NEBRASKA BOARD OF

FEATURE STORYcontinued from p.7Evaluation of the delegation planincludes obtaining feedback fromthe delegate, measuring the client/patient response and goal attainmentrelated to the delegated task, andaltering the delegation plan, basedon the client/patient response. TheRN is ultimately accountable forthe outcome of nursing care, whichincludes evaluation of care providedby others, such as via nursingdelegation.Implementing the Delegation PlanExample 1Mr. Brown is a 76-year-old male,2 days post-stroke. He has left sidedweakness, swallowing difficulties andsome cognitive impairment.Right person: Nurse Aide Smith isa 25-year-old who has worked on thissub-acute unit for 1 year, and is familiarwith the stroke population.Plan: assist in feeding stroke patientat meal timesNurse Leaders Start Here.Online. Accredited. RN to BSN.With the right degree, there’s no limitto what you can accomplish.If you’re looking to make major changes in healthcare, you needa degree that meets today’s industry standards and prepares youto adapt as those standards evolve. Request information aboutBellevue University’s online, accredited RN to BSN today.Visit bellevue.edu or call 800-756-7920 to get started.The baccalaureate degree program in nursing at Bellevue University is accredited by the Commission on Collegiate Nursing Education, 655 KStreet, NW, Suite 750, Washington, DC 20001, 202-887-6791. A private, non-profit institution founded in 1966, Bellevue University is accredited byThe Higher Learning Commission (hlcommission.org), a regional accreditation agency recognized by the U.S. Department of Education.8 NEBRASKA NURSING NEWSInstruction: Mr. Brown has rightsided weakness and has to take smallbites, followed by sips of thickenedliquids. Please watch for signs ofchoking (coughing or gagging), foodpocketing, and allow extra time. Pleasereport any feeding difficulties as well asamount of food consumed and fluidsingested.Competency: Nurse Aide Smithvoices competency in feeding a patientsuch as Mr. Brown and asks questionsspecific to Mr. BrownSupervision: RN remains on unitover lunch time to be available toNurse Aide Smith as needed (direct).Evaluation: RN discusses task,post-feeding with Nurse Aide Smith.He indicates that Mr. Brown ate veryslowly, with some pocketing of food,and needed much encouragement.His intake was 75% of his tray and100% of thickened liquids provided.Provided oral cares after feedingcomplete. RN assessment of thepatient indicates clear lung sounds,active bowel sounds, and patientresting comfortably.Example 2Mrs. Jones is a 77-year-old female,5 days post AP resection for coloncancer with a permanent colostomy.She was moved to the sub-acute unitfor pain control. She needs help withself-care of her ostomy as well.Right person: Nurse Aide Peters isa 20-year-old, just off of her six weekorientation.Plan: develop patient’s self-care ofcolostomyInstruction: Mrs. Jones has apermanent colostomy from her surgery5 days ago. Have you ever cared for acolostomy? (no) My goal is for her tobecome independent in her colostomycare, but she is still having some pain.Let’s plan to work with her together,so I can show you how to empty thepouch, while evaluating how muchMrs. Jones knows and will do forherself.Supervision: (direct) RN engagesaide and patient in emptyingpouch which as determined to be a

become complex. Mrs. Jonesrefusal to participate in theemptying of the colostomy pouchrequired further evaluation andmodification of the plan of care bythe nurse.noncomplex nursing intervention;teaching about when and howto empty. Patient is refusingto do self-care; so aide returndemonstrates and encouragespatient on next pouch emptyingopportunity with patient.Evaluation: teaching bothpatient and nurse aide togetherallows for each to encourage theother in a new skill, with theRN taking accountability for thelearning/performance of both.ACTIVITIES WHICHCANNOT BEDELEGATEDEvaluating the Delegation PlanIn the preceding example Mrs. Jones reliance on the RN forassessment and management ofpostoperative pain was a complexnursing intervention. Nurse AidePeters provided the patient withbath assistance, postoperativeambulation and was effectivelydirected to assist the patient withemptying the colostomy pouch—all noncomplex interventions.Noncomplex interventions canThe four thingswhich can neverbe delegated areassessment, planning,evaluation and nursingjudgment.The four things which cannever be delegated are assessment,planning, evaluation and nursingjudgment. Nursing serviceadministrators must identifyselected interventions through anorganizational description of anursing service delivery model oremployer guidelines.In summary, most delegationplans are not in print, but secondnature to the RN in practice.This article is intended to provideclarity to the many misconceptionsabout appropriate RN delegationin Nebraska.snigeberutufruoYwith whyAt Nebraska Methodist College, healthcare is ourpassion and expertise. Our online study options helpyou prepare for what's next in your career with anMBA in Healthcare, MSN, DNP and many more.Tell us your why. We'll show you how.402.354.7200Blake S., graduate studentSee his why at ASKA NURSING NEWS 9

