defining scope of practice

Defining Scopeof Practice.

EVERY THING MAT TERS: IN PATIENT CARE | VOLUME 25 ISSUE 3 | SUMMER 2012

Kim Davis (center), a nurse practitioner, collaborates with Tracey Latham, RN (left) and medical assistant Sharon Kormanik (right).

Understanding your scope of practice helps improve patient care.

EVERYTHING MATTERS: IN PATIENT CARE 43 EVERYTHING MATTERS: IN PATIENT CARE

Features

3 The Scoop on Scope of Practice - It’s Not Just for Nurses by Duane Kusler, Vice President, Emergency Services and Maureen Sims, Education Nurse Specialist

13 Workplace Violence Awareness by Rhonda Colborn, AD, CPHQ Nicole Spencer, BS, CPHQ

Articles

7 Peripheral Nerve Catheters by Tarun Bhalla, MD

9 Nurses’ Week 2012: Advocating, Leading and Caring by Cheryl Boyd, PhD, RN, NE-BC, NP-BC Susan Hedrick, MSN, RN

11 Implementing the Electronic Medical Record with Traumas by Beth Malehorn, RN, BSN, CEN Valerie Hendren, RN

18 Scope of Nurse Practitioners by Robin Canowitz, JD, Associate Counsel, Legal Services

19 School Nursing: Caring for the Whole Child by Maryanne Tranter, RN, MS, CPNP

21 6th Vital Sign: Hospitalized Children’s Evaluation of the Quality of their Daily Nursing Care by Nancy A. Ryan-Wenger, PhD, RN, CPNP, FAAN

23 Eosinophilic Esophagitis: An Allergic Response that Can Mimic Reflux by Sandra Jacobs, Nurse Practioner, PAA

24 In Recognition

Editorial Staff

EditorCharline Catt

Managing EditorCarol McGlone

Editorial BoardAdeline Cursio Margaret Carey

Cindy Iske Hollie Johnson Marcie Rehmar Nanette Spence

Jill Tice Danielle Worthington

Editorial AssistantNancy Denney

Editorial SupportMegan Shock

Art Director & DesignerJohn Ordaz

PhotographyBrad Smith Dan Smith

EVERYTHING MATTERS: IN PATIENT CAREV O L U M E 2 5 I S S U E 3 | S U M M E R 2 0 1 2

EVERYTHING MATTERS: IN PATIENT CARE, previously published as Heartbeat, is a quarterly publication of the Patient Care Services Division of Nationwide Children’s Hospital, Inc., Columbus, OH. Comments regarding the content of this publication are welcomed. References for articles are available by calling (614) 722 -5962. Articles may be reprinted with permission. Send all inquiries and material for publication to EVERYTHING MATTERS: IN PATIENT CARE in care of Nancy Denney, Administration, Nationwide Children’s Hospital, Inc., or call (614) 722-5962. Nationwide Children’s Hospital is an affirmative action, equal opportunity employer. Copyright 2012, Nationwide Children’s Hospital, Inc. All Rights Reserved.

A Celebration of You and Your Accomplishments!

Linda Stoverock, RN, MSN, NEA-BC,

Senior Vice President, Patient Care Services,

Chief Nursing Officer

Six years ago, groups of interdisciplinary teams from Nationwide Children’s began visiting newly constructed pediatric hospitals and adult hospitals with the goal of transforming care for our patients and families. On June

20, 2012, six years of detailed work came to fruition as we moved into the Nationwide Children’s new main hospital. When I look back at the countless people, meetings, planning sessions, vendor selection, pilots, process changes and more, there is a lot to be celebrated. You are truly a part of transforming care for the patients and families at Nationwide Children’s Hospital.

Not only was a hospital built, but additional changes occurred impacting all of our nurses who engage with patients. In the past six years, you have focused on better patient and team communication with the implementation of an integrated medical record system for inpatient, ED, and ambulatory clinics. You adopted Clinical Practice Management (CPM) content to guide evidence-based practice. You expanded your use of shared governance to include Interdisciplinary Forum, added Mount Carmel St. Ann’s to our neonatal senates, and added bar coding technology to enhance safety for medications, labs and human milk. You adopted new technology for infusions and have driven medication safety to new levels.

Educational changes over the past six years incorporated evidence-based practice, the integration of professionals outside of nursing into new hire orientation, and the mentoring of student nurses from 23 institutions at LPN, AD, BSN, MSN, DNP and PhD levels. Not only are you training new students and new hires, but many staff have also returned to school to advance their own education. Others have sought certification in their specialty.

You have engaged in a culture of inquiry and worked to perfect safety, wellness, and health prevention by contributing to changes and improvements in the outcomes of the populations of patients whom you serve. Whether assisting the parent of a neonate, helping a family ensure their children have immunizations and flu shots, or preventing pressure ulcers, you let evidence and research guide your decisions and changes to practice.

The six year journey to opening our new hospital has flown by. When you pause to look at the transformations in your practice, you can see why. I celebrate each of you in this magnificent journey for transformational practice. When a child needs a hospital, everything matters. Every nurse matters!


Scope of practice discussions often result in many questions. Am I practicing within my scope of practice? What really is my scope of practice?

Can my employer restrict my state-approved scope of practice? If I perform a skill that I am not currently competent in, am I outside my scope? What happens if I have been instructed to perform a task outside of my scope of practice by a practitioner such as a physician or Advanced Practice Nurse (APN)?

Scope of practice issues have become increasingly complex as the role of the health care provider expands. With new technology and continuously evolving treatment modalities, it is imperative for those in health care, both leaders and staff, to understand scope of practice and to identify appropriate resources to help guide the patient care professional in the complex realm of providing patient care.

Scope of practice protects both the health care provider and the patient by providing boundaries to the provider’s individual practice.

