FALL 2016 VOLUME 13 {NO 1} EDITION 37 www.ncbon.com

WHAT COULD HAPPEN: The Consequences of “Practice Drift”... Is It Worth the Risk? – page 6

Publication of the North Carolina State Board of

...... FALL 2016 BULLETIN N NC Nursing Bulletin is the official C publication of the North Table of Carolina Board of Nursing. CONTENTS Office Location 4516 Lake Boone Trail O Raleigh, NC 27607 VOLUME 13 {N 1} EDITION 37 Mailing Address P.O. Box 2129 Raleigh, NC 27602 Telephone (919) 782-3211 Fax 6 WHAT COULD HAPPEN: The Consequences (919) 781-9461 of “Practice Drift... Is It Worth the Risk? Website www.ncbon.com Office Hours 14 LPN-BSN ACADEMIC PROGRESSION 8 a.m. to 5 p.m., IN NORTH CAROLINA: Challenges and Monday through Friday Board Chair Recommendations Report Martha Ann Harrell Executive Director Julia L. George, RN, MSN, FRE 16 TELEHEALTH/: Editor Position Statement for RN and LPN Practice David Kalbacker Managing Editor Elizabeth Langdon 18 COMPLEMENTARY THERAPIES: Photography Position Statement for RN and LPN Practice DayMeetsNight Media Services Mission Statement 20 Election Results for 2016 The mission of the North Carolina Board of Nursing is to protect the public by regulating the Executive Director Nationally Recognized practice of nursing. 21 with Highest Award in Nursing Regulation Advertisements contained herein are not necessarily endorsed by the North Carolina Board of 22 LITERATURE REVIEW: Nursing. The publisher reserves the Nurse Fatigue Related to Shift Length right to accept or reject advertise- ments for the Nursing Bulletin. All art (photos, paintings, draw- ings, etc.) contained in this pub- lication is used under contractual agreement. 150,000 copies of this document were printed and mailed for a cost of $0.22 per copy. The North Carolina Board of Nursing is an equal opportunity employer. DEPARTMENTS: 4 From the Editor 20 pcipublishing.com Summary of Activities Created by Publishing Concepts, Inc. 30 Classifieds $ % !"( %  #! For Advertising info contact "   (  &" NURSING $   #! ThinkNurse.com BULLETIN ...... 3 NC

from the EDITOR

Eyeing that slippery slope I first want to congratulate new Board members, Lisa Hallman and Glenda Parker on their election efforts and the re-election of Sharon Moore to the 2017 Board of Nursing. I also want to thank departing Board members, Jennifer Kaylor, Cheryl Duke and Margaret Conklin for their hours of dedicated service on behalf of the Board. To read more about our incoming Board members see the article on Page 20. The CE cover story on Page 6 highlights the issue of “Practice Drift.” In it, author Kathy Chastain, RN does a great job describing the “slippery slope” that licensees are known to take that eventually leads them to appear before the Board. I assure you this is NOT a work of fiction. We hear licensees describe these practices all the time — in defense of their actions. The article is a compelling read and will definitely help you identify problem areas where drift might occur.

Also in this issue is a short article, on Page 14, about the Foundation for Nursing Excellence (FFNE) and their efforts to report on steps that might be taken to address academic progression for LPNS. We have included a link to the report.

As 2016 comes to a close, I am already looking toward the future and a long session of the 2017 North Carolina General Assembly. I will keep you posted on Board of Nursing issues in the legislature.

David Kalbacker Editor, NC Board of Nursing

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...... 5 WHATREQUIREMENT COULD HAPPEN: vs. PROFESSIONALISM The Consequences of “Practice Drift”... Is It Worth the Risk?

Kathy Chastain, MN, RN, FRE and Linda Burhans, PhD, RN, FRE

Purpose: To assist nurses in under- standing and identifying practice drift and how to eliminate/mitigate effects.

Objective: 1. Explain “practice drift.” 2. Recognize factors that contribute to the occur- rence of “practice drift.” 3. Discuss the impact of “practice drift,” 4. Create a plan to eliminate and decrease “practice drift.”

Have you ever… because you were pressed for T failed to scan the bar code on a 1. Deviated from the procedure for safe time and/or you were trying to medication because the scanner medication administration? save a few steps; wasn’t working; T administered a medication prior to T carried medications in your T made assumptions when orders obtaining an order from a provider pocket and wasted them at the were incomplete or were illegible because you “knew” what the end of the shift because there because you didn’t want to bother physician would order; wasn’t anyone available at the the provider; or, T borrowed a medication from time to serve as a witness; T hidden away unused medications another patient or used STAT T signed as a witness to a narcotic from discharged patients for orders to override the system as medication waste you did not administration to other patients if a workaround to bypass slow observe because you trusted your needed in the future to avoid delays. pharmacy services; co-worker; 2. Neglected a patient? T administered a pain medica- T left a patient’s medications on T failed to perform an assessment or tion without completing a pain the bedside table because he/she treatment because the patient was assessment because you were was on the phone; sleeping; in a hurry; T failed to check 2 identifiers when T silenced a piece of equipment (bed T prepared medications simultane- administering medication because alarm, IV pump, cardiac monitor, ously for more than one patient you were in a rush; etc.) because it kept alarming for