Results from the 2017 LPN Renewal SurveyBy Juan-Paulo Ramírez, Ph.D.IntroductionA total of 5,671 surveys were received by the Nebraska DHHS Licensure Unit during the 2017 LPN Renewal process(online surveys: 96%; paper surveys: 4%). The survey contains 28 questions that cover demographics, education level, worksituation, work setting, geography, salary, nursing practice positions, and satisfaction levels with the profession. The setof questions is in accordance with the standardized minimum dataset developed by the National Forum of State NursingWorkforce Centers and the National Council of State Boards of Nursing (NCSBN). From the total number of surveysreceived, 5,004 LPNs (88%) indicated that their primary employer was located in Nebraska. The following are key findingsof the survey.Figure 1: Urban and Rural Counties where LPNs WorkGeographic distributionThree-fourths of LPNs work in urban areas (77.0%) and one-fourth work in rural areas (23.0%). Figure 1. Similar geographicdistributions are found at the national level (U.S. DHHS, 2013).Eight counties (Douglas, Lancaster, Hall, Madison, Buffalo, Sarpy, Scottsbluff, and Gage) concentrate 60% of all LPNsworking in Nebraska. Three out of ten LPNs working in rural areas travel more than 20 miles (one-way) to their work places.In comparison, only two out of 10 LPNs travel the same distance in urban areas.10 NEBRASKA NURSING NEWS

DemographicsPer capita LPN workforce: There are 260 LPNs per 100,000 residents in Nebraska, which is higher than the national rate(225 LPNs per capita). Geographic differences were found when comparing rural vs. urban LPNs per capita: Rural areas havea higher supply of LPNs than urban areas (303 vs. 250 LPNs per capita, respectively). See Figure 2. Counties with the highestLPN per 100,000 people in Nebraska are: Boone (841), Fillmore (788), Hooker (742), and Garden (735). Counties with thelowest number of LPN per 100,000 people are: Sarpy (96), Frontier (38), and Dakota (30). Twelve counties do not have apresence of LPNs.Figure 2: LPNs per 100,000 Residents in Urban and Rural AreasAge: The average age of LPNs in Nebraska is 46.1 yearsold (median 46), which is higher than the nationalaverage of 43.6 years of age. One-third of the LPNworkforce are baby-boomers (currently 54 years and older).See Figure 3. LPNs working in rural areas are on averageone and a half years older than LPNs working in urbanareas. On average, LPNs are four years older than 10 yearsago. A similar trend has occurred at the national level.Gender: In Nebraska, 3.2% of LPNs identifiedthemselves as male and 96.8% as female, which showsan increment of 0.1% in male nursing participation incomparison to the 2015 LPN nursing workforce. At thenational level, 7.6% of LPNs are male.Figure 3: Distribution of Nebraska Licensed Practical Nurses by AgeRace/ethnicity: Nearly 90% of LPNs are White, followed by African American/Black (5.2%), and Hispanics (3.9%).Overall, 11.7% of the Nebraska LPN workforce is a minority, which is 1.1% higher when compared to the 2015 LPN nursingworkforce. See Figure 4. At the national level, race/ethnicity is more diverse, where over one-third of LPNs are a minority(36.8%).continued on page 12NEBRASKA NURSING NEWS 11

