Ohio Nurse - March 2021

emiller

Volume 14 | Number 2 | March 2021

Quarterly publication direct mailed to approximately 10,000 RNs in Ohio

and delivered electronically via email to 260,000+ RNs and LPNs in Ohio

Moral Injury in the

Nursing Workforce

Page 8

What’s inside this issue?

Hospital Licensure May

Finally Come to Ohio

Page 18

Nurse Licensure Compact – Why Isn’t Ohio a Compact State?

Tiffany Bukoffsky, MHA, BSN, RN &

Jessica Dzubak, MSN, RN

Takeaways:

• The loss of authority, sovereignty, and regulatory

power of the Ohio Board of Nursing following

participation in the Compact puts Ohio patients

at risk.

• Joining the Compact will place a significant

financial burden on the Ohio Board of Nursing

and Ohio nurses.

I have heard a lot of states are joining the Nurse

Licensure Compact. What does this mean, and is

Ohio going to join?

The Nurse Licensure Compact (NLC) provides

a multistate license that allows nurses who hold a

Compact license in participating states to practice

in other states that belong to the Compact without

obtaining additional licenses in each individual

state. It is run by the Interstate Commission of

Nurse Licensure Compact Administrators, a part

of the National Council State Boards of Nursing

(NCSBN). Currently, thirty-four states have enacted

the Enhanced Nurse Licensure Compact, with five

states, including Ohio, having pending legislation.

Supporters and proponents of the Compact

claim it is convenient for nurses who wish to

practice in multiple states, such as travel nurses

or those living on the border of multiple states.

However, the Compact is not without its risks.

The Ohio Nurses Association (ONA) has reviewed

the Nurse Licensure Compact and weighed the

benefits and risks of Ohio joining the Compact.

In the past, ONA has not supported the Compact

because of these risks, however, ONA has worked

tirelessly over several interested party meetings

since the summer of 2020 to address concerns

with introduced legislation. Senate Bill 3, the

most recent Nurse Licensure Compact bill, was

introduced by Senator Kristina Roegner in January

of 2021. ONA has continued to work in good faith

with the Senator, along with a representative from

the National Council of State Boards of Nursing

(which oversees the Compact), and the Ohio

Board of Nursing, to add amendments that are now

included in the current version you read today.

Ohio Nurses Association’s and Ohio Board of

Nursing’s Position on NLC

In 2005, the Ohio Board of Nursing (Board)

reviewed and examined the multi-state licensure

compact and, by Board vote, decided at that time to

“delay action seeking the introduction of interstate

compact legislation until such time more information

[was] gathered to assure that the benefits of multistate

licensure outweigh[ed] any risks related to

public safety”. The Board, since its first introduction

to multi-state licensure, worked at the national

level to address Ohio’s concerns. At its April 2019

meeting, the Board updated and reissued its position

statement. Per the 2019 statement:

Since 2005, the Board has discussed multistate

licensure at numerous meetings and

continuously has worked at the national

level to address Ohio’s concerns. Annually

the Board has discussed the Compact and

has reaffirmed its belief that the potential

risks of harm to the public outweigh the

potential benefits because nurses with multistate

licenses could practice in Ohio without

meeting the current statutory and regulatory

standards established by the General

Assembly and the Board to protect the public.

The Board continues to address these issues

through the National Council of State Boards

of Nursing (NCSBN).

The Board reviewed the eNLC to weigh

the benefits and potential risks. Concerns

regarding the eNLC include (but are not limited

to) the following:

(i) the eNLC would establish a Commission

that would be funded by state revenue, but

would not be subject to state transparency

requirements (open meetings/open

records acts);

(ii) the Commission could adopt rules binding

on Compact member states without

undergoing state rule-making processes;

(iii) concern was expressed that state would

be ceding their legal authority to a privately

operated Commission.

Nurse Licensure Compact continued on page 6

Inside this Issue

current resident or

Non-Profit Org.