URSING 6 N N ORTH CAROLINA BULLETIN {Official Publication of the Board of Nursing } ...... no apparent reason and you felt it change because you were busy was disturbing the patients; or, with another patient; or, N T failed to complete the “time out” T allowed unlicensed personnel to in surgery because the surgeon was make assignments and delegate C upset with how long it took to set patient care tasks to others. up for his/her patient. 7. Accepted an assignment when you of the risk attached to everyday behaviors, 3. Failed to maintain an accurate knew you were not fit for duty? or to mistakenly believe the risks taken patient ? T worked while so fatigued that you to be justified. Decisions about what is T pre-documented an assessment were nodding off to sleep because important on a daily list of tasks are based or care delivered to save time you agreed to work an extra shift on the immediate desired outcomes and because the information was at the request of your manager; or, over time, as perceptions of risk fade away, always the same; T worked an early shift while still individuals try to do more with less and T pre-documented medication “hung over” from a party that take shortcuts, drifting away from behav- administration because you knew ended only a few hours before. iors they know are safer (ISMP, June 2012). you would not have time later; or, Articles published by the Just Culture T waited until the end of the shift to Chances are you have done some Community, have identified “at-risk” document all assessments and care of these yourself, or if not, you have behaviors as the most common of the rendered because you didn’t have worked with someone who has! The 3 types of errors (human, at-risk, reck- time during the shift to get it done. multiple “at-risk” behaviors listed less). Marx of Outcome Engineering 4. Breached a patient’s confidentiality? above all describe “practice drift.” The (2005) explains, T out of curiosity, looked up infor- term “practice drift” is another way of “We all tend to lose perception of the mation on a patient you were describing a “work- around,” “shortcut,” risk attached to everyday activities, or not assigned to provide care; or “rule-bending” done in order to mistakenly believe in some situations a T posted pictures or comments accomplish an immediate goal, to meet a risk is justified. Often our decisions to about patients or family members perceived expectation of another, and/or circumvent an evident or perceived on social media; to promote efficiency (Collins, 2003). workflow hindrance are based on T discussed patient information in All of these incidents are types of immediate outcomes (time saver) in a public setting (e.g., elevator or practice violations which the NC Board order to meet a goal or to achieve it cafeteria) or commented on a of Nursing has investigated. Thankfully more readily and do not consider the patient’s condition to another the vast majority of these incidents did potential or uncertain consequence patient or family member. not result in serious negative patient (patient harm) which is more remote.” 5. Exceeded scope of nursing practice? outcomes but each incident represents a Studies have shown that once you T acted outside your scope of “drift” from the standard of care and has have bent the rules and had a favorable practice by writing “verbal orders” the potential to jeopardize patient safety. outcome and/or a positive response without actually speaking with the from your peers and supervisors, you provider, believing they would be STOP READING: Make a list are likely to be tempted to do it again signed off at next rounds; or, of work-arounds, shortcuts, and (Collins, 2003). If left unquestioned, T performed a procedure that was rule-bending in your practice setting. the rule-bending action then tacitly outside your scope of practice (e.g., What variations from standards of becomes acceptable practice not only rupturing membranes to induce practice or policies and procedures by that individual but may be adopted labor) because the provider have you witnessed? Which varia- by others in the unit or facility and instructed you to do so. tions have you used? How often does many times leads to what is referred 6. Inappropriately delegated a task to “practice drift” occur in your prac- to as a “cultural norm.” However, an unlicensed staff member? tice and that of your co-workers? work-arounds and rule-bending are T directed a nurse aide (not appro- often just temporary fixes for bigger priately educated and validated Behavioral research has shown that problems in the system and do not competent) to administer a medi- all humans are mentally programed to promote an environment supportive cation or perform a simple dressing drift into unsafe habits, to lose perception of safe patient outcomes.

...... 7 STOP READING: Go back to to “work-around” the rule included the T potentially threaten professional your “practice drift” list. For each intimidation the nurses felt due to the relationships. variation, list the reason(s) for surgeon’s threats, the nurses’ desire to Now, can you identify “practice drift” those variations. Why do you and make up for lost time, and the time in the following scenario? your co-workers use these work- delay caused by the lack of prepared- Cindy, a , has arounds and shortcuts and bend ness in failing to verify the day before worked on the evening shift in a long term established rules? What are you that the equipment was available. As care skilled nursing facility for a number of trying to achieve? What problems described in this example, it is likely years. The facility does not have an on-site in the system or environment that this cultural norm will be perpetu- pharmacy; therefore, all ordered resident make it seem necessary to use ated by the new nurse for whom this medications are obtained from a pharmacy these approaches? was identified as acceptable behavior. in a neighboring town. On the date of this In addition, this cultural norm was incident, a new resident was transferred Consider the following scenario: reinforced again for all the nurses by the from the hospital to Cindy’s unit. They Megan, a newly-employed Registered lack of untoward outcomes in this case. were understaffed, which was not an Nurse in the Operating Room of a small uncommon occurrence on that unit. That rural hospital, was assigned to circulate STOP READING: Go back to evening Cindy was falling behind with all with another experienced nurse on a your “practice drift” list. Highlight the tasks she was assigned to complete. She surgical case for Dr. S, a very impatient those variations that have become completed the admission assessment but surgeon. The set up for the procedure “cultural norms” in your setting. failed to review the orders. The Unit Secre- was taking longer than expected because Is this “practice drift” so common tary transcribed all the medication orders a specific piece of equipment that had that it is used routinely by all onto the Medication Administration Record been requested the day before could not nurses? Is it used only by some of (MAR) for Cindy to verify. Cindy was be located. Dr. S voiced his frustration the nurses? If so, why do the other preparing to do her first medication pass for and threatened that he would cancel the nurses not use these approaches? the shift. She took the Medication Adminis- surgery and “start taking his surgeries tration Record (MAR) without verifying elsewhere” as they were never ready and Dr. Van Sell (2012), noted that nurses the orders because she had no doubts that it always caused him to be behind in his will engage in a reasoned, intentional rule was accurate. She proceeded to pre-pour all schedule. The nurses rushed to finish the bending behavior to solve an immediate scheduled medications for all residents for the set up and due to the delays the experi- problem and not realize the potential entire shift and place them into individual enced nurse instructed Megan that they negative consequences. Factors such as baggies which she labeled with the residents’ would forgo doing the required “time staffing levels, patient acuity, workload, room numbers. At the same time, she out” to verify the patient, procedure, time constraints, interruptions/emergen- documented that all medications poured had site, allergies, and antibiotics adminis- cies, lack of access to providers, lack of been administered at the times noted in the tered. Megan voiced concerns but was input in design of workflow and proce- MAR. She believed these practices to be safe. assured this was “common practice” for dures, familiarity and trusting relation- She had worked with these residents for a this surgeon to keep him happy as you ships with providers, and lack of proper long time and knew who they were as well never wanted to be on his bad side. working equipment/supplies/medications as what medications they took. Throughout This example demonstrates how are just some of the challenges nurses face the shift, she completed the medication passes “practice drift” became a “cultural norm” every day when trying to do what needs to which she had pre-poured and pre-documented. for this facility. Based on extensive be done to provide effective patient care. The new resident had an order for an studies and the patient safety literature, Work-arounds develop in response oral antibiotic which had not been delivered. the risk severity potential of omitting to factors that: Cindy knew another resident on the unit the “time out” procedure was high, but T are perceived to prevent or under- was taking this same medication so she the probability of incident was incor- mine nurses’ care for their patients; “borrowed” one dose because she didn’t rectly perceived by the nurses to be T are not considered in the best have time to wait on the pharmacy. She low as there had been no reports of interests of the patient; failed to check the new resident’s allergies, wrong patient or wrong site surgeries T make performance of their job thus failing to see that there was a docu- in this hospital. The decision drivers difficult; or mented allergy to the antibiotic she had

