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. No. It is not within the LPN or RN scope of practice to:
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 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: As a nurse, can I be employed in non-nursing positions?
A: A licensed nurse in ND may choose to work in a non-nursing position in which the job description does not include use of nursing knowledge, skills, and abilities. However, the individual could not claim those hours as nursing practice hours for purposes of licensure renewal.
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 temporary permit or work authorization, when hired to a position which requires nursing knowledge in a nursing unit, regardless of title. If the individual is licensed, registered, or otherwise authorized to perform the work required in that position they may do so (for example, a nurse who is also registered as a certified nursing assistant may serve in that role without having a license, permit or work authorization to practice nursing) (Initial 1996, Reaffirmed 2018, 2022).
Q: Am I allowed to complete orientation prior to obtaining my nursing license, permit, or work authorization?
A: 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 (Initial 1987, Reaffirmed 1998 and 2018 motion).
The Board temporarily approved allowing nurses to participate in general non-nursing facility orientation at the October 28, 2021, meeting in response to the extreme nurse staffing shortage and requests from state stakeholders. The Board extended temporary approval of the allowance through October 2022 when it will be reviewed. The Board reaffirmed (October 2018) that any nursing-specific orientation for a nursing position was considered practice.
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 NDBON 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. Nurses should fill medication boxes from properly labeled bottles for a specific client to which they are providing care. Unlicensed assistive personnel (UAP) may not fill a medication planner. This is an intervention that cannot be delegated to an UAP.
Q. Is it within the scope of practice of the licensed nurse to give out drug samples?
A. No. 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. The nurse should follow the organizational policy while maintaining scope of practice related to this:
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.
Q. What is the role and responsibility of the licensed nurse in medication reconciliation?
A. The prescriber is responsible for the process of medication reconciliation. A prescriber may be a physician, physician assistant, or an APRN with prescriptive authority. A licensed nurse is not authorized or approved to sign medication orders that have not been reconciled by the prescriber with the patient. Medication reconciliation is a formal process that creates a complete and accurate list of the patient’s current medications and compares 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.
Nursing assessment has always included taking a medication history, but the nurse is practicing beyond their scope of practice if they reconcile these medications without the prescriber’s signature in the chart.
There can be many variations to this procedure and nurses need to be aware of the medication reconciliation process in their organization and what is within the regulatory requirements of their practice.
The suggested nursing procedure for medication reconciliation follows:
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 pharmacy profession is solely responsible to relabel or repackage medications. Pharmacy expertise is required for the proper labeling, storage and cautionary information required.
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 may renew/refill a prescription without consulting the prescriber when 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 for maintenance prescriptions intended for continuation until the patient’s next scheduled visit. For example, the RN receives a refill/renewal request from the pharmacist to the clinic. The RN 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.
The LPN in ND must follow a specific order written for a renewal, refill, or extension of a client prescription. It is not within the LPN scope of practice to follow a protocol.
Q: Can I employ graduate nurses?
A. Graduates of nursing education programs who receive a work authorization for license by examination from the Board may work as a graduate nurse until they pass the licensure exam and are licensed or fail the exam. If the employer chooses to retain a graduate nurse employee in a UAP/CNA role they may do so.
Q. What is the scope of practice for the graduate nurse?
A. The graduate nurse:
The Guidelines for Employment of Graduate Nurses before Licensure can be accessed in their entirety on the board’s web site at: Guidelines for Employment of Graduate Nurses before Licensure - ND Board of Nursing (ndbon.org)
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 matters, 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 concerns. A nurse’s refusal 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 their abilities to determine the number of hours in which they can safely provide nursing care. Only the individual nurse is aware of their physical, mental and/or emotional fatigue and needs to communicate that condition to their employer as needed. Nurses working extended or 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 swing bed. 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 always on call and available within twenty minutes. If 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.”
It is incumbent on the nurse to function within their role and scope in any health care setting. NDAC Article 54-05 Standards of Practice outlines the role and scope for the RN & LPN and are available on the website at www.ndbon.org then click on administrative rules and regulations. The NDBON has approved the RN-LPN Scope of Practice Comparison Chart which can be found at the following link: RN-LPN Scope of Practice Comparison - ND Board of Nursing (ndbon.org)
Q: May I, as a nurse, assume an employment role below my level of licensure?
A. A job description for the licensed nurse may be as broad as the scope of practice allowed in NDCC 43-12.1 Nurse Practices Act and NDAC Standards or narrower. The employer develops a job description and establishes the minimum qualifications necessary to perform the job, and the responsibilities and accountability for the job.
The Registered Nurse (RN) and Licensed Practical Nurse (LPN) have the competencies necessary to perform Unlicensed Assistive Personnel (UAP) interventions. If the minimum qualification for a job is a LPN, the RN is licensed to perform those interventions. It is an employer and employee decision whether the licensed nurse will perform interventions below licensure level and be paid the wages associated with the respective job description.
Licensed nurses are employed for different job descriptions, often within the same institution. The nurse, employer, and support staff must be clear about the minimum qualifications required for each job description. The RN and the LPN are accountable for their respective scope of practice even if practicing in a position below their licensure level. The licensed nurse uses their legal licensure credential (LPN or RN) when signing records. The licensed nurse may claim hours of nursing practice worked below scope to maintain eligibility for licensure renewal. A nurse with a suspended or revoked license cannot practice as a nurse, UAP or certified nurse aide while under suspension or revocation.
The Board’s responsibility is to assure public protection through regulation of standards for practice. The employer establishes the minimal qualifications for each job description and hires persons who meet or exceed the minimal requirements to fill the position. (Initial 1987; Reaffirmed 2018, 2022)
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 they have directly witnessed an act, such as narcotic wastage. The ND Century Code and Administrative Code do not require co-signatures. A nurse must, however, follow facility policy if it requires a co-signature. Each licensed nurse is responsible for accepting assignments that are within their educational preparation, experience, knowledge, and ability. Both LPNs and RNs are required to document the nursing care they render; each is held accountable for doing it accurately, timely, and completely.
The RN co-signing for something that is beyond the LPN’s scope of practice does not legitimize the LPN’s 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, they are responsible for notifying the individual who made the assignment that it is beyond their 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 setting. RNs and facilities should consider evidence-based practice guidelines put forth by professional specialty organization(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)
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, or Nurse Manager)?
A. The LPN is a dependent practitioner in North Dakota. 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). LPNs can assign and delegate to other LPNs and UAPs; they cannot organize, manage, or supervise the practice of nursing. The NDBON has approved the RN-LPN Scope of Practice Comparison Chart which can be found at the following link: RN-LPN Scope of Practice Comparison - ND Board of Nursing (ndbon.org)
Q. Can an LPN initiate/develop the nursing care plan?
A. The Board recommends review of 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. The Nurse Practices Act and Administrative Rules and Regulations may be accessed in its entirety at www.ndbon.org under the Law/Rules tab.
Q. Can a LPN supervise the practice of a RN if the LPN has more years of experience in nursing?
A. No. The LPN practices under the direction of the RN, APRN or licensed practitioner. The LPN may monitor or supervise another LPN or unlicensed assistive person and report to an RN, APRN or licensed practitioner. RN practice is the result of a higher level of education, knowledge, and skill than the LPN practice. The NDBON has approved the RN-LPN Scope of Practice Comparison Chart which can be found at the following link: RN-LPN Scope of Practice Comparison - ND Board of Nursing (ndbon.org)
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.