U.S. Postage Paid

Princeton, MN

Permit No. 14

Nurse Licensure Compact.................1

Message from the Chair..................2

You Should Run.........................3

What’s New on CE4Nurses................3

Upcoming Events .......................3

Why Should I Care About Health

Policy & The ONA Advocacy Network? .....4

Ohio Nurse Receives ANA Diversity Award......5

Moral Injury in the Nursing Workforce........8

Ask Nurse Jesse.......................10

The Year of the Nurse and the Midwife -

An Interview with Penny Marzalik........ 11

Continuing Education - The Role of the

Nurse in Patient & Family Education........ 12

Happy Volunteer Month! .................16

Nurse Mandatory Overtime

Companion Bills Introduced.............16

American Nurses Foundation Launches

National Well-being Initiative for Nurses ... 17

Hospital Licensure May Finally Come

to Ohio................................ 18

The 1st Annual ONA Human Trafficking

Awareness Symposium. . . . . . . . . . . . . . . . . . . 19

Are you Re-Licensure Ready?................. 19


Page 2 Ohio Nurse March 2021

A colleague of mine recently

said, “We are all in the same

storm, but we are not all in

the same boat.” That conjures

up quite a vision in my mind. I

see a dark, rolling sea. There

are a few large, multimilliondollar

yachts. The people on

board are dining, drinking and

dancing. They’re barely aware

of the storm.

There are many mid-size

boats. Some are taking precautions

to avoid the storm

MESSAGE FROM THE CHAIR

Susan Stocker, RN

ONF Chair

while others don’t really realize just how bad the

storm is and are taking their chances rather than

trying to reach safety.

Yet, others are in row boats. Some have capsized,

and the passengers are hanging on for dear life. And

finally, some don’t even have a boat. They are doing

whatever they can to survive the storm.

Unfortunately, many have already lost the battle

and succumbed to the rolling sea.

I think you get the picture. Nurses must not

forget about this catastrophic storm after it passes.

Research must be conducted on health disparities.

We all need the same tools and resources.

I see the sun on the horizon and calmer seas

ahead. There’s hope that we will make it out of the

storm. But wait, some of the boats are stuck in the

storm and can’t get out. They can’t see what the

others see.

In partnership with our City Health Department,

we hold a vaccine clinic on our campus every week.

We vaccinate 50 people each time. So far, I’ve seen

only one minority. She rode the city bus to the clinic,

and she noticed she was the only person of color

who was present. She asked, “Where are all of the

other black people?” I wondered the same. We need

to stop wondering and ask “Why?” And then working

together, we should develop a path forward.

Yes, I am hopeful there will be brighter days

ahead, but we all need to be in the same boat,

rowing in the same direction.

OHIO NURSE

The official publication of the

Ohio Nurses Foundation

3760 Ridge Mill Drive

Hilliard, OH 43026

(614) 969-3800

Web site: www.ohionursesfoundation.org

Articles appearing in the Ohio Nurse are

presented for informational purposes only and

are not intended as legal or medical advice

and should not be used in lieu of such advice.

For specific legal advice, readers should

contact their legal counsel.

2020-2022 Ohio Nurses Foundation

Board of Directors

Camp Nurses Needed!

CHAIRPERSON: Susan Stocker

VICE PRESIDENT: Shelly Malberti

TREASURER: Annie Bowan

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If you are a qualified nurse who enjoys working with kids,

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SECRETARY: Joyce Powell

DIRECTORS:

Paula Anderson

Gina Severino

CEO / PRESIDENT:

Lisa Ochs

The Ohio Nurse is published quarterly in

March, June, September, and December.

Address Changes: The Ohio Nurse obtains its

mailing list from the Ohio Board of Nursing. Send

address changes to the Ohio Board of Nursing:

17 South High Street, Suite 400

Columbus, OH 43215

614-466-3947

www.nursing.ohio.gov

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contact Arthur L. Davis Publishing Agency, Inc.,

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to reject any advertisement. Responsibility for

errors in advertising is limited to corrections in

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Acceptance of advertising does not imply

endorsement or approval by the Ohio Nurses

Foundation of products advertised, the

advertisers, or the claims made. Rejection of

an advertisement does not imply a product

offered for advertising is without merit, or that

the manufacturer lacks integrity, or that this

Foundation disapproves of the product or its

use. ONF and the Arthur L. Davis Publishing

Agency, Inc. shall not be held liable for any

consequences resulting from purchase or use

of an advertiser’s product. Articles appearing

in this publication express the opinions of the

authors; they do not necessarily reflect views

of the staff, board, or membership of ONF.

Medical Disclaimer: This publication’s

content is provided for informational

purposes only and is not intended as

medical advice, or as a substitute for the

medical advice of a physician, advanced

practice registered nurse or other

qualified healthcare professional.


March 2021 Ohio Nurse Page 3

You Should Run

Yes, you! Why? Because the Ohio Nurses

Association (since 1904) has relied on a diverse and

qualified group of leaders to move the organization

forward. If you were a member or board member of

your SNA in college, does your career path include

leadership aspirations? If so, why not now? If you are

a staff nurse, your contribution beyond the workplace

matters. If you are an educator, administrator or

entrepreneur, we value your expertise. The ONA

Nominating Committee hopes to inspire you to run for

office in 2021 for ONA and now is the time to begin

thinking about it.