URSING 8 N N ORTH CAROLINA BULLETIN {Official Publication of the Board of Nursing } ...... administered. The resident had an allergic The above scenario involved multiple check of reviewing the allergies reaction resulting in the resident having to “practice drifts.” How many did you find? as well. be transferred back to the hospital. T Insufficient staff on the unit con- T Instead of waiting on the phar- While trying to take care of the transfer tributed to Cindy’s decisions to macy or calling to see why the arrangements for the above resident, a “cut corners.” She did not request resident’s medications had not nursing assistant (who is currently in assistance because she “knew” it been delivered, Cindy decided ) informed her that another would not be available, leaving to bypass policy and borrow the resident was requesting her pain medica- the supervisor unaware of the medication from another resi- tion. Cindy reviewed the MAR and unit status. dent. Had she called the phar- noticed the medication was ES-Tylenol. T She rationalized that she did not macy she would have been She poured the medication and handed have to check the orders and informed that there was a it to the nursing assistant directing her MAR because she trusted the question regarding the order. to take it to the resident. In addition, a secretary and believed she would This third safety mechanism nurse arrived at 8:30pm to assist with not make an error in transcribing. would have prevented an error. medication administration but left and T She failed to consider that the T Cindy believed that pre-pouring went back to her own unit when she unit secretary was not educated in all the medications at once would reviewed the MAR and saw all medica- clinical nursing and pharmacology save her time and be more efficient. tions had already been administered and would not likely identify the Because she knew the patients, she through 10:00pm doses. The relief problem between the resident’s believed that she could label the nurse reported to the supervisor that allergies and the medication ordered. baggies with room numbers only. there was a discrepancy related to T In her rush to complete the medi- She chose to ignore all patient medication administration. cation pass, she omitted the safety safety policies and procedures.

...... 9 T Cindy’s decision to pre-document drift.” Her overall intent was to provide “Practice drifts” operate as adaptions all the medications that were sched- the best care possible with limited to inefficiencies and have the potential uled to be administered on her shift resources. However, the time Cindy to both subvert and augment patient ultimately resulted in confusion as thought she was saving by using short- safety. Occasionally, workarounds operate to what medications had been ad- cuts, bending rules, and implementing as localized acts of resilience, are at times ministered when another nurse work-arounds, resulted in compromised crucial to the delivery of services, place came to assist. Notification of the patient care, damage to her professional the patient’s best interests at the forefront, supervisor resulted in an internal reputation and credibility, a potential operate as adaptions to inefficiencies, and investigation into Cindy’s medica- loss of her job, and a potential sanction provide opportunities for improvement. tion administration practices and of her nursing license. When operating in this manner, they are resulted in a report to the Board. As It is not uncommon for any one of us, used as unique, short-term solutions and a result of this action, Cindy’s cred- when faced with having to do more with the opportunities for improvement are ibility was called into question less or when pushed for time, to find ways immediately addressed. More frequently, causing her employer to question if to use work-arounds and take shortcuts. however, because rule-bending, work- she falsified patient records routinely. In a busy work environment, particularly arounds, and shortcuts circumvent safety T Finally, Cindy inappropriately one that is understaffed, rule-bending may blocks, mask environmental and opera- delegated medication administra- seem like the only solution. But none of tional deficiencies, and undermine stan- tion to an unlicensed nursing these influence substantive change and dardization they have the potential to assistant. This, too, was a violation they only provide a temporary fix when jeopardize patient safety as well as your reported to the Board. what is needed is a change in the under- career. When a patient is injured because Ultimately, Cindy’s actions on this lying condition that made work-arounds, you deviated from the standard of care, there shift demonstrated extreme “practice short-cuts or rule bending necessary. is little defense to be found (HPSO, 2016).

10 NURSING BULLETIN ...... “I BELONG TO NCNA” North Carolina Nurses Association The professional association for ALL registered nurses since 1902. You can stay on the cutting edge of nursing policy, education, and practice in an ever-changing healthcare environment by joining NCNA. We are proud to be the only nursing association in the state that represents all of North Carolina’s Registered Nurses. If you want to help shape the future of nursing, join NCNA today!

· Continuing Education · Professional Networking · Legislative Advocacy

“NCNA provides the means to help me fulfill my professional interests beyond employment JOIN TODAY! and participate in decisions www.ncnurses.org that impact nursing at large.” (800) 626-2153 - Donna Owen, RN, BSN [email protected] ...... 11 Rules: we can’t live without them, nursing-practice-act-nursing- but there is probably not a day goes by practice-act) and Administrative when we don’t break or bend one. Rule- Code Rules (http://www.ncbon.com/ bending, work-arounds, and shortcuts dcp/i/laws-rules-administrative- are all reflective of the “practice drift” code-rules-administrative-code- used to achieve specific outcomes. They rules) to identify sections relevant often seem like the only solution to to this discussion. fixing what is wrong. They become part of the culture and the need to identify All nurses must strive to uncover and address the root cause of the issue and address the underlying causes is hidden. We fail to see that we have of rule-bending, work-arounds, and institutionalized a temporary, inadequate shortcuts to affect substantive change. fix. In many cases, it is not until an ad- Nurses, nurse managers, and adminis- verse event requires deeper examination trators must work together to identify that the underlying conditions that led and address the underlying issues in to unsafe “practice drift” are identified. each work environment – both chronic Nurses, according to the Gallup Poll, and acute – which influence “practice have ranked as the most trusted profession drift.” Nurses must speak out to iden- for the last 14 years (ANA, 2015). Nurses tify the “practice drift” they and their strive to do a good job and to provide peers are using; specifically identify safe, effective care. We strive to identify the underlying reasons: short staffing, more efficient ways to accomplish effective inadequate supplies, unresponsive outcomes. Unfortunately, once we get pharmacy services, inadequate comfortable in doing something, our education, etc.; and collaborate practice may begin to drift in an attempt with managers and administrators to find ways to accomplish more with less to identify effective, evidence-based or to do something “faster” or “better.” solutions. It is essential that safe We lose sight of the risk inherent in the solutions to underlying problems resulting deviations from established be implemented. Patient safety and standards of care, policies, and procedures. well-being is the ultimate shared goal. We assume that risk through the behav- ioral choices we make. When a patient is NOW: Go back to your “prac- injured because we deviated from the stan- tice drift” list and make a plan to dard of care, we bear that responsibility. address at least one variation! How The NC Nursing Practice Act (Law) will you alter your own practice to and Rules provide clear direction con- move away from at-risk behavior? cerning the variables that determine the How will you communicate the responsibilities or assignments that can be risks of “practice drift” to your safely accepted by an RN or LPN. Likewise, co-workers? How will you address specific criteria designate considerations the underlying system changes with when assigning or delegating to others. your manager and administrator? Nurse manager and administrator re- sponsibilities for staff, unit environment, IN THE FUTURE: Prioritize and nursing systems are also spelled out. your “practice drift” list and address one at a time. Enlist support and STOP READING: Explore the involvement from your co-workers and NC Nursing Practice Act (http:// manager. Patient safety and well- www.ncbon.com/dcp/i/laws-rules- being is your ultimate shared goal!