Figure 4: Distribution of Nebraska LPNs by Racial/Ethnic Backgroundcontinued from p.11Settings, positions and specialties: NursingHome/Extended Care is the major employerof LPNs with 33.9% of LPNs, followed by“Ambulatory Care Setting (Clinic)” (23.2%),“Hospital” (10.7%), “Other” (10.3%), “HomeHealth” (5.6%), and “Assisted Living Facility”(4.9%). See Figure 5. At the national level, nearly30% of LPNs work in hospitals.In Nebraska, a higher proportion of LPNswork in hospitals in rural areas than LPNs inurban areas (18.2% vs. 8.9%, respectively).In terms of positions held, eight out of tenLPNs work as a “Staff Nurse,” followed by“Nurse Manager” (6.9%). In terms of specialties,over one-third of LPNs work in “Geriatric/Gerontology” (32.1%), with noticeable differencesby geographic location (46.4% of rural LPNs, vs. Figure 5: Nebraska LPN Work Settings27.9% of urban LPNs).Satisfaction Levels: A high proportion ofLPNs report that they are “Very Satisfied” or“Somewhat Satisfied” with their nursing career(97.6%), and only 2.4% indicated that they arenot satisfied with their profession. See Figure 6.Nebraska Veterans’HomesRN & LPNPositions!GREAT BENEFITS: 12 Paid Holidays Retirement (156% match) Health Insurance (79% paid) and more!“Taking Care ofAmerica’s Heroes” Bellevue Grand Island Norfolk ScottsbluffApply online:www.statejobs.nebraska.govEEO/AA/VET12 NEBRASKA NURSING NEWSFigure 6: Satisfaction Levels withNursing as a Career

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Ask the Practice ConsultantThe MedicalAssistantInquiry: Medical Assistants do nothave a scope of practice, therefore,they can perform any task that isdelegated to them by another healthcare professional?Response:Scope of practice. It is correct thatMedical Assistants do not have a scopeof practice. Only licensed health careprofessionals have a scope of practice.Scope of practice is defined in healthcare professionals’ Practice Acts.Delegated nursing interventions.Medical Assistants may only performdelegated nursing interventions.Registered Nurse (RNs) or AdvancedPractice Registered Nurse (APRNs) havelicensure authority to delegate select,non-complex nursing interventions toMedical Assistants (see Delegation this issue of Nursing News ).Inquiry: If there is not a nurse ina particular practice setting, what canMedical Assistants do?Response:Medical Assistants support thepractice of licensed health careprofessionals. They may appropriatelyperform administrative duties likescheduling and computer entry—orclinical support tasks like roomingpatients and collecting data andinformation from the patient thatnursing and medical providers requireto inform their plan of care (NebraskaBoard of Nursing, July 2018a).Inquiry: Certified MedicalAssistants can do more, i.e., have moreskills than Medical Assistants who arenot certified?Response:Medical Assistant certification isnot a recognized credential in Nebraska(Uniform Credentialing Act [UCA],Neb. Rev. Stat. §§ 38-101). Employersmay require certification as a conditionfor employment, but being trainedand certified to perform a particulartask does not mean that task may be14 NEBRASKA NURSING NEWSInquiry: Accept verbal orders?Response: Verbal orders areprescriptions from APRNs and medicalproviders responsible for the care ofa particular patient with licensureauthority to prescribe medications,diagnostic tests and therapeuticinterventions. Medical Assistants, likeother unlicensed persons, may notaccept verbal orders from a licensedprescriber (Nebraska Board of Nursing,2018b). They may, however, acceptand complete a task that they areotherwise qualified and may lawfullyperform in response to a written orderfrom a provider, e.g., phlebotomy toobtain a laboratory specimen.performed under Nebraska law.Inquiry: What tasks may MedicalAssistants perform under Nebraskalaw?Response: Medical Assistantsas unlicensed persons may performany task that is not limited to thepractice of a credentialed health careprofessional. Credentialed means alicense, certification or registrationrecognized by Nebraska law. A personwith an active credential has the rightto represent himself or herself as havingthe credential and the right to practice(UCA, Neb. Rev. Stat. §§ 38-113,38-117, 38-121).Inquiry: What about phlebotomy,i.e., drawing blood?Response: Peripheral venous bloodsamples can be collected by any person,including a Medical Assistant, whohas been trained and demonstrated thecompetency to do so. Phlebotomy doesnot require a credential.Inquiry: Can Medical Assistantsdraw blood from or flush centralintravenous catheters or ports?Response: Access and care of centrallines is intravenous (IV) therapy and canonly be performed by qualified licensednurses (Nurse Practice Act, 2017).Inquiry: Transcribe provider ordersfor electronic order entry?Response: Centers for Medicare &Medicaid Services (CMS) regulationspermit licensed health care professionalsand certified Medical Assistants toenter provider orders for medications,laboratory and radiology intocomputerized provider order entrysystems (CPOE). These rules arespecific for those health care entitiesparticipating in meaningful usecalculation under the Medicare andMedicaid Electronic Health Record(EHR) Incentive Programs (CMS.gov, 2018). In Nebraska, as noted inthe preceding section, since MedicalAssistants may not accept verbal orders,they may only complete electronicorder entry if they have exact writteninstructions from the prescriber.Changes or clarifications must also bemade by the provider in writing, orthe electronic entry amended by theprovider themselves (Nebraska Board ofNursing, 2018b).Inquiry: Telephone triage?Response: Patient triage, eitherby telephone, or in-person and/or thegiving of advice to patients can only beperformed by licensed nurses. Triagemeans sorting or responding to patientrequests for care. Triage requiresassessment of the patient. Assessment iswithin the scope of practice of the RN.Licensed Practical Nurses contribute topatient assessment under the direction