The October 2021 ONA Convention is October 4-7,

2021 and elections are held then. Offices to consider

are President, 1st Vice President, 2nd Vice President,

Secretary and Treasurer. These two-year terms are

Executive Committee positions. Vice president roles

vary according to the needs and leadership of the

president yet complement and support one another. In

addition, there are nine Board of Directors positions with

a service commitment of four years. Half of the directors

(four or five) are elected each biennium and represent

both EG+W and non-bargaining members. Duties are

established after the convention to fulfill the biennium

directives established by the House of Delegates.

So how do you get more information about the

offices? Contact current board members about their

roles or any of the seven Nominating Committee

Members who represent different geographical areas

in Ohio. As a matter of reintroduction, the 2019-21 ONA

Nominating Committee Members are:

Carol Sams, Chair, Cleveland, Cuyahoga County

caroljsams@gmail.com

Doris Edwards, Columbus, Franklin County

dorisedwards@columbus.rr.com

Deborah Schwytzer, Cincinnati, Hamilton County

debora.schwytzer@uc.edu

Connie Stopper, Kent, Portage County

stoppeco@mountunion.edu

Casandra Ball, Pierpont, Ashtabula County

ballsarerolling@gmail.com

Sara Harkleroad, Salem, Columbiana County

saraharkleroad@gmail.com

Gloria Kline, Massilon, Stark County

Gloriakline67@gmail.com

Please use this time as an opportunity to reach out to

us with questions. You can be assured to hear from us

often in the coming months.

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UPCOMING EVENTS

SAVE THE DATE

May 7th (During 2021 Nurses Week)

Virtual Nurses Choice Awards

Sign-up for the Ohio Nurses Foundation’s annual

fundraiser to celebrate the profession of nursing!

Scholarships and grants will be awarded to

recognized and noteworthy student nurses and

nurse researchers, as well as, nursing’s allies with

Nurses Choice Awards.

June 8th – The Retired Nurses Forum

presents: Healthcare Issues Potpourri 2021

October 4th – The Cornelius Leadership

Conference - Virtual

October 5th-6th – ONA Virtual Convention

Join us for Convention 2021: where Ohio’s

nurse leaders are coming together to create

a vision for nursing and healthcare for the

year 2022 and beyond.

To view or register for all ONA events visit:

https://ohnurses.org/ona-events/

To become part of our dedicated team of professionals, please visit our career page at

https://vsecommunities.org/careers/

Currently hiring faculty in Cincinnati for

all specialty areas.

We change the life of one to care for the

lives of many

Student Success, Institutional Excellence, Relationships, Stewardship

Galen College is currently hiring expert educators and committed

professionals in all areas of expertise whose guidance and experience

contribute to the success of thousands of students entering the

nursing field every year.

Must have MSN, DNP or PhD degree

galencollege.edu/careers

The Ohio Nurses Association is accredited as

a provider of nursing continuing professional

development by the American Nurses

Credentialing Center’s Commission on

Accreditation. (OBN-001-91).


Page 4 Ohio Nurse March 2021

LEGISLATIVE HAPPENINGS

Why Should I Care About Health Policy & the ONA Advocacy Network?

Tiffany Bukoffsky MHA, BSN, RN

ONA Director of Health Policy

If you think you are too small to make a

difference, try sleeping with a mosquito.

The Dalai Lama sums up activism with that one

quote. Each of us has a voice and we all have the

opportunity and the obligation to speak up for what is

right. So what does that mean, exactly, when we are

talking about nursing?

Did you know that among the 99 members of the

Ohio House of Representatives and the 33 Ohio

Senators, only a few are healthcare professionals?

Of the current members, three are physicians

(Senator Steve Huffman, Senator Terry Johnson, and

Representative Beth Liston), one holds a Doctor of

Public Health in health policy (Representative Alison

Russo), one holds a Master of Public Health (House

Minority Leader Emilia Sykes), one is a Family Nurse

Practitioner (Representative Jennifer Gross), and one

is a nurse who hasn’t had an active RN license since

1995 (Representative Diane Grendell)? Take a moment

to let that settle in. Our Ohio General Assembly is made

up of 132 members and only two have the education

and training as a nurse, but only one holds an active

registered nurse and CNP license in Ohio. However,

our members show up in the “people’s house” to pass

laws that directly affect patient care and the nursing

Beavercreek Health and Rehab is looking for

profession. Even if you forget what your high school

civics class taught you about how a bill becomes a law,

you know enough about the government process to

realize that the majority of our legislators are passing

(or not passing) laws for a profession to which they have

limited experience in. Now, I obviously do not expect

our legislators to become experts in every field of

study, nor do I blame them for using their own personal

background, knowledge, and experiences to formulate

their opinion on health care and nursing. However, we

have the unique opportunity as nurses to educate our

members of the General Assembly.