URSING 12 N N ORTH CAROLINA BULLETIN {Official Publication of the Board of Nursing } ...... REFERENCES: American Nurses Association (2015, EARN CE CREDIT December). Nurses rank as most honest, “What could happen: The consequences of practice drift…is it worth ethical profession for 14th straight year. the risk!” (1.5 CH) News release, 12/21/15. Silver springs, MD: Author. INSTRUCTIONS Collins, S.E. (2003, July). Legally Read the article. There is not a test requirement, although reading for speaking: The problem with breaking comprehension and self-assessment of knowledge is encouraged. the rules. RN Magazine. Debono, D.S., et al. (2013). Nurses’ RECEIVE CONTACT HOUR CERTIFICATE workarounds in acute healthcare Go to www.ncbon.com and scroll over “Nursing Education;” under settings: A scoping review. BMC Heath “Continuing Education” select “Board Sponsored Bulletin Offerings,” Services Research; BioMed Central Ltd. scroll down to the link, What could happen: The consequences of practice HPSO. (2016). The Risks of bending drift…is it worth the risk. the rules. Available at: www.hpso.com/ risk-education/individuals/articles/ Register, be sure to write down your confirmation number, complete Hutchinson, S.A. (1990). Responsible and submit the evaluation, and print your certificate immediately. Subversion: A study of rule bending among nurses. Sch Inq Nurs Pract, 4(1), 3. If you experience issues with printing your CE certificate, please email Institute for Safe Medication Prac- [email protected]. In the email, please provide your full name and the name of the CE offering (What could happen: The consequences of tices (IMSP). (2012, May). Just culture practice drift…is it worth the risk). and its critical link to patient safety (Part 1). ISMP Medication Safety Alert! Registration deadline is 11-01-2018. (First published 2006.) Institute for Safe Medication Practices PROVIDER ACCREDITATION (IMSP). (2012, June). Our long journey The North Carolina Board of Nursing will award 1.5 contact hours towards a safety-minded just culture: Where for this continuing nursing education activity. we are going (Part 2). ISMP Medication Safety Alert! (First published Sept. 2006.) The North Carolina Board of Nursing is an approved provider of Marx D, Comden SC, Sexhus Z, eds. continuing nursing education by the North Carolina Nurses Association, (2005, Nov/Dec). Repetitive at-risk behav- an accredited approver by the American Nurses Credentialing Center’s ior - what to do when everyone is doing it. Commission on Accreditation. Just Culture Community News Views, 1, 5-6. Outcome Engineering. (2005). An NCBON CNE CONTACT HOUR ACTIVITY Introduction to Just Culture. Dallas, DISCLOSURE STATEMENT Tex: Outcome Engineering, Inc. The following disclosure applies to the NCBON continuing nursing Available at: www.justculture.org/ education article entitled “What could happen: The consequences of downloads/jc_overview.pdf. practice drift…is it worth the risk!” Outcome Engineering. (2005, March). The Just Culture Algorithm-version 1.0. Participants must read the CE article in order to be awarded CNE Dallas, Tex: Outcome Engineering, Inc. contact hours. Verification of participation will be noted by online registration. No financial relationships or commercial support have Available at: www.justculture.org/ been disclosed by planners or writers which would influence the downloads/jc.algorithm05.pdf planning of educational objectives and content of the article. There Van Sell, S. (2012, Dec 8). What is no endorsement of any product by NCNA or ANCC associated are the implications of breaking a with the article. No article information relates to products governed nursing law? Texas Woman’s University. by the Food and Drug Administration. Available at: www.researchgate.net/post/ What_are_the_implications

...... 13 Polly Johnson, RN, MSN, FAAN. CEO, r, Foundation for Nursing Excellence LPN-BSN ACADEMIC PROGRESSION IN NORTH CAROLINA Challenges and Recommendations Report

As part of our efforts to increase both the diversity and licensed in NC, nurse educators at PN, ADN and BSN educational preparation of our nursing workforce in NC, the levels as well as employers from across the state, and nurse Foundation for Nursing Excellence (FFNE) convened a small leaders from other states. We are pleased to share a link workgroup of nursing program leaders as well as representatives to our September 2016 LPN-BSN Feasibility Workgroup from the NC Area Health Education Centers program, the Report, LPN-BSN Academic Progression in North NC Board of Nursing and NC Community Colleges System Carolina: Challenges and Recommendations, for your to lead a feasibility study and, based on findings, make recom- review and consideration of the recommendations for action. mendations for future actions that North Carolina might take We also ask that you distribute the link to this report at in addressing academic progression for LPNs. Information http://ribn.org/library/library/other-resources/2016-lpn-bsn- related to current LPN-BSN academic interest and/or initia- feasibility-report.pdf to your colleagues in both the practice tives to help build the nursing workforce of the future was and education communities who are committed to academic gathered from a variety of stakeholders including LPNs progression for all levels of nursing in North Carolina.

URSING 14 N N ORTH CAROLINA BULLETIN {Official Publication of the Board of Nursing } ......

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Both RN and LPN Role: 1. Report and record nursing care Issue: provided. Licensed nurses (RN and 2. Accept responsibility and account- LPN) may practice nursing ability for client care via telehealth/ using telehealth/telenursing telenursing modalities only if possess modalities, provided required the documented education and criteria are met. validated competence necessary to deliver nursing services safely. 3. Accept orders for medical interven- tions via telehealth/telenursing from The NCBON has determined that Physicians, Nurse Practitioners, nursing practice occurs at the location Certified Nurse Midwives, and of the client at the time services are Physician Assistants authorized being provided. to make medical diagnoses and Licensed nurses practicing and prescribe medical regimens. providing client care via telehealth/ 4. Standing orders and protocols for telenursing modalities are required to teaching nursing personnel/students; care must meet requirements as be licensed or hold the privilege to prac- administering nursing services; stated in the NCBON Standing tice in the state(s) where the client(s) collaborating; and consulting. Orders Position Statement for is located. Licensed nurses must practice LPN Role: Must be supervised by RN and LPN Practice available in compliance with the laws, rules, and an RN, physician, , at www.ncbon.com. standards of practice of the state(s) physician assistant, or other person 5. Employing agency’s policies and where the client(s) is/are located. authorized by state law to provide the procedures address telehealth/ Definition: Telehealth/telenursing supervision. telenursing services and are avail- (alternatively termed telemedicine) Telehealth/telenursing by the LPN able in the facility. is the practice of healthcare within includes participating in assessing, a professionally designated scope of planning, and evaluating client care, References: practice using electronic communi- implementing client care according G.S. 90-171.20 (7) & (8) – cation, information technology, or to an established plan, and Nursing Practice Act other means between a licensee in collaborating with other healthcare 21 NCAC 36.0224 - RN Rules one location and a client in another providers in compliance with nursing 21 NCAC 36.0225 - LPN Rules location with or without an inter- law and rules (G.S. 90-171.20 (8) and NCBON Standing Orders Position vening healthcare provider. 21 NCAC 36.0225). LPN supervision Statement for RN and LPN Practice RN Role: Telehealth/telenursing of others is limited by state laws and RN Scope of Practice – Clarification includes assessing (including triaging) rules. It is beyond the scope of LPN Position Statement for RN Practice clients; planning, implementing, and practice to perform complex, independent LPN Scope of Practice – Clarification evaluating client care; teaching and decision-making, such as that poten- Position Statement for LPN Practice counseling clients; managing and tially required to triage client care needs supervising the delivery of care; via telehealth/telenursing modalities. Approved: 5/2016