of a RN or Licensed Practitioner(Nurse Practice Act, 38-2211-38-2212).Assessment cannot be delegated by theRN to an unlicensed person (172 NAC99-004.01C).Inquiry: My provider’s office toldme that I could expect a phone callfrom ‘the nurse.’ The person whocalled and answered my questions wasa Medical Assistant.Response:Title protection. Health careprofessionals are obligated to correctanyone who incorrectly identifies themby a credential title that they do nothave. ‘Nurse’ is a protected title. It isunlawful for any person to use the titlenurse in reference to himself or herselfin any capacity, except individuals whoare or have been licensed as an LPN orRN (Nurse Practice Act, Neb. Rev. Stat.§§ 38-2228).Telephone contact. MedicalAssistants may make phone calls topatients on behalf of licensed healthcare professionals, but the informationprovided to patients must be limited togeneral instructions such as the date,time and location for appointmentsand health care services, i.e.,information generated as a result of theadministrative support tasks performedby the Medical Assistant.Inquiry: Can the Medical Assistantprovide patient teaching?Response: Only RNs can providepatient teaching and counseling.The unlicensed person may provideinformation related to promotingindependence in personal careand activities of daily living. Theunlicensed person may also be taughtto recognize and report basic deviationsin patients from healthy behavior andcommunication patterns (172 NAC99-004.01C).Provider instructions, such as thosefor medications or post-procedurecare, may be reviewed with patients byMedical Assistants with patients in apre-printed format. Medical Assistantsmay not respond to questions oroffer patients information regarding aparticular diagnosis or medical plan ofcare, e.g., diabetes education.Inquiry: Can Medical Assistantssupervise licensed health careprofessionals?Response:Employers may create supervisoryroles for unlicensed persons, but theunlicensed person has no authorityrelated to a licensee’s scope of practice.For example, a Medical Assistants mayassume supervisory responsibilities fornurses that include clinic workflow, e.g.,patient scheduling or preparing examrooms. The Medical Assistant maynot assume supervisory responsibilitiesthat include training and monitoringthe performance of activities that arelimited to nursing scope of practicesuch medication administration andtreatments.Inquiry: Can Medical Assistantsadminister medications?Response:Medications may be providedto patients by a Medical Assistantif registered, i.e., credentialed asa Medication Aide in Nebraska(Medication Aide Act, 2013).Medication provision is a component ofmedication administration. Provision islimited to the act of giving or applyinga dose of a medication (Medication AideAct, Neb. Rev. Stat. §§ 71-6721).Medication provision isparticipation in medicationadministration. Licensed healthcare professionals may administermedications if they have the statutoryauthority, i.e., it is within their scopeof practice to do so (Medication AideAct, Neb. Rev. Stat. §§ 71-6722).Medication administration is the act ofproviding a medication, and observingand taking appropriate action regardingdesired effects, side effects, interactionsand contraindications associated with aparticular medication (Medication AideAct, 71-6721).The provision of medications bypersons credentialed as MedicationAides is subject to specific regulatoryNorth Platte, NELinden Court is looking for Newand Experienced nurses seeking tobe a part of a compassionate andgrowing team.Offering Competitive Benefit Packages: Hire on bonus Relocation assistance Tuition reimbursement andrepayment Health insurance Shift differential .and much more!Contact Jess Bertschinger(308) 532-5774 orjbertschinger@vhsmail.comTo view openings, visit www.lindencourt.comand click on “Our Careers” tab4000 W. Philip Ave. – North Platte NE 69101continued on page 16NEBRASKA NURSING NEWS 15

continued from p.15Referencesrequirements for training, competencyassessment, direction and monitoring,and documentation. There are additionalrequirements fo

Nebraska Center for Nursing, who recently released the supply and demand data for LPN, RN, and APRNs in Nebraska through 2025. Currently in 2018, there is a total nursing shortage of 3,543 nurses (all licensees) in Nebraska. If nothing changes, that shortage will g