In nursing school, we are taught that it is the nurse’s

responsibility to help foster autonomy, integrity, social

justice and to be our patient’s advocate, but when is it

ingrained within us to do the same among our peers

and our profession? Who is the nurse’s advocate? How

do we advocate for our own profession? As nurses, we

value the dignity and worth of each human being and

we tend to put others’ needs before our own. To this, I

raise the questions; do you personally feel the dignity

and worth of the nursing profession? Do you advocate

for your own profession? Would you put your own and

your profession’s needs first if it meant saving patients’

lives?

If nurses aren’t advocating for their own profession,

no one else will. I do not mean to sound cynical, but the

concept of, “The squeaky wheel gets the grease” most

certainly applies to the legislative process and how

decisions are made at the Statehouse. Legislators get

ideas for bill proposals from their constituents, district

leaders, special interest groups (like nurses), and

from their own background knowledge and personal

experiences.

If nursing is not at the table when decisions are

made, the voice of nursing will never be heard.

We all know that nurses spend each day educating

patients and families about disease processes,

treatment options, and medications, among many other

things. We also know that nurses are the healthcare

experts because we are at the bedside 24 hours a day,

7 days a week. So why not use this expertise to educate

our members of the General Assembly?

With well over 210,000 licensed registered nurses

in the state of Ohio, we have the unique opportunity

to advocate for our profession, patient safety, and the

future of health care. Imagine if every registered nurse

partnered with their elected officials and became the

healthcare expert in both the House and Senate; if

every registered nurse communicated regularly with

the legislators in their district; if every registered nurse

had a personal relationship to which a legislator felt

comfortable enough to call upon when healthcarerelated

legislation is up for a vote. We would be much

more than a pesky mosquito or a squeaky wheel.

My challenge to you is to get involved in some way.

Write a letter to a legislator. Listen to the news once a

week. Read the weekend newspaper. Make phone

calls for a legislator you support. Help on the campaign

trail. Attend an Ohio Board of Nursing meeting. Join

a taskforce. Become active in your professional

association. Educate your colleagues on what’s

happening down at the Statehouse. Be your legislator’s

expert in nursing.

The Ohio Nurses Association has a couple of ways

to get involved!

ONA launched the Advocacy Academy and the

Legislative Ambassador program five years ago. To

date, ONA has trained over 100 registered nurses as

Legislative Ambassadors who have been assigned to

an Ohio legislative district to be the nurse expert in that

area. If this sounds like something you’d be interested

in joining, contact Lisa Walker for more information at

lwalker@ohnurses.org.

Three years ago, the ONA Policy team launched the

Ohio Nurses’ Action Center and Advocacy Network.

This Center is a place where you can keep up-do-date

with our profession’s biggest policy issues, as well as

what may be affecting health care in Ohio! You can

sign up as an advocate and take action on the issues

we care about most. To join the ONA Advocacy

Network, text ONAADVOCATES (all one word)

to the number 52886. Click on the link that you will

receive in the return text message and fill out your

information! The information you provide will be stored

in the Ohio Nurses’ Action Center and will only be used

for our advocacy efforts.

Join a powerful network of nurses and nurse

allies who care about advancing and protecting the

nursing profession and health care in Ohio.

You have nothing to lose, but the nursing

profession has everything to gain.

If I am not for myself, then who will be for me? And

if I am only for myself, then what am I?

And if not now, when?

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March 2021 Ohio Nurse Page 5

Ohio Nurse Receives

ANA Diversity Award

Barbara Brunt, MA, MN, RN, NPD-BC, NE-BC

Ronald Lee Hickman Jr., PhD, RN, ACNP,

FNAP, FAAN received the American Nurses

Association Diversity in Nursing Award in

October, 2020. This award was inspired

by two forward thinking nurse leaders,

Luther Christman and Mary Ellen Mahoney,

who, through their courage and pioneering

spirit, advanced diversity and inclusion

in the nursing profession. By challenging

the foundations of traditional thinking, they

introduced diverse perspective, fostered

creativity, and made a positive impact on

the profession and practice of nursing. This

award recognizes an individual registered

nurse or a group of registered nurses for long-standing commitment and significant

contributions to the advancement of diversity and inclusion within the nursing

profession.