URSING 16 N N ORTH CAROLINA BULLETIN {Official Publication of the Board of Nursing } ...... 17 COMPLEMENTARYC M MENTARY THERAPIES Positionosition StatementS atement for RN andan LPN Practice

Issue: Complementary therapies refer to a broad range of modalities such as, but not limited to, massage therapy, therapeutic touch, biofeedback, magnet therapy, reflexology, imagery, hypnosis, aroma- therapy, and acupressure. Some of these therapies are inherent in basic nursing practice while others require additional education/training prior to performing them. Complementary therapies are intended to be used in conjunc- tion with the existing treat- ment plan, not to replace it. 2. Documented in the patient’s medi- times within the scope associated cal record consistent with require- with their highest level of active ments for reporting and recording licensure. Refer to “Practicing at Level Other Than Highest Licensure/ Both RN & LPN Roles: Notes: Approval/Recognition Position A. It is within scope of practice to 1. Any state or local laws, which Statement for RN, LPN, and perform complementary therapies require licensure to perform the APRN Practice” available at provided licensee has: complementary therapy, must be www.ncbon.com for more detail. 1. Documented knowledge, skill, followed. For example, massage may and competency necessary to be utilized as a nursing care inter- References: carry out the therapy in a safe vention but a massage license is G.S. 90-171.20 (7) (b & h) and (8) manner, required to offer, provide, or prac- (b & f) – Nursing Practice Act 2. Employing agency’s policies and tice massage in a broader context. 21 NCAC 36.0224 (d) and (f) - procedures support nurse’s use 2. Acupuncture can only be performed RN Rule of complementary therapies. if the individual is licensed to 21 NCAC 36.0225 (d) and (f) - perform this modality in North LPN Rule B. When complementary therapy is Carolina consistent with NC used as a nursing intervention; this GENERAL STATUTES 90, Article Approved: 5/2001 should be: 30 (Practice of Acupuncture). Revised: 4/2006, 4/2007, 5/2009, 1. Reflected in the patient’s plan of 3. Licensed nurses are held responsible 11/2009, 5/2016 care, and and accountable for practicing at all Reviewed: 2/2013

URSING 18 N N ORTH CAROLINA BULLETIN {Official Publication of the Board of Nursing } ...... 19 SUMMARY of ACTIVITIES

Administrative Matters: Newly Elected and Re-Elected Members K Approved proposed amendments to rules related to revoca- K Newly Elected: Glenda Parker, RN and Lisa Hallman, RN tion, suspension or denial of license. The current rule places K Re-elected to 2nd term: Sharon Moore, RN a greater procedural burden and more restriction on the Chair and Vice Chair for 2017 Board of Nursing than is required by the Administrative K Chair: Pat Campbell, Public Member Procedures Act and fails to capture needed nursing prac- K Vice Chair: Deborah Herring, RN tice. Amendments include technical changes throughout the rule and the creation of new violations in section (a) where Regulatory Compliance Matters: a need was seen to capture acts previously outside the K Removed probation from the license of 11 RNs and 1 LPNs. Board’s disciplinary jurisdiction. Lastly, deletions were K Accepted the Voluntary Surrender from 9 RNs and 1 LPNs. made of provisions in the rule that are covered in law K Suspended the license of 14 RNs and 0 LPNs. pursuant to the North Carolina General Statutes or that K Reinstated the license of 5 RNs and 1 LPNs. generally place unnecessary burden not required by law K Number of Participants in the Alternative Program for on staff during the enforcement/disciplinary process. Chemical Dependency: 146 RNs and 10 LPNs (Total = 156) K Approved proposed amendments to rules related to K Number of Participants in the Chemical Dependency annual renewal, continuing education and prescribing Program (CDDP): 95 RNs, 11 LPNs (Total = 106) authority for Nurse Practitioners. Amendments include K Number of Participants in Illicit Drug and Alcohol/ language to clarify requirement for maintaining national Intervention Program: 28 RNs, 15 LPNs (Total = 43) certification for annual renewal, establishing continuing education hours in prescribing practices in accordance Education Matters: with Session Law 2015 – 241 Section 12 F16(b) and Ratification of Full Approval Status clarifying language regarding authorized prescription refills. K University of North Carolina Wilmington - BSN K A Public Hearing on the proposed amended Rules is Ratification to Approve the Following Expansion in Enrollment scheduled for November 17 at 1:00 pm. Visit our website K Southwestern Community College – ADN, increase of 28 at http://www.ncbon.com/dcp/i/laws-rules-administrative- for a total 80 beginning August 16, 2016 code-rules-proposed-rule-changes for specific details as Initial Approval for New Program they are available. Additional information will also be K Mayland Community College - PN published in subsequent issues of the magazine.

ELECTION RESULTS FOR 2016

New Members with the Department of Public Department Chair for Practical Glenda Parker, Family Nurse Practi- Safety is from Raleigh, NC and was Nursing at Forsyth Technical tioner for Minute Clinic, from Concord, elected as RN – Staff Nurse to the Community College. NC, was elected as RN – Advanced NC Board of Nursing. Mrs. Hallman Practice to the NC has more than 21 years of nursing Chair & Vice Chair Elections Board of Nursing. Mrs. Parker comes experience. Pat Campbell, public member and to serve on the Board with more than 2016 Vice Chair, was elected to 37 years of nursing experience. Sharon Moore, was re-elected to Chair the Board for 2017. the Board in the position of Nurse Lisa Hallman, Nurse Manager at Educator – PN, to serve another Deborah Herring, RN – At Large, Johnston Correctional Institution 4 year term. Mrs. Moore is the was elected as Vice Chair for 2017.

