) Position Statement titled “Care of Patients Receiving Analgesia by Catheter Techniques” and the American Society for Pain Management Nursing (ASPMN) Position Statement titled “Registered Nurse Management and Monitoring of Analgesia by Catheter Techniques” for non-obstetrical patients. (1/18/18)
The two ND Board of Nursing Practice Statements “Role of the RN in the Management of Analgesia by Catheter Techniques for Obstetrical Patients” and “Role of the RN in the Management of Analgesia by Catheter Techniques for non-Obstetrical Clients” were retired by the Board. (1/18/18)
Licensed Practical Nurse Practice
Q. Is it within ND law/rules for the LPN to act in the role of nurse administrator of nursing services or units (ex. Director of Nursing, Nursing Supervisor)?
A. In ND, the LPN is a dependent practitioner. It is within LPN standards and scope to assign interventions to other LPNs and to delegate to UAPs, which includes monitoring and evaluating cares assigned (54-05-01-09). However, it is not within the LPN standards to supervise the practice of nursing. Supervising and acting as nurse administrator of nursing services is included in the RN standards (NDAC 54-05-02-07), as well as the APRN standards (NDAC 54-05-03.1-03.2).
Q. Can an LPN initiate/develop the nursing care plan?
A. The Board recommends you review NDAC 54-05-01 Standards for Licensed Practical Nurses. NDAC 54-05-01-08 Standards of Practice related to Licensed practical nurse scope of practice, the nursing process clarifies that the LPN participates in the development of the plan of care and modification to the ongoing nursing care plan. Only the RN may develop the initial nursing care plan and make a nursing diagnosis (NDAC Chapter 54-05-02 Standards of Practice for RNs). This difference between the LPN and RN scope of practice is based on differences in educational preparation of nurses licensed at each level as defined in the NDAC Chapter 54-03.2-06 Curriculum. View the Nurse Practices Act and Administrative Rules and Regulations
Q. Can a Licensed Practical Nurse supervise the practice of a Registered Nurse if the LPN has more years of experience in nursing?
A. No. The Licensed Practical Nurse practices under the direction of the registered nurse, advanced practice registered nurse or licensed practitioner. The LPN may monitor or supervise another LPN or unlicensed assistive person and report to an RN, APRN or licensed practitioner. Registered nursing practice constitutes a higher level of education, knowledge and skill than does the licensed practical nursing practice.
Q. Can LPNs participate in health teaching of clients and their families?
A. Yes. The Board interprets NDAC 54-05-01-08 (10): Health teaching of clients and their families may be implemented by the LPN utilizing an established teaching plan/protocol as assigned by the RN, APRN, or Licensed Practitioner. The LPN is participating in health teaching to promote, attain, and maintain the optimum health level of clients.