Dr. Hickman is the inaugural Ruth M. Anderson Endowed Professor and

Associate Dean for Research at the Frances Payne Bolton School of Nursing, Case

Western Reserve University (CWRU). He is known nationally and internationally

for his groundbreaking research focused on testing technology-based innovations

to support decision making and chronic illness management, his unwavering

commitment to mentoring nurse scientists, and advocacy for increasing diversity,

equity, and inclusion in the nursing profession and its science.

Dr. Hickman started his education at CWRU with a Bachelor of Arts in Biological

Science and then received a Certificate of Professional Nursing. He received

a Master of Science in Nursing as an Acute Care Nurse Practitioner and then

went on to receive a Doctor of Philosophy from CWRU in 2008. He was the first

African American male to graduate from the PhD program. After he completed his

doctorate, he did a post-doctoral fellowship focusing on multidisciplinary clinical and

translational research with the School of Nursing and School of Medicine at CWRU.

In addition to being named a Fellow of the American Academy of Nursing. Dr.

Hickman is also an elected fellow of the National Academies of Practice (NAP).

NAP is a non-profit organization founded in 1981 to advise government bodies

on our healthcare system. This interprofessional group of healthcare practitioners

and scholars is dedicated to supporting affordable, accessible, coordinated quality

healthcare for all. NAP is dedicated to lifelong learning from, with, and among

different healthcare professions to promote and preserve health and well-being for

society.

Dr. Hickman is proud of the fact that he is one of only two nurses to be

recognized as an Emerging Leader in Health and Medicine Scholars by the

National Academies of Medicine. This three-year program, which started July 1,

2020, connects the ten selected professionals with leaders in all three branches of

the National Academies of Sciences, Engineering and Medicine. Hickman said he

is looking forward to the opportunity to connect with NAM members to “go beyond

disciplinary silos” to see a broader view of public health and policy in America.

School of Nursing Dean Carol Musil said the NAM Emerging Leaders award is

indicative of Hickman’s past work and future possibilities, “but even more, it speaks

to his potential for groundbreaking contributions to transforming the future of health

care for this nation.”

The accomplishments that led to the diversity award are too numerous to list.

Highlights of his many accomplishments are listed below:

• Collaborated with the Vice-President for Diversity and Inclusion at CWRU to

draft the university’s first mandated training program for all faculty, staff, and

students on mitigating bias.

• Conducted research studies funded by the National Institute of Health (NIH) to

promote health equity among Americans who are marginalized by society.

• In addition to sustaining partnerships with minority-serving institutions to

create a pipeline, served as a champion for providing the needed resources to

move the needle of diversity for the profession.

• Help founded a chapter of the American Association of Men in Nursing.

Dr. Hickman’s technology-based interventions leverage serious game

technology and conversational agents or avatars, three-dimensional digital

representations of human in virtual environment, to facilitate behavior change and

decision support. His technology-based interventions (eSMART-HD, eSMARTT,

and INVOLVE) that incorporate avatars have been shown to significantly improve

outcomes of patients and family caregivers. His innovative technology-based

interventions using avatars are shifting nursing and decision science toward

on-demand technology-based interventions that offer effective alternatives for

clinical or paraprofessional-led support to improve self-management behavior and

enhance the quality of healthcare decisions.

Dr. Hickman has an impressive record of external funding and recognition. He

has been principal investigator or co-investigator on more than 20 research and

training grants totaling over $20 million. He has disseminated his research through

150 peer-reviewed journal articles, commentaries, chapters, books and scientific

presentations.

Committed to mentoring nurse scientists and leaders, Dr. Hickman has served

as a dissertation advisor or committee member for nearly 50 PhD and DNP

students. Additionally, he has been the primary mentor to six NIH funded postdoctoral

trainees. He has mentored nurses from seven different countries around

the world.

In his spare time, Dr. Hickman spends time with his wife and enjoys perfecting

whiskey cocktails, and listening to jazz. During the pandemic he has become a

Peloton cycling enthusiast.

Visit ohionursesfoundation.org for more information

WE DON’T JUST

TREAT SYMPTOMS.

We take care of the entire person.

If you’re a nurse practitioner

interested in psychiatric or primary care,

contact us!

Text ASPIRE

to 89743

Or call us at

(317) 587-0500


Page 6 Ohio Nurse March 2021

Nurse Licensure Compact continued from page 1

Further, the Board continues to be concerned

about public safety issues due to differences

between states that are not addressed in the

Compact, such as mandatory reporting, complaints

and investigations. Mandatory reporting is not a

requirement for all Compact states as it is in Ohio.