URSING 20 N N ORTHO RTH CAROLINAARO BULLETIN {Official Publicationtion of the Board of Nursing } ...... ExecutiveExe iv Directorector NationallyNati Recognized with HigHighestst Award in NursingNur Regulation

JuliaJ L. George, MSN, RN, FFRE,RE, EExecutive Director, North common interest.rest NCSBN’s CarolinaCarolin Board of Nursing,rsin was honhonored with the prestigious membership is comprised of R. Louise McManus Award. IndividIndividuals receiving this award the BONS in the 50 states, have made sustained and significantgnifican contributions through the the District of Columbia, highest commitment and dedicationedication to the mission and vision of and four U.S. territories – The National Council of Stateate BoardBoards of Nursing Inc. (NCSBN). American Samoa, Guam, NCSBN recognized dedicatedcated and exceptional membership at Northern Marina Islands its annual awards ceremony during the NCSBN Annual Meeting and the Virgin Islands. and Delegate Assembly, heldd in ChicaChicago, IL, August 18, 2016. There are also 27 associate In addition to receiving thee R. Louise McManus Award, members that arere eeither George was also elected as President-Electdent-Elect to the NCSBN nursing regulatorylatory bodies Board of Directors. This is a 4-yearr commitmencommitment, serving 2 or empoweredwered regregulatory Julia L. George, MSN, years as President-Elect and 2 years as President. authoritiesthorities from other RN, FRE NCSBN was founded March 15, 1978, ass an independent countriecountries or territories. not-for-profit organization and was created to lessen the NCSBN Member Boards protect the public by ensuring that burdens of state governments and bring together boards of safe and competent nursing care is provided by licensed nurses. nursing (BONs) to act and counsel together on matters of These BONs regulate more than 4.5 million licensed nurses.

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...... 21 Deborah J. Martin, MBA MSN, RN, NE-BC, FACHE, Senior Director, Professional Practice Banner Health

LITERATURE REVIEW Nurse Fatigue Related to Shift Length

Reprinted with permission from the Arizona Regulatory Journal

The issue of nurse fatigue is of increasing concern to nurses and healthcare organizations. Evidence to document the fatigue issue continues to emerge and provide more specific data and insights for the healthcare community. The relation- ship of fatigue to patient safety and risk of self-injury is documented in several sources. The purpose of this literature review is to present the most recent evidence and recommen- dations specific to nurse fatigue for nurses and their managers in understanding these relationships. Symptoms of fatigue include, but are not limited to de- creased alertness, irritability and sleepiness. The Occupational Safety and Health Administration (OSHA)1 cautions against working more than 8-hour shifts as longer shifts may result in reduced alertness. Fatigue is correlated to nurse performance and chronic fatigue is related to the number of hours worked.2 Health care workers are not alone in shift work and working long hours. The Department of Transportation regulates the number of hours of service for those in aviation, highway, rail and nautical professions.3 Not only are shift times regulated; some have restrictions on weekly and monthly work allot- ments. Sleep and rest are noted to be important for those in the rail industry,4 airline industry,5 and the forest industry.6 Long working hours may have an impact on errors as well as near errors,7 and decrease the nurse’s vigilance in critical care.8 Research conducted by Barker and Nussbaum (2011) found that acute fatigue resulted from long hours of work, and that fatigue was negatively correlated with performance. It was identified that an increased number of shifts worked by nurses in the prior 72 hours were significantly associ- ated with hypoglycemic events in ICU patients receiving insulin infusions.9 Documentation of patient care can also be impacted by working longer hours; there were 26 percent less charting errors with fewer call hours in the surgical setting.10 working long shifts were more likely to be burned out, In addition to patient clinical outcomes, a correlation dissatisfied with their job and intended to leave their job exists between hospitals where nurses worked 13 hours in within the year.11, 12 Shifts scheduled for 12 hours often length or longer and patient dissatisfaction with communi- exceed that timeframe, as many as 40% of the work shifts cation, pain control and help when they wanted it.11 Nurses logged for their study exceeded 12 hours.7

URSING 22 N N ORTH CAROLINA BULLETIN {Official Publication of the Board of Nursing } ...... Nurse’s personal safety related to impact of working longer shifts.27 The policies and practices to limit hours longer worked hours is also a concern. Institute of Medicine (IOM)28 recom- worked in a shift as well as the number Extended work hours are a contributing mends limiting the number of hours of hours worked in a week11, 28 that the factor in needle stick injuries among worked in a day by nurses as a patient “routine use of twelvehour shifts should nurses,13 and rates of nurses driving safety precaution. They find the evi- be curtailed”7 (p. 210), and that over- drowsy doubled when they worked dence to be “very strong” (p. 236) time after a 12-hour shift should be more than 12.5 hours.14 In a study related to prolonged work hours and eliminated.7 Another recommendation that examined the impact of a 9-hour worker fatigue. Recommendations are is to decrease shift length to allow shift compared to an 8-hour shift, the that health care organizations establish recovery time between shifts.29 Health nurses working the 9-hour shift had more health issues, were not as satisfied and had more fatigue.15 In variables associated with worker injury, those working 12-hour shifts had a higher medical cost per injury than those who worked 8-hour shifts.16 Findings in a simulated environment demon- strated older people were not able to perform as well as younger people.17 This is important for the health care industry to consider as the nursing workforce ages and there is a need to retain them through improved job attributes.18 If shorter shifts are not available, planning to decrease the effects of fatigue can include regular and frequent breaks,1, 7, 19, 20 meal breaks,1, 7, 19 staff getting enough sleep or naps,21, 22, 19, 23 limiting caffeine19, 23 eating well and exercising19 and limit the number of shifts worked in a row.20 Additional options include avoiding double back shifts such as an evening shift followed by a day shift with less than eight hours between, limit on-call hours, and allow sleeping during the night shift. Imple- mentation of a formal fatigue counter- measures program for nurses has provided evidence of improvement in nurse fatigue.24 With consecutive 12-hour shifts, nurses were not able to recover between shifts and used caffeine as a possible mechanism to improve alertness.25 It is a legal and ethical obligation to educate the nursing staff about the effects of long work hours.26 It is important for senior management to be aware of the