There are many factors that affect an individual’s scope of practice including national and state regulatory bodies, professional organizations and the institution

or organization employing the individual. The individual also has a responsibility in determining and understanding what is within their scope of practice based on regulations put forth by these governing bodies.

Federal agencies can restrict and/or recommend restrictions to a discipline’s scope of practice. Scope of practice can be set by a federal agency; for example, the Drug Enforcement Agency (DEA) sets the scope for who can prescribe controlled medications or administer controlled substances. In addition, individual state boards may further define or restrict the regulation or provide clarification. Federal agencies, such as the Centers for Disease Control and Prevention (CDC) which promotes clinical standards that ultimately govern scope of practice, may also provide recommendations or guidelines. Your scope of practice may be further defined and/or restricted if you work in an institution governed by federal agencies or by national regulating bodies. For example, the Centers for Medicare and Medicaid Services (CMS) set standards and regulations for organizations that bill governmental agencies. These regulations do not affect your scope of practice if your employer does not bill a governmental agency for services. The Joint Commission is another non-federal agency who sets regulations for organizations who seek accreditation. These regulations may further limit your state-approved scope of practice while providing care as an employee of an organization accredited by The Joint Commission.

Professional organizations make recommendations and often set practice guidelines for their specific discipline, members or contingents. While these organizations often have statements regarding a group’s scope of practice, they are not regulatory agencies and cannot truly govern an individual’s scope of practice. Associations such as the American Nurses Association (ANA), the American

Dental Hygienist’s Association (ADHA), the National Athletic Trainers Association (NATA) and the American Dietetic Association (ADA) have position statements that help to define the professional’s specific practice boundaries but they do not approve or define the scope of practice of an individual. The expertise and vision from these organizations provide a foundation for other governing bodies to clarify scope of practice issues. As a profession evolves, these organizations frequently advocate for change to regulatory standards to meet the changing needs of the patients they serve.

There are many state boards, departments and agencies that define professional scope of practice. These entities often define who can use specific titles, set the educational requirements and testing standards and govern practice. The state agencies are responsible for developing administrative rules and policies that allow an individual to practice within that specific state. Often, the rules are general and require the state agency to further define the boundaries of an individual’s scope of practice.

Scope of practice is state-specific and varies between states. It is important to investigate and to frequently refer to your state’s practice act. State boards and other state agencies are responsible for setting the standards of licensure for an individual within the state. These boards and agencies are responsible for determining a discipline’s ability to delegate and to supervise another discipline, such as Unlicensed Assistive Personnel (Patient Care Assistant (PCAs) and Medical Assistant (MAs). An individual state often determines which individuals must hold an independent license to practice as a professional in a specific discipline such as a physician, a dentist, a registered nurse or a physical therapist. Under the scope of practice for each discipline, these individuals are usually allowed to assess, to interpret, to plan care and to start treatment or interventions based on his or her assessment.

Some disciplines are granted a license or certification by a state agency that allows them to practice within restrictive boundaries, usually under the supervision and/or the delegation of an independently licensed

professional. Individuals such as a Licensed Practical Nurses (LPN), a Licensed Social Worker (LSW), and a Recreational Therapist perform valuable tasks that are delegated or pre-determined by another professional, who is independently licensed.

The Unlicensed Assistive Personnel (UAP) category includes those individuals who hold a state certification and individuals who are trained to provide a specific task. State-Tested Nurses’ Aides, patient care assistants, home health aides and medical assistants are examples of UAP. UAPs work as part of the health care team providing high quality care to patients and are delegated tasks as defined by a state agency if their training and oversight are provided by a licensed professional.

Information or data collection is an important aspect necessary to develop a plan of care. Most health care workers are permitted to gather data or information. Information-gathering often includes performing tasks such as obtaining a blood pressure, a temperature or a pulse. Information-gathering also includes documenting parent or patient-reported information such as allergies, eating habits or patient concerns and collecting responses to screening questions. Data collection is completed without drawing conclusions or making judgments or assumptions. Data collection may be performed by a licensed professional or UAP. Analyzing and interpreting the collected data in combination with the licensed professional’s assessment findings are used to create the patient’s plan of care. For example, a registered nurse can determine a nursing diagnosis, interventions and nursing plan of care.

State agencies have the authority and the responsibility to protect the public and are the ultimate body to set the scope of practice for an individual’s practice within the state. Violation of a scope of practice may result in disciplinary action, licensure restriction and/or loss of a professional license or certification. The state has the authority to file criminal charges against a person suspected of practicing outside of his or her scope. It is essential that you to investigate and understand your scope of practice prior to providing care.

The Scoop on Scope of Practice - It’s Not Just for Nurses

Duane Kusler, Vice President, Emergency ServicesMaureen Sims, Education Nurse Specialist

Scope of practice helps to identify procedures, actions and processes an individual is permitted to perform. An individual’s scope of practice is also based on specific education, experiences and demonstrated competence.


An organization may further restrict the scope of practice for their employees based on policy within the organization. While a professional may be allowed to perform a task by the state board for a specific discipline, an organization can choose to limit the employee’s full scope of practice. Organizational leaders may limit an individual’s scope of practice if they believe a more qualified professional is available who has more knowledge and would be the better choice to perform the care. Leaders in the organization are responsible for ensuring and validating the competence of all individuals performing a specific task. Leaders may choose to limit the disciplines performing a high-risk skill or to reduce the number of individuals they need to maintain as

competent. Scope of practice decisions are usually based on the skill mix and the availability of individuals to perform the skill or the task.

The individual also has an obligation to further restrict his or her own scope of practice based on personal knowledge, skills and comfort level in preforming a specific task. For example, a respiratory therapist is allowed by his or her state board’s scope of practice and the employer’s institutional policies to adjust ventilator settings. However, if that individual has not recently worked at the bedside with ventilated patients and is not confident in this skill, it is his or her responsibility to seek assistance and/or contact their manager prior

to proceeding with the skill. Each individual is responsible for determining his or her competencies and capabilities within his or her approved scope of practice.

While it is important to understand the details of your scope of practice, it is also important for each professional to practice to the fullest extent of their scope. Health care providers who function at the fullest level of their scope as defined by both the state and their employers provide their patients with the highest quality of care.

If you are uncertain if you are working within your scope of practice, investigate! Ask your manager or a lawyer to help you investigate if the task is within your scope of practice. Another good source of information is your respective state board; they frequently have practice information available on their respective websites.

Many practitioners are not clear on the various scopes of practice for other disciplines and may unintentionally ask you to perform a skill outside your own scope of practice. It is important for you to understand and to be able to explain the boundaries of your scope. For example, a practitioner asks a LPN to assess the patient to determine if the patient needs to be seen in the office or go to the emergency room. By law, the Ohio Board of Nursing limits the LPN’s practice to gathering data. In Ohio, the LPN cannot assess patients or determine the disposition of their care. The LPN must be able to explain the boundaries of his or her license.

In conclusion, scope of practice varies greatly within disciplines and from state to state and it is impacted by each employer’s governing bodies and policies. Understanding your individual scope of practice and staying within your boundaries is each individual’s responsibility. New technology, research findings and ever-changing health care needs drive changes to scope of practice. It is important to periodically investigate the scope of practice for your discipline.

Read your organization’s policies and, if you are still uncertain, ask your manager or a lawyer to help you determine your scope of practice.


The Department of Anesthesiology and Pain Medicine at Nationwide Children’s provides the

opportunity for our patients to receive regional anesthesia for appropriate surgeries. Regional anesthesia may include a peripheral nerve block and/or a peripheral nerve catheter (PNC). A nerve block may be a single injection of local anesthetic or the insertion of a catheter for a continuous infusion of a local anesthetic. This is used to achieve a localized area of analgesia for post-operative pain control. A peripheral nerve catheter is a flexible tube placed directly into the patient’s surgical site or around the nerves innervating the surgical site.

A PNC can provide improved postoperative analgesia and improved functionality after surgery. The PNC is typically placed in the operating room by the anesthesiologist on the Acute Pain and Regional Anesthesia Team. While one end of the catheter is placed around the nerves, the other end is connected to a pump by tubing. The pump is filled with a local anesthetic and continuously infuses

Peripheral Nerve Catheters:Improving Functionality After Surgery

Tarun Bhalla, MD, Director of Regional Anesthesia and Acute Pain, Department of Anesthesiology and Pain MedicineLauren Renner, MS, RN-BS, CPNP

the medication at a constant rate to block the feeling of pain in the affected area. The Ambu® pump is currently used at Nationwide Children’s. The catheter will usually stay in place from two to five days. When the pump is empty, the catheter is removed and the pump and tubing are discarded.

Peripheral nerve catheters are typically placed around the nerve or nerves that innervate the specific operative area. These areas may include the brachial plexus (upper extremity), the femoral and sciatic (lower extremity), the lumbar (back), the transverse abdominis (abdomen) and the intercostal (chest) areas. The catheter can also be placed in or around the surgical site. The local anesthetic does not cause sedation but works directly on the nerve receptor. It is important to be aware of the symptoms of local anesthetic toxicity when taking care of a patient who has a PNC in place. Symptoms of toxicity include tinnitus, circumoral numbness, dizziness, anxiety, restlessness, blurred vision, cardiac arrhythmia, and seizure activity. Management of toxicity includes |lipid infusion.

There are only about ten major pediatric institutions in the country that offer these services in the pediatric population, making the Comprehensive Pain Services Team at Nationwide Children’s rare. The members of the Acute Care and Regional Anesthesia Team are experts in ultrasound guidance which is used when placing regional blocks and specifically a PNC. Nationwide Children’s is also a member of the Pediatric Regional Anesthesia Network which is a consortium of the top fifteen pediatric institutions in the country that prospectively obtain data for every regional block performed in operating rooms. To date, this is the largest regional block database in the world and will be utilized to monitor for complications as well as to publish relevant literature.


• Linda Stoverock hosted a Nursing Leadership Luncheon to express her appreciation. At the event, Cathleen Opperman, MSN, RN, CPN presented a Culture of Safety program that incorporated Zero Hero tools, the importance of Magnet, and the seven steps of evidence-based practice. The program included the unveiling of the updated Nationwide Children’s Hospital Professional Practice Model. A Magnet Recognition sub-committee from inpatient, outpatient and off sites developed the current professional practice model which continues to be applicable to Nationwide Children’s current practice but which updated the model’s visual representation. The components of the updated model include: • Environment: our work culture • Patients and Families: the center of our work • Resources: competent, interdisciplinary caregivers • Processes: critical reasoning, Do the Right Thing, evidence-based practice • Structure: system guidance such as policies and procedures, technology, shared governance • Outcomes: always reach for the best

Watch for more information on the updated model in future communications from the Magnet Steering Committee and sub-committees.

• The week concluded with a birthday celebration for Florence Nightingale. More than 250 staff attended the Friday afternoon activity where they viewed unit-sponsored cakes and toured poster displays. Best practice and research-based posters were presented by individuals and units. Participants voted on the best themed cake, most creative cake and the People’s Choice award. The winners were awarded a unit pizza party. • GI Clinic/Procedures placed first in the Best Unit Theme and People’s Choice awards. • PACU placed second with the Most Creative award. Nationwide Children’s Hospital appreciates all who participated and supported this annual event.

• An early morning staff appreciation breakfast where Linda Stoverock, SVP and CNO presented an update on nursing’s contributions to the accomplishment of Nationwide Children’s Hospital’s Strategic Plan. An encore presentation of the Town Hall occurred mid-week to honor the excellent service that our nurses provide to our patients and their families.

• Outstanding continuing education activities occurred during the week. Legal Services presented Boundaries, Social Media and the Ohio Board of Nursing. Linda Manley, RN, CNP, shared a program on Near-Death Experiences. Jeanette Foster, MSW, LISW-S and Jonathon Thackeray, MD offered a program on case scenarios entitled Child Maltreatment and Reporting: Ethical Considerations.

• Nursing Congress presented a display on the Centennial Wall recognizing the number of nurses serving in the various specialty areas.

• Lynn Gallagher-Ford, MSN, RN, NE-BC, Director of Transdisciplinary Evidence-Based Practice and Clinical Innovation at The Ohio State University, presented a lively and interactive program on the application of research, quality improvement and evidence to nursing practice.

• Our Pastoral Care Department celebrated a Blessing of the Hands service in the Chapel and on each unit where the contributions of nursing’s healing touch were recognized.

Nurses Week 2012: Advocating, Leading and Caring

Cheryl Boyd, PhD, RN, NE-BC, NP-BC, Director of Professional Development

Susan Hedrick, MSN, RN, Professional Development Nurse Specialist

The recognition of the services that nurses provide to patients and families was celebrated the entire week by the organization and by service units. Nationwide Children’s Hospital celebrated National Nurses’ Week May 6 through12, the actual birthday week of Florence Nightingale, the founder of modern nursing. Celebration

events included Town Hall meetings, continuing education programs and scholarly events. Departments and individuals donated more than $1,000 dollars for door prizes, gift cards and celebrations to honor the excellent service that Nationwide Children’s nurses provide to our patients and their families. Activities for the week included:


Nationwide Children’s Emergency Department is a very busy level-one trauma center. The Emergency Department treats approximately

75,000 patients each year; 1,200 of these visits are trauma alerts. Historically, the documentation of trauma patients was done on paper. Due to the rapid resuscitation and/or stabilization that the patient receives prior to being transferred to the intensive care unit or the operating room, it was thought that it would be too difficult to keep up with the documentation electronically.

However, on July 5, 2011, the Emergency Department officially began documenting traumas within the Electronic Medical Record (EMR). Nationwide Children’s became one of the few hospitals in the nation that can make this claim, including being the first hospital known in Ohio to use electronic documentation during trauma resuscitation and stabilization. Although predominantly a nurse-driven initiative, team members from all disciplines helped create the end product including doctors, nurses, surgeons, pharmacists and representatives from Information Services. After several years of planning and development, the ability to successfully document a trauma in the EMR became a reality. This was due to the dedication from a collaborative team approach with multiple departments working together to find a solution that would benefit and provide the best care to our patients.

The value of using an EMR has long been established. It is known to provide safer care, clearer documentation,

better communication and continuity of care. The ability to access a patient’s past medical history, allergies, age, and documented weight prior to the patient arriving or on arrival is a substantial improvement from paper documentation. In addition to these benefits, the EMR also generates real time patient orders. This instantly produces an up-to-date medical

record that is immediately accessible by all team members caring for the trauma patient including the Emergency Department, Trauma team, the Operating Room, Pharmacy, Radiology, and in-patient units. Furthermore, the EMR allows all of the patient’s information to be documented in one location. Prior to the EMR, it was necessary for team members to access the patient’s complete record in more than one place. This included information such as the patient’s medication administration record,

Implementing the Electronic Medical Record with Traumas

Beth Malehorn, RN, BSN, CEN, Emergency Department, Nurse Educator

Valerie Hendren, RN, Information Services, Epic Application Coordinator

lab results, and imaging readings, all of which are imperative to the immediate decision-making needed to provide the most optimal patient care.

Some of the key features that are offered within the new trauma documentation are one-step medications, customized primary and secondary assessments, a physical diagram, and the ability to quickly arrive staff to the trauma. The one-step mediations allow the nurse to place a verbal order in an emergency; at the same time, it acknowledges the order, signs off the medication in the medication administration record (MAR), and sends a cosign message to the ordering provider. This saves valuable time, allowing the nurse to keep up with documentation of all the other events of the trauma that are quickly unfolding.

Early in the project, the trauma nurses requested the ability to document the patient assessments and the interventions performed without requiring the staff to toggle between multiple screens in EPIC, the electronic medical record system. This was accomplished through using a creative custom build by the Nationwide Children’s EPIC team. Documentation of all the events is incredibly important to provide the safest, best care to our patients. Additionally, the documentation needs to be discrete and include many key elements so that the hospital can continue to maintain its level one trauma certification. Nationwide Children’s was the first pediatric hospital in Ohio to receive this certification; the team worked closely with the Trauma team to ensure that these needs were still met through electronic documentation.

Overall, the implementation of the EMR has proven to have many benefits. Not only does it provide a minute-to-minute, real-time picture of the patient but it also delivers a new level of safety that previously was not available. The Trauma team is extremely proud of this accomplishment and will continue to evaluate patient safety to make certain that the best care for every child is always provided at Nationwide Children’s.

It is known to provide safer care, clearer documentation, better communication and continuity of care.

Workplace Violence Awareness Rhonda Colborn, AD, CPHQ, Accreditation Coordinator, Quality Improvement Services

Nicole Spencer, BS, CPHQ, Accreditation Coordinator, Quality Improvement Services


In June 2010, The Joint Commission published Sentinel Event number 45: “Preventing violence in the healthcare setting.” According to the Sentinel

Event number 45 publication, health care settings, which were once considered safe havens, “are confronting steadily increasing rates of crime, including violent crimes such as assault, rape and homicide.”

As stated by the Occupational Safety and Health Administration (OSHA) and the National Institute of Occupational Safety and Health (NIOSH), workplace violence is defined as “a physical assault, threatening behavior or verbal abuse occurring in the work setting.” This violence can range from threats and verbal abuse, to physical assaults and homicide. On OSHA’s Workplace Violence website, the Bureau of Labor Statistics Census of Fatal Injuries (CFOI) reported that in 2010 there were 4,547 fatal workplace injuries in the United States; of these 506 were acts of homicide that occurred in

the workplace. In the United States, homicide is the fourth leading cause of occupational injuries. Workplace violence is often unreported; it is estimated that nearly 2 million Americans workers are victims each year. Workers at a higher risk for workplace violence include health care professionals, delivery drivers, public workers, customer service agents, law enforcement personnel, those who work alone or in small groups, and those who exchange money with the public. Even though workplace violence homicides are the most highly publicized incidents, verbal abuse is the most common form of violence according to the Workplace Bullying Institute.

Type 2 is the most common form of workplace violence found in the health care setting. Type 3 workplace violence, also known as horizontal or lateral violence, and Type 4 violence are both increasingly becoming more prevalent. The graphic below depicts OSHA’s categorization of the four types of workplace violence.

OSHA CATEGORIZES WORKPLACE VIOLENCE INTO FOUR TYPES:

Workplace violence is very unpredictable and an organization needs to equip its employees with prevention tools. Staff need to be aware and have a plan at all times to protect themselves and the patients they care for. Generally speaking, the most effective defense if attacked or threatened is to have a plan ahead of time. Education is the crucial key to providing staff with the necessary tools so that one or more of the following elements can be eliminated, thus reducing the risk of workplace violence. Although multiple strategies can be employed to help reduce the risk of workplace violence, there are three key elements required to provide the perfect setting for workplace violence. The violence triangle below provides a visual description of these elements:

Joe Rosner from Best Defense USA presented at a January 2012 Ohio Hospital Association conference and explained the three elements needed for violence to occur: 1. Opportunity is a set of circumstances that are

required to permit a violent act to occur. 2. Intent is the state of a person’s mind that directs his

or her actions in an attempt to improve one or more conditions via the use of violence.

3. Ability is having the size, strength, skill or a weapon able to cause physical harm to another person.

Mr. Rosner stressed that, if any one of these elements is eliminated, violence can be avoided.

While no definitive system has been proven 100% effective, there are multiple strategies to use to reduce risk.

One of the best protections that an employer can provide is a well-written and implemented zero tolerance policy. The policy, combined with staff training and a consistent review of the work environment, can help reduce the risk of violence.

There are many characteristics or cues that staff can use to help identify when a situation may turn violent. Patients who are in pain or have an altered mental status may be more likely to become violent. Families or patients who are required to wait for long periods of time, who are in disagreement with their medical plan, or who feel that they have lost control of their medical situation may pose a greater risk for violence. Having a rigid personality, known access to weapons, prolonged sadness or anger, being fearful or enjoying causing fear in others, being fixated on violence and possibly having a previous history of violence are all cues or keys to assessing increased risk in patients, families or co-workers.

Identifying possible risk factors is the first step in attempting to reduce workplace violence. These strategies can be used by staff daily to help mitigate the risk:• Awareness – Note a person’s verbal cues as well as

body language. Trust your intuition. If someone seems uneasy or edgy, be observant. When entering a space such as a patient room and encountering unknown persons including a new patient, or a new visitor

and/or family member with a patient, be alert to verbal and non-verbal cues.• Utilize appropriate behavior to defuse a tense

or uncomfortable situation – Remain calm, be considerate, acknowledge feelings and respect their personal space.

• Know your surroundings – Be aware of your surroundings and look for potential exit routes from the situation before there is a problem.

• Set limits – Set clear and simple limits, convey that the patient/family member/visitor has a choice, offer options and remain professional. Staying in control of the situation is key.

Source: OHA presentation “The Epidemic of Violence in the Healthcare Setting”.

TYPE

Type 1 – Criminal Intent

Type 2 – Clients, Patients, Customers

Type 3 – Worker on worker

Type 4 – Personal Relationship

DESCRIPTION

The perpetrator has no legitimate connection with the workplace

The perpetrator does have a legitimate connection with the workplace

Perpetrator is either a current or previous employee at workplace

The perpetrator has a personal relationship with the victim

OPPORTUNITYSource: OHA Presentation “Workplace Violence Plans, Policies & Procedures”

ABILITY INTENT

VIOLENCE


Scope of Nurse Practitioners Robin Canowitz, JD, Associate Counsel, Legal Services

• Get help – Contact security, alert another co-worker or a supervisor as soon as possible. This should be done during the confrontation if feasible or as soon as possible afterwards. Remove yourself from the situation as quickly as possible.

Other environmental prevention strategies include a zero tolerance policy, installing panic buttons and alarms, providing cameras and increased lighting in high risk areas, providing security patrols and continued education of staff regarding early identification and de-escalation techniques. Remember that simply having a workplace violence policy in place will not help if staff and managers are not frequently engaged in training and education sessions. Education and training are both important aspects for staff and active involvement should be encouraged.

Nationwide Children’s is taking steps to reassess our current workplace violence initiatives with efforts to improve on the process as needed. The current policy is being reviewed and soon all staff will have the opportunity to express their opinion regarding workplace violence in the annual compliance survey. All managers and supervisors will be required to participate in workplace violence education and training. More initiatives are planned but the first step is to assess our current status in order to prepare for the direction that we need to go. Nationwide Children’s is committed to providing a safe environment for all employees, for patients and their families, and for all visitors.

In conclusion, it is imperative that a zero tolerance policy toward aggression and intimidation, including verbal abuse, be instituted in the workplace to ensure a safe and healthy environment for all.

Nurse Practitioners (NPs) are first trained and recognized by their state as registered nurses (RNs). They are then certified, either nationally or by the state, in their advanced practice role. The scope of practice for NPs depends upon their education, their certification, and any specialized training which they have received. Pediatric Nurse Practitioners (PNPs) are often faced with a question regarding what to do when a patient “ages out” of their pediatric parameters. Is it still within their scope of practice to treat a 22-year-old patient?

Many PNPs, Family Nurse Practitioners (FNPs) and Neonatal Nurse Practitioners (NNPs) are concerned about the parameters of the ages of children they are allowed to treat. Unfortunately, there is no black and white answer to this question. Some babies stay in the NICU for more than two years. Many diseases are considered “pediatric” and adult practitioners are not as familiar with those disease processes and how to treat those patients. The National Association of Pediatric Nurse Practitioners (NAPNAP) defines the population

of those cared for by PNPs to be children from birth to age 21 years. However, in certain situations, they may continue to see patients past the age of 21. In a 2008 position statement, NAPNAP stated that PNPs may provide health care to patients older than 21 years with unique needs and for young adults during their transition to the adult health care setting. NAPNAP also recognized that there may be some underserved areas with little access to health care; in those areas, PNPs may need to treat adults during their transition period.

In Ohio, the scope of a NP is determined by his or her board certification and formal education. Many hospitals have set up parameters for PNPs allowing them to care for patients who are beyond their 22nd birthday if they have an established relationship with the patient or if the patient has a chronic, pediatric-related disease process such as cystic fibrosis or a congenital heart defect. The same type of scenario would apply to the FNP and the NNP. This flexibility enables the NPs to continue to care for patients in their specialized areas.

According to the Occupational Safety and Health Administration (OSHA) and the National Institute of Occupational Safety and Health (NIOSH), workplace violence is defined as “a physical assault, threatening behavior or verbal abuse occurring in the work setting.”


School Nursing: Caring for the Whole Child

Imagine an obese child losing substantial weight over the course of several weeks. The child has no primary care provider. She has been seen occasionally by an urgent care for a sore throat. After assessing the child in the school, she is sent to the Emergency Room. She is admitted as a newly diagnosed diabetic in ketoacidosis. Such is a day in the life of a school nurse.

School nurses are in the unique position to care for our children holistically: physically, cognitively and emotionally. They use knowledge and heart to not only care for the children but also the families. After working as a nurse practitioner in a public school system the past two years, I appreciate the expertise of these colleagues. They are vital to our profession.

Traditionally, school nurses screen and refer for vision, hearing, scoliosis and other health concerns. They decrease the incidence of communicable diseases by assuring that children are immunized. They help manage chronic illnesses such as spina bifida, diabetes and sickle cell anemia. When they become aware of medication changes, school nurses reinforce education for the families and the students. They teach the child about his or her medications: the name, the color, the side effects and when to take it. This education is reinforced daily. The school nurse may even call the parents or the dispensing pharmacy to confirm a child is taking the correct medicine.

However, there can be repercussions when school nurses are not in the building if other school personnel lack the knowledge in triage and decision-making. There are examples of children dying from asthma attacks or seizures due to a lack of medication administration when a nurse was not at the school as well as children not getting their medication during allergic reactions.

In addition to addressing the physical needs of children, school nurses assess many of their cognitive and social-emotional needs. Addressing these areas is vital to help children who are most vulnerable break the cycle of poverty for not only their future but also ours as well. School nurses have been known to keep kids in class by driving them when they miss the bus and the parent is unable to get them to school. They pick up prescription glasses if parents are not able, enhancing vision, eliminating headaches and advancing school success. They take parents to the child’s medical appointments. They comb hair, clip nails, treat for lice, serve as homework tutors and teach manners. They dispense clothing during cold weather, provide belts for pants that are too big, and wash dirty and soiled clothing. They are experts at knowing what insurance covers to help guide parents where to go for health care. They attend to emotional needs, giving tender loving care to the kids. When parents do not come to the school, they conduct home visits. These visits result in checks on absenteeism, medical concerns, complaints of no heat or water and, at times, calls to protective services. This is a day in the life of a school nurse.

Some school nurses provide classes to staff and parents on nutrition, diabetes, sickle cell, gang prevention and prenatal care. To promote health, they lead exercises during morning announcements, obtain grants to serve fruit and vegetable snacks, spearhead community gardens, write columns in newsletters, and promote afterschool programs to keep kids safe. Recently, one of our school nurses resuscitated a counselor using an AED, thus saving her life.

Understandably, not all school nurses have the time to do all they would like to do. Many school districts in this country do not have school nurses or their nurses

Maryanne Tranter, RN, MS, CPNP; Nurse Practitioner, Ambulatory Pediatrics; School Based Health Care Services

cover many schools. This leaves the nurse with less time per child, thereby, limiting the nurse’s ability to spend the time needed to fully assess all aspects of the children’s health. Fortunately, in the Columbus City School district, no school nurse is responsible for more than two schools and, in many schools, there are full-time nurses.

I have seen many examples of school nurses being the care provider who is the first to identify health problems. The school nurse then refers the child to the appropriate medical specialty. The nurses also identify acute issues. Serving in the schools enables me to assist in caring for

these children. School nurses send kids to me whose parents have concerns about long-lasting colds, crusty eyes, sore throats or possible ear infections. I diagnose and treat these acute illnesses so the child may be out of the classroom for only 15 to20 minutes. I also refer children to their primary care providers, specialists, or help them get into primary care if they do not have a regular doctor. Working with school nurses has helped me become a better nurse, identifying the needs of our patients and appreciating what it takes to care for these children holistically.


Millions of children and adolescents are hospitalized every year. Post-discharge patient satisfaction surveys are written for and completed by their parents. Pediatric patients are rarely asked to evaluate their own hospital experience or the care that they received, yet most 6-year-old to 21-year-old patients are fully capable of providing this information. In a first-of-its-kind study, researchers at Nationwide Children’s asked nearly 500 patients what they thought about their care.

Nancy Ryan-Wenger, PhD, RN, and William Gardner, PhD, received a Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative

(INQRI) grant to measure the quality of pediatric nursing care from the children’s perspective. A total of 496 hospitalized patients, ages 6 years to 21 years, participated in this cross-sectional descriptive study. Forty percent (n = 199) were interviewed on the day they were discharged; the others were interviewed on their 2nd to 337th hospital day. It was the first hospitalization for 184 (37.1%) of the children. In response to the question, “What do you like and dislike about what your nurses do for you?” the children reported 1,673 positive nurse behaviors and 485 negative nurse behaviors. Responses to each question were inductively sorted into categories (see Table).

Our current research team includes Jackie Watercutter, RN, MS; Michelle Walsh, PhD, RN, PNP; Andrea Manning, MBA/MSN, RN; and Micah Skeens, RN, PNP, MS, from Nationwide Children’s, and Denise Angst, PhD, RN, from Advocate Hope Children’s Hospital in Chicago. Building on the INQRI study data, we received a Clinical and Translational Research Intramural Grant to evaluate the effectiveness, utility, and feasibility of a consumer engagement intervention called the 6th Vital Sign. The 6th Vital Sign is a 10-item self-report instrument designed to be routinely administered to hospitalized children and adolescents, ages 6 years to 21 years, once during each hospital day. An example item is “my nurses try not to hurt me.” Nurses will respond to these reports by making relevant changes in the children’s care plans. In this longitudinal, randomized, controlled clinical trial at

Nationwide Children’s and Advocate Hope, participants will be randomized to a control, attention control, experimental-paper, or experimental-electronic study group. Outcomes include the children’s current physical and emotional symptoms measured by self-reported levels of fear, sadness, anger, worry, fatigue, and pain. Nurses will evaluate the utility and feasibility of the 6th Vital Sign intervention from their own perspectives.

Our research team strongly believes that daily improvements in children’s physical and emotional symptoms and the quality of nursing care will improve from the perspectives of each group when children and their nurses are systematically engaged in a mutual assessment of children’s nursing care experiences and expectations.

6th Vital Sign: Hospitalized Children’s Evaluation of the Quality of

their Daily Nursing CareNancy A. Ryan-Wenger, PhD, RN, CPNP, FAAN

POSITIVE NURSE BEHAVIORS............... N (%) ....................... HOW THIS MAKES ME FEEL Gives me what I need when I need it ...........210 (42.3) ................... Like they really care, like I am important, happy Checks on me often ....................................172 (34.7) ................... Good, safer, that she cares about me Talks, listens to me .....................................163 (32.9) ................... At ease, very important, like they care, good Nice, friendly ...............................................158 (31.9) ................... Happy, not so nervous, that I am special Gives me medicine .....................................144 (29.0) ................... More comfortable, safe, less pain, like I will get well Gives me things to do .................................142 (28.6) ................... Happy, not bored, very very happy Helps me do things ......................................100 (20.2) ................... They care about me, happy, like I am the best patient Takes care of me ......................................... 87 (17.5) .................... Good, secure, better about being here Makes me comfortable ................................ 82 (16.5) .................... Good, a lot better, as if they really care about me Laughs and jokes with me .......................... 60 (12.1) .................... Great, happy, like I’m not a kid or a regular patient Plays with me ............................................. 54 (10.9) .................... Really happy, good Gives me respect and privacy ...................... 34 (6.9) ...................... Important, like they care about my sleep NEGATIVE NURSE BEHAVIORS ...................N (%) .......................... HOW THIS MAKES ME FEEL Hurts me; makes me uncomfortable ...........206 (58.5) ................... Kind of scared, pain, hurt, mad, uncomfortable Wakes me up ............................................... 85 (24.0) .................... Mad and tired, not very happy, tired and dizzy Doesn’t give me what I need ....................... 67 (18.9) .................... Bad, mad, like they don’t care about me Doesn’t talk or listen to me .......................... 25 (7.1) ...................... Annoyed, frustrated, irritated Not nice or friendly ...................................... 25 (7.1) ...................... Sad, scared, kind of sad and mad No respect or privacy ................................... 19 (5.4) ...................... Exposed, aggravated, like they don’t respect me


In RecognitionEosinophilic Esophagitis: An Allergic Response that

Can Mimic RefluxPRESENTATIONSCheryl Boyd, Susan Copeland, Margaret Burns: “The Management of Quality and Outcomes of Academic Partnerships: Moving from Paper to the Electronic Age,” National Nurs-ing Staff Development Organization Conference, July 2011

Maureen Sims, Gretchen Bodnar: “Integrating Ambulatory-Specific Components into an Already Existing Nursing Orientation Program,” Pediatric Nursing Conference, October 2011

Cheryl Boyd, Susan Copeland, Margaret Burns: “The Management of Quality and Outcomes of Academic Partnerships: Moving from Paper to the Electronic Age,” The Honor Society of Nursing, Sigma Theta Tau International, October 2011

Melanie Stevens: “Passy Muir Valve (PMV) Use in the NICU,” American Speech-Language & Hearing Associa-tion meeting, November 2011

Barbara Draheim, Jill Karnes, Lynn Pease: “The Cost of Caring: Self-Care for Palliative Care Professionals,” Midwest Care Alliance Annual Conference for Home, Hospice and Palliative Care, November 2011

Claudia Lupia: “Bleeding Disorder Versus Child Abuse,” National Hemophilia Foundation’s Annual Meeting, November 2011

Carol McGlone: “Documentation by School-based Nurses,” Columbus Public School Nurses’ Professional Education Day, February 2012 Holly Miller-Tate, Cliff Cua: “Interstage Weight Gain for Patients with Hypoplastic Left Heart Syndrome Undergoing the Hybrid

Procedure,” Cardiology 2012: Developing a Lifelong Interdisciplinary Strategy for Your Patient with Congenital Heart Disease, February 2012

Kimberly Cyphert, Rise Gordon, Barry Halpern, Stephanie Stafford: “Implementation of a Morphine Protocol to Treat Neonatal Abstinence Syndrome,” Annual Nationwide Children’s Hospital Neonatal Retreat, February 2012

Correction in Winter 2011 issue:Claudia Lupia: “Factor IX the Royal Disease,” National Hemophilia Foun-dation’s Annual Meeting, November 2010 (not November 2011)

CERTIFICATIONSKellie Bass: Outstanding Graduate Student Award for the Neonatal Nurse Practitioner Program, June 2011

Kellie Bass: NCC Neonatal Nurse Practitioner Boards, July 2011

Alicia McVity: Pediatric Emergency Nurse, September 2011

Jeanette Corlett: Sigma Beta Delta, Honor Society of Business, Manage-ment & Administration, November 2011

Solomon Atnafu: Certified Post Anesthesia Nurse, December 2011

Morgan Dunn: Vascular Access Board Certified, December 2011

Ginger Radcliff: Vascular Access Board Certified, December 2011 Wing Shan (Sandy) Tam: Certified Specialist in Pediatric Nutrition, January 2012

Linda Adams: PNCB recertification, February 2012

Taralyn Johnson: ANCC Pain Management Exam, February 2012

Cheryl Kokensparger: Certified Pe-diatric Nurse Exam, February 2012

Lauren Renner: ANCC Pain Management Exam, February 2012

Sara Ellis: Level III NICU certification, March 2012

PUBLICATIONSStevens, Melanie; Finch, Jennifer; Justice, Leslie; Geiger, Erin: “Use of the Passy Muir Valve in the Neonatal Intensive Care Unit,” Neonatal Intensive Care: The Journal of Perinatology-Neonatology, November/December 2011

GRADUATIONSKellie Bass: Master of Science in Nursing, Neonatal Nurse Practitioner, Ohio State University, June 2011

Elizabeth Spears: Associate’s Degree in Nursing, Chamberlain College of Nursing, October 2011

Cathy Lang: Master of Science in Nursing, Case Western Reserve University, January 2012

Kelly Kennedy: Master of Science in Nursing, Hospital Administration, Capital University, May 2012

AWARDSBecky Thorn: $2,500 Society of Pediatric Nursing Scholarship, Society of Pediatric Nursing, March 2012

Sandra Jacobs, Nurse Practioner, PAA

Have you heard about a child with regurgitation, heartburn and swallowing difficulty? Your first thought may be that he or she has gastroesophageal reflux or GER. While that may be the case, there is another medical condition with similar symptoms. Eosinophilic Esophagitis (EE) is an allergic inflammatory condition of the esophagus with symptoms that can mimic GER. Children can present with a variety of symptoms including difficulty swallowing, epigastric pain, recurrent vomiting, food impaction, and, in younger children, poor growth and feeding aversion. This condition is more commonly found in males and is often diagnosed between the age ranges of 7 and 12 years of age. While EE was not recognized as a separate clinical entity until the 1990s, it has been discussed in the medical literature since the 1930s. There has been an increase in the number of patients diagnosed with EE with reported prevalence as high as four cases per 10,000 children.

Eosinophilic esophagitis is often associated with other diagnoses including allergic rhinitis, asthma and eczema. The diagnosis of EE requires an upper endoscopy with pinch biopsy. This is not the first line of diagnostic evaluation of symptoms consistent with reflux. Children may undergo other diagnostic tests including upper GI series. The upper GI may show a “ringed esophagus” but, in most cases, is found to be unremarkable. Although not thought of as a diagnostic test, a trial of acid-blocking medicine is tried as an attempt to provide treatment and to relieve symptoms. A brief trial of an H2 blocker such as ranitidine may be initiated first. If the symptoms do not improve, a trial of a proton pump inhibitor (PPI) such as lanzoprazole or omeprazole is considered. When those therapies do not offer relief of the child’s symptoms, an upper endoscopy is considered as a means of ruling out other reasons for the child’s ongoing symptoms.

During an upper endoscopy, the physician inserts an endoscope to visualize the esophagus, stomach and the first portion of the small intestine. The diagnosis of EE can often be suspected on visual inspection of the esophagus by the presence of linear furrowing, by the loss of vascular markings, and by edema caused by inflammation. If a patient is on acid-blocking therapy, pinch biopsies are necessary to confirm the diagnosis of EE. Once the diagnosis is made it is important for the family to understand the diagnosis and the difference between EE and the classic allergy-type symptoms. A referral to an allergist may be helpful in assisting the family in understanding these issues.

Currently, the treatment approach to managing EE consists of three strategies. The first is dietary elimination if specific food allergens can be identified. If no specific allergens are identified and the child’s symptoms are severe, they made be placed on a hypoallergenic diet, where all sources of protein are replaced with an amino acid-based formula. This can be extremely difficult since these formulas are often non-palatable and may require placement of a feeding tube. While there are no medications that specifically treat and eliminate the condition, topical steroids may be used to help control the inflammation by trying to eliminate eosinophils in the esophagus. This is accomplished by the child spraying the aerosolized steroid directly into the mouth and swallowing. The steroids are those classically used as inhalation therapy for the treatment of asthma. The child is then instructed to not eat, drink or brush his or her teeth for at least 30 minutes after administration. Acid suppression with PPI may also be used in combination with the swallowed steroids. The duration of treatment depends upon the patient’s response to the therapy. A follow-up endoscopy may be recommended to determine the effectiveness of the therapy.

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