Also, complaints and investigations are handled

differently. For example, some Compact states

require clear and convincing evidence to substantiate

a violation of their Nurse Practice Acts. Ohio requires

a preponderance of evidence. Because clear and

convincing evidence is a higher standard of proof

than a preponderance of the evidence, those boards

may not investigate complaints that the Ohio Board

of Nursing would investigate.

Financial Impact-

During an Ohio Board of Nursing meeting held on

January 11th, 2021, the Executive Director shared

information with members of the Board regarding

the impact of Ohio entering the Nurse Licensure

Compact. Of top concern to her was the financial

impact on Ohio nurses and the state. According to

preliminary information, the Board stated that:

Based on data obtained from the Ohio eLicense

system, for RNs and LPNs with Compact state

addresses, the loss of revenue is estimated to be

$1,930,010.00 over a one-year period. Compact

state residents with multi-state licenses would no

longer reinstate, reactivate, or renew in Ohio. For

example, Compact nurses are required to renew

in their home state/state of residence. Therefore,

for nurses with addresses in Compact states

who practice in Ohio, it is likely they will have or

will obtain multi-state licenses. In these cases,

the nurse will renew in their home state and no

longer renew in Ohio. Ohio will lose the renewal

fees previously paid. The same applies if their

license lapses or is made inactive – they will not

reinstate or reactivate their license in Ohio and

those fees will be lost.

While language has been included in Senate Bill

3 that allows the Board to charge additional fees for

nurses choosing to apply for a Compact license, the

revenue generated from this new Compact license

would not sufficiently offset the loss in revenue from

multi-state licensees.

Therefore, ONA believes this loss in revenue

would be passed on to Ohio nurses choosing a

single, home state license or to the state of Ohio, and

licensing fees would increase for Ohio nurses.

State Sovereignty and Authority of the Interstate

Commission-

The Attorneys General in Oklahoma, Indiana,

Kansas, Louisiana, and Nebraska have rendered

formal opinions that the multi-state nurse licensure

Compact interferes with state sovereignty. The

Compact would impose complicated regulatory

mechanisms that would allow the joint public entity

known as the Interstate Commission of Nurse

Licensure Compact Administrators (Commission),

composed of the party states that adopt the

Compact, to promulgate rules that are binding on

each state in the Compact by a simple majority vote.

This essentially grants full rule-making authority to

the Commission, which is not a government entity

or state agency, nor based in Ohio. According to

the National Council of State Boards of Nursing,

each state would be subject to administrative

rules not passed at the state level. In this way, the

Commission is usurping policy-making authority

from the Board and state Legislature. Additionally,

the Commission has “enforcement action” authority,

which means that the Commission has the authority

to remove any state from the Compact, should a

state board of nursing not adhere to the Compact

statute and/or rules. This again, represents an

appropriation of Ohio’s sovereignty.

The Commission would have the opportunity to

hold closed, non-public meetings for certain reasons

and would have immunity to lawsuits. Many of these

provisions of the Compact may violate the Ohio

Constitution, the Ohio Open Meeting Act, the Ohio

Ethics Law and/or Ohio statute and may potentially

create a monopoly system, where NCSBN holds

full national licensure examination and regulatory

authority. Some states that have joined the Compact

are witnessing violations of their state’s open

public meeting laws. For example, New Mexico

has open meeting laws similar to Ohio’s, and when

the New Mexico legislature passed a law requiring

that documents related to the administration of

the Compact be released per New Mexico’s public

disclosure laws, the Commission sent a letter

threatening New Mexico with legal action.

The Compact language in SB 3 states, “The

Commission shall have the following powers: To

promulgate uniform rules to facilitate and coordinate

implementation and administration of this Compact.

The rules shall have the force and effect of law and

shall be binding in all party states.” Essentially, the

Commission has the power to enact rules that are

binding on each state in the Compact by a simple

majority vote. ONA agrees with the following Ohio

Board of Nursing comments during their January

11th meeting: “Each State would be subject to

administrative rules not reviewed under the same

State processes as other rules and not passed

or reviewed at the State level. This provision may

violate the Ohio Constitution and possibly federal

anti- trust laws requiring “active state supervision”

depending on the rule.”

The Compact language also allows the

Commission to “convene in a closed, non-public

meeting” for certain reasons, and this is concerning

to ONA. While we appreciate the fact that most

Compact meeting materials and agendas are

available to the public online, we remain concerned

about the ability of the Commission to use the

exceptions to the public meeting provision to flout

transparency. Additionally, the Commission has

immunity/defenses to lawsuits and is not subject

to any independent auditor or legal authority with

oversight over its operations or finances. From

ONA’s perspective, this setup gives power and

control to a non- governmental entity that receives

money from a not-for-profit organization that also

develops the nursing licensure examination taken

by nurses across the country. Rather than removing

unnecessary big government from the licensure

process, the Compact, in ONA’s opinion, transfers

this power to an independent national organization

with little accountability. In fact, many states have

questioned whether the Interstate Commission

violates individual state constitutions and interferes

with state sovereignty. In December of 2020, the

Michigan governor vetoed the Nurse Licensure

Compact, stating that the Compact would take

“away the state’s authority to regulate the nursing

profession”.

Regulation, Public Safety, and Disciplinary Action-

The mission of the Ohio Board of Nursing is to

actively safeguard the health of the public through

the effective regulation of nursing. However, the

Compact would not require that out- of-state nurses

be licensed in the state of Ohio, which means that

the Board would no longer review and approve

license applications from out-of-state residents.

In addition, the effects of how disciplinary actions

would work in practice in other Compact states are

unclear. Because a nurse would have jurisdiction to

work in a remote state without that state’s licensure,

it is unclear how that remote state would know to

check an individual nurse’s license and previous

disciplinary actions.

During a 2020 interested party call between ONA,

the Ohio Board of Nursing, and a staff member from

the Commission at the National Council of State

Boards of Nursing (NCSBN), NCSBN stated that

disciplinary action is two-fold for states who join the

Compact. The remote state Board of Nursing would

have authority to discipline a non-Ohio nurse through

privilege to practice restrictions, but only the home

state Board of Nursing would have the authority to

take action on the license itself. Thus, the Ohio Board

of Nursing would not have the authority to place

licensure restrictions or take action on an out-of-state

Compact license. It is unclear how the remote state

would stay in constant contact with each home state’s

licensees and what disciplinary actions have been

taken on the license itself, and vice versa. As stated

in the January 11th, 2020 Ohio Board of Nursing

meeting materials, “If the remote state does not know

the nurse is practicing in their state, it is not clear how

the remote state would know to check the individual

nurse’s license/discipline in Nursys (an online license

system used by some states)”


March 2021 Ohio Nurse Page 7

Additionally, the effects of regulation, licensing and

the lack of absolute bars significantly compromises

public safety and places the responsibility for

screening licensees onto the employers. Employers

would ultimately be the ones be accepting or denying

nurses for practice and not the regulatory Board.

Furthermore, Ohio is a mandatory reporting

state- which means that employers are mandated to

report nurses to the Board of Nursing for potential

practice violations. Mandatory reporting, however, is

not a requirement of the Nurse Licensure Compact.

According to the Ohio Board of Nursing documents

shared on January 11th, “The lack of this requirement

in other states impacts Ohio because employers

and others may not report potential violations. This

increases the possibility that nurses with multistate

licenses (MSLs) may not have been reported to their

home state board of nursing and these nurses will be

practicing in Ohio.”

While ONA respects the perspective of the

Compact that this system must be successful

because 34 states have chosen to join the Compact,

we believe the lack of state registration requirements

and disciplinary action tracking does not provide

adequate data to determine if Compact license is

truly successful and safe.

Voice of Professional Nurses Associations-

The way the Compact shifts power to the

Commission, giving it the authority to enact rules

that are binding on each state in the Compact, takes

power and authority away from the Ohio Board of

Nursing. If there was a dispute between Ohio and

the Commission, the matter would be handled in the

Illinois court system, where NCSBN is located, and

not in our state’s jurisdiction. ONA believes this takes

influence away from professional associations and

does not provide other interested parties an opportunity

to voice opinions, suggestions, or concerns during the

promulgation or review of administrative rules. ONA

currently has the valued opportunity to participate in

such processes with the Board.

The Commission holds four meetings a year,

two of which are in Chicago and two of which are in

other various locations across the country. While the

meetings are open to the public, it is unclear as to

how the voice of Ohio nurses would be heard at the

meetings.

(7) The individual is providing nursing care

during any disaster, natural or otherwise,

that has been officially declared to be a

disaster by a public announcement issued

by an appropriate federal, state, county, or

municipal official;

Therefore, enacting compact licensure for Ohio

is not necessary to protect Ohioans in the case of

an emergency. Licensed nurses from other states

may practice in Ohio in these situations without

having a multi-state license.

Complexity of Telehealth Services-

ONA understands and appreciates the need

for mobility and flexibility for nursing practice

in today’s healthcare environment, as well as

the accessibility that telehealth services offer

to healthcare professionals and patients. While

telehealth is necessary, the services provided and

where they are provided need to be considered.

License jurisdiction and the preeminence of

both patient and nurse location has been long

discussed among regulatory boards and nurses

throughout the country.

Nurse regulatory boards believe license

jurisdiction and practice belongs where the patient

is located, while professional nurses’ associations

and nurses believe license jurisdiction and

practice lies where the nurse is practicing. The

Compact has and will always be based on the

premise that the practice of nursing occurs where

the patient is located. This fundamental belief that

governs the operations of the Compact hold both

the nurse and patient at significant risk.

Based on the ideology that practice follows the

patient, a nurse engaging in telehealth must know

the exact location of every patient he/she is providing

care to. It also means that any nurse offering

telehealth services should know, understand, and

abide by all fifty states’ practice laws and rules. A

patient could theoretically be on vacation in another

state or in an entirely different country and it would

be the responsibility of the nurse to know where the

patient is located and what the nurse can practice

through telehealth services to be safe and effective

in that state or country. The Compact assumes that

scope of practice is identical in all fifty states and

that every nurse working in telehealth is familiar

with every state in which they are practicing. This is

neither accurate, nor is it realistic. ONA believes this

puts patients and nurses at risk.

Protecting Ohio Nurse Jobs-

The Ohio Nurses Association is committed to

protecting nurses across the state through labor

representation and collective bargaining contracts.

Part of this representation includes advocating

for a fair contract and protecting nurses’ jobs.

Healthcare organizations will lose incentives to

come to fair collective bargaining agreements

with Ohio nurses if the licensure Compact is

enacted, as it allows out-of-state nurses to easily

replace Ohio nurses who are advocating for

safe work environments and fair compensation.

Furthermore, the ONA opposes the multi-state

nurse licensure Compact because it allows

greater opportunities for out-of-state nurses to

work in Ohio facilities in the event of a labor union

strike. Not only does this directly impact the jobs

and financial security of our members, the ONA

has great concerns about public safety should

an influx of out-of-state nurses, who are not

familiar with our state’s Nurse Practice Act, begin

practicing and caring for Ohioans. Coupled with

the decreased regulatory authority of the Board

and the complex disciplinary processes outlined

by NCSBN, the Ohio Nurses Association believes

the Compact is not in the best interest of Ohio’s

nurses and all Ohioans.

ONA appreciates the continued conversations

and working with Senator Roegner and all the

other interested parties to address concerns

with SB 3 and the Compact. However, based on

the above remaining concerns and unanswered

questions regarding the financial impact and

disciplinary processes, ONA respectfully remains

an interested party at this time.

Ohio Offers State of Emergency Practice for Outof-State

Nurses-

Supporters of the Compact believe that Ohio

needs to join the Compact to allow nurse mobility

during times of disasters or emergencies. ONA

realizes that the ability to mobilize nurses to Ohio

during such emergencies and disasters is critical;

however, Ohio already covers this need under

Section 4723.32(G)(7) of the Ohio Revised Code.

Section 4723.32(G)(7):

(G) The activities of an individual who currently

holds a license to practice nursing or

equivalent authorization from another

jurisdiction, but only if the individual’s activities

are limited to those activities that the same

type of nurse may engage in pursuant to

a license issued under this chapter, the

individual’s authority to practice has not been

revoked, the individual is not currently under

suspension or on probation, the individual

does not represent the individual as being

licensed under this chapter, and one of the

following is the case:

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Page 8 Ohio Nurse March 2021

Moral Injury in the Nursing Workforce

Cynthia Hammond, PhD, MS, RN, and

Shirna Gullo, DNP, MSN, BSN, RN

Kettering College Division of Nursing

Marquis and Houston (2017) emphasized the

prevalence of key terms identified to “describe the moral

indifference, moral uncertainty, moral conflict, moral

distress, moral outrage, and ethical dilemmas” faced by

nurses (p. 85). However, this list of terms did not include

moral injury. Moral injury was coined by the psychiatrist,

Dr. Jonathan Shay. Dr. Shay studied military veterans

that suffered from Post-Traumatic Stress Syndrome

(PTSD). He defined moral injury as a “betrayal of what is

right by someone who holds legitimate authority in a high

stakes situation” (Delima-Tokarz, 2017, p.1). As a result

of this research, Dr. Shay discovered that while soldiers

were in active duty, they could reconcile their own moral

values with military duty but when they returned to

civilian life, the same moral conflicts, caused the