...... 23 care workers in the United States often or on the way home if in an accident Asked Questions. Retrieved from work 12-hour shifts prompting Lockley30 caused by driving while drowsy. http://www.osha.gov/OshDoc/data_ to state “hours routinely worked by A literature review reveled that shift Hurricane_Facts/faq_longhours.html health care providers in the United length has been correlated with nurse 2 Barker, L. M., & Nussbaum, M. A. States are unsafe” (p. 14). The Ameri- fatigue and has become a growing (2011). Fatigue, performance and can Nurses Association31 notes that in concern in the United States with the the work environment: a survey of addition to employee accountability routine shift length of 12 hours. Out- registered nurses. Journal of Advanced comes correlated to shift length and Nursing, 67(6), 1370-1382. doi: fatigue includes errors or near errors in 10.1111/j.1365-2648.2010.05597.x A literature review patient care. In addition to concerns in 3 National Transportation Safety Board reveled that shift patient care outcomes, the impact of Safety report NTSB/SR-99/01. (1999). fatigue on the nurse is also noted. Evaluation of U.S. Department of length has been Nursing is a profession, and as a Transportation Efforts in the 1990s correlated with profession, we need to be self-regulating. to Address Operator Fatigue. Wash- If we are not able to mitigate the impact ington DC: National Transporta- nurse fatigue and of fatigue, it could become regulated as tion Safety Board. Retrieved from has become a grow- with other industries such as transporta- http://www.ntsb.gov/doclib/reports/ tion, logging and nuclear power workers. 1999/SR9901.pdf ing concern in the 4 Dorrian, J., Baulk, S. D., & Dawson, D. United States with Acknowledgement: (2011). Work hours, workload, sleep and the routine shift A special ‘thank you’ to Kathy Malloch, fatigue in Australian Rail Industry PhD, MBA, RN, FAAN who encouraged employees. Applied Ergonomics, 42(2), length of 12 hours. me to take the leap and go back to school 202-209. doi: http://dx.doi.org/ Outcomes correlated for a DNP in Innovation Leadership at 10.1016/j.apergo.2010.06.009 ASU and for recognizing the importance 5 Roach, G. D., Petrilli, R. M., Dawson, to shift length and of this topic to the nursing profession. D. & Lamond, N. (2012). Impact of fatigue includes layover length on sleep, subjective Author: fatigue levels, and sustained attention errors or near errors Deborah Maust Martin received her of long-haul airline pilots. Chronobi- in patient care. Master’s degrees in nursing and business ology International, 29(5), 580-586. administration from West Virginia 6 Lilley, R., Feyer, A., Kirk, P., & University and is currently employed by Gander, P. (2002). A survey of forest Banner Health as the System Director workers in New Zealand: Do hours of regarding fatigue, employers are obli- of Professional Practice. She has served work, rest, and recovery play a role in gated to provide adequate staffing to on various local and national boards in accidents and injury? Journal of care for patients. It is not the individual an effort to strengthen the profession of Safety Research, 33(1), 53-71. doi: nurse’s responsibility to cover all shifts nursing. One of these was the Congress on http://dx.doi.org/10.1016/S0022- by working extra hours. Nursing Practice and Economics with the 4375(02)00003-8 The evidence is compelling that American Nurses Association where she 7 Rogers, A. E., Hwang, W., Scott, L. long shift lengths are correlated with contributed to the Scope and Standards D., Aiken, L. H., & Dinges, D. F. negative outcomes for both patients and of Practice (2010) and the Principles (2004). The working hours of hospital nurses. Patients are impacted by errors for Nurse Staffing (2012). Deborah is staff nurses and patient safety: both in their care and are more dissatisfied currently enrolled in a doctoral program errors and near errors are more likely when nurses work longer shifts. For the at Arizona State University. to occur when hospital staff nurses nurse, the outcomes of working longer work twelve or more hours at a stretch. shifts can be injury to self and intent to References: Health Affairs, 23(4), 202-212. leave their job. Injuries may happen on 1 Occupational Safety and Health 8 Scott, L. D., Rogers, A. E., Hwang, the job such as needle sticks or strains; Administration. (n.d.) Frequently W., & Zhang, Y. (2006). Effects

URSING 24 N N ORTH CAROLINA BULLETIN {Official Publication of the Board of Nursing } ...... THE PROMISE OF WILSON

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...... 25 of critical care nurses’ work hours Levels Of Burnout And Patient 15 Josten, E. J., Ng-A-Tham, A., Tham on vigilance and patients’ safety. Dissatisfaction. Health Affairs, J. E., & Thierry, H. (2003). The American Journal of Critical 31(11), 2501-2509. doi: http://dx. effects of extended workdays on Care, 15(1), 30-37. doi.org/10.1377/hlthaff.2011.1377 fatigue, health, performance and 9 Louie, K., Cheema, R., Dodek, P., 12 Stimpfel, A. W., Lake, E., Barton, S., satisfaction in nursing. Journal of Wong, H., Wilmer, A., Grubisic, M., Gorman, K.C. and Aiken. (2013). Advanced Nursing, 44(6), 643-652. . . . Ayas, N. T. (2010). Intensive How differing shift lengths relate to 16 Brown, N., & Thomas, N. (2003). nursing work schedules and the risk quality outcomes in pediatircs. The Exploring variables among medical of hypoglycaemia in critically ill Journal of Nursing Administration. center employees with injuries: devel- patients who are receiving intrave- 43(2), 95-100. oping interventions and strategies. nous insulin. Quality & Safety in 13 Trinkoff, A. M., Le, R., Geiger- American Association of Occupational Health Care, 19(6), e42. doi: Brown, J., & Lipscomb, J. (2007). Health Nurses Journal, 51(11), 470-481. 10.1136/qshc.2009.036020 Work schedule, needle use, and 17 Reid, K., & Dawson, D. (2001). 10 Warren, A., & Tart, R. C. (2008). needlestick injuries among registered Comparing performance on a simu- Fatigue and charting errors: the nurses. Infection Control & Hospital lated 12 hour shift rotation in young benefit of a reduced call schedule. Epidemiology, 28(2), 156-164. and older subjects. Occupational and AORN Journal, 88(1), 88. doi: 14 Scott, L. D., Hwang, W., Rogers, A. Environmental Medicine, 58(1), http://dx.doi.org/10.1016/j.aorn.2008. E., Nysse, T., Dean, G. E., & Dinges, 58-62. doi: 10.1136/oem.58.1.58 03.016 D. F. (2007). The relationship 18 Letvak, S. (2005). Health and safety 11 Stimpfel, A. W., Sloane, D., & Aiken, between nurse work schedules, sleep of older nurses. Nursing Outlook, L. (2012). The Longer The Shifts For duration, and drowsy driving. Sleep, 53(2), 66-72. doi: 10.1016/j.outlook. Hospital Nurses, The Higher The 30(12), 1801-1807. 2004.09.005 19 Hughes, R. G., & Rogers, A. E. (2004). First, do no harm. Are you tired? Sleep deprivation compromises nurses’ health -- and jeopardizes patients. American Journal of Nursing, 104(3), 36-38. 20 McGettrick, K. S., & O’Neill, M. A. (2006). Critical care nurses-- perceptions of 12-h shifts. Nursing in Critical Care, 11(4), 188-197. 21 Caruso, C. & Hitchcock, E. (2010). Strategies for nurses to prevent sleep- related injuries and errors. Rehabili- tation Nursing, (35)5, 192-197. 22 Dean, G. E., Scott, L. D., & Rogers, A. E. (2006). Infants at risk: when nurse fatigue jeopardizes quality care. Advances in Neonatal Care, 6(3), 120-126. doi: 10.1016/j.adnc.2006. 02.001 23 Witkoski, A., & Dickson, V. V. (2010). Hospital staff nurses’ work hours, meal periods, and rest breaks: a review from an occupational health nurse perspective. AAOHN Journal, 58(11), 489-497. doi: http://dx.doi. org/10.3928/08910162-20101027-02

URSING 26 N N ORTH CAROLINA BULLETIN {Official Publication of the Board of Nursing } ...... NORTH CAROLINA Education/Practice Committee: 24 Scott, L. D., Hofmeister, N., Rogness, November 30, 2016 N., & Rogers, A. E. (2010). An inter- BOARD OF NURSING Canceled ventional approach for patient and CALENDAR nurse safety: A fatigue counter- Hearing Committee: measures feasibility study. Nursing Board Meeting: January 26, 2017 Research, 59(4), 250-258. doi: January 20, 2017 http://dx.doi.org/10.1097/NNR. Licensure Review Panel: 0b013e3181de9116 Administrative Hearings: December 8, 2016 25 Geiger-Brown, J., Rogers, V. E., December 1, 2016 January 12, 2017 Trinkoff, A. M., Kane, R. L., Bausell, February 23, 2017 February 9, 2017 R. B., & Scharf, S. M. (2012). Sleep, sleepiness, fatigue, and performance of 12-hour-shift nurses. Chronobiol- ogy International, 29(2), 211-219. doi:10.3109/07420528.2011.645752 26 Miller, J. A. (2011). When time isn’t on your side: 12-hour shifts. , 42(6), 38-43. doi: http://dx.doi.org/10.1097/01. NUMA.0000395197.70014.a5 27 Keller, S. M. (2009). Effects of extended work shifts and shift work on patient safety, productivity, and employee health. AAOHN Journal, 57(12), 497-502; quiz 503-494. doi: 10.3928/08910162-20091124-05 28 Page, A. (Ed.) (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academies Press. 29 Blouin, A. S. (2013, March). “Short on sleep”: Preventing staff and patient consequences. Presented at the Amer- ican Association of Nurse Executives annual meeting, Denver, CO. 30 Lockley, S. W., Barger, L. K., Ayas, N. T., Rothschild, J. M., Czeisler, C. A., & Landrigan, C. P. (2007). Effects of health care provider work hours and sleep deprivation on safety and performance. Joint Commission Journal on Quality & Patient Safety, 33(11), 7-18. 31 American Nurses Association (2007). Inside ANA – Issues up close: ANA position statements call for RNs and employers to prevent working fatigued. American Nurse Today, April, 44-45.

...... 27 NOMINATION FORM FOR 2017 ELECTION Although we just completed a succesful Board of Nursing election, we are already getting other Board-related information. You also may contact Chandra, Administrative Coordinator, at ready for our next election. In 2017, the Board will have two openings: RN – At Large, LPN. [email protected] or (919) 782-3211, ext. 232. After careful review of the information packet, This form is for you to tear out and use. This nomination form must be completed on or you must complete the nomination form and submit it to the Board office by April 1, 2017. before April 1, 2017. Read the nomination instructions and make sure the candidate(s) meet all the requirements. Guidelines for Nomination 1. RNs can petition only for RN nominations and LPNs can petition only for LPN nominations. Instructions 2. Only petitions submitted on the nomination form will be considered. Photocopies or faxes are Nominations for both RN and LPN positions shall be made by submitting a completed petition not acceptable signed by no fewer than 10 RNs (for an RN nominee) or 10 LPNs (for an LPN nominee) eligible 3. The certificate number of the nominee and each petitioner must be listed on the form. to vote in the election. The minimum requirements for an RN or an LPN to seek election to the 4. Names and certificate numbers (for each petitioner) must be legible and accurate. Board and to maintain membership on it are as follows: 5. Each petition shall be verified with the records of the Board to validate that each nominee 1. Hold a current unencumbered license to practice in North Carolina and petitioner holds appropriate North Carolina licensure. 2. Be a resident of North Carolina 6. If the license of the nominee is not current, the petition shall be declared invalid. 3. Have a minimum of five years experience in nursing 7. If the license of any petitioner listed on the nomination form is not current, and that finding 4. Have been engaged continuously in a position that meets the criteria for the specified Board decreases the number of petitioners to fewer than ten, the petition shall be declared invalid. position, for at least three years immediately preceding the election. 8. The envelope containing the petition must be postmarked on or before April 1, 2017, for the Minimum ongoing-employment requirements for both RNs and LPNs shall include nominee to be considered for candidacy. Petitions received before the April 1, 2017, deadline continuous employment equal to or greater than 50% of a full-time position that meets the will be processed on receipt. criteria for the specified Board member position, except for the RN at-large position. 9. Elections will be held between July 1 and August 15, 2017. Those elected will begin their terms of office in January 2018. If you are interested in being a candidate for one of the positions, visit our website at Please complete and return nomination forms to 2017 Board Election, North Carolina Board www.ncbon.com for additional information, including a Board Member Job Description and of Nursing, P.O. Box 2129, Raleigh NC 27602-2129.

Nomination of Candidate for Membership on the North Carolina Board of Nursing for 2017

We, the undersigned currently licensed nurses, do hereby petition for the name of , RN / LPN (circle one), whose Certificated Number is , to be placed in nomination as a Member of the N.C. Board of Nursing in the category of (check one): † RN – At Large † LPN

Address of Nominee: Telephone Number: (Home) (Work) E-mail Address:

PETITIONER - (At least 10 petitioners per candidate required. Only RNs may petition for RN nominations). TO BE POSTMARKED ON OR BEFORE APRIL 1, 2017 NAME SIGNATURE CERTIFICATE NUMBER

Please complete and return nomination forms to 2017 Board Election, North Carolina Board of Nursing, P.O. Box 2129, Raleigh, NC 27602-2129.

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URSING 30 N N ORTH CAROLINA BULLETIN {Official Publication of the Board of Nursing } ...... 31 Presorted Standard U.S. Postage Paid Little Rock, AR P.O. Box 2129 Permit No. 1884 Raleigh, NC 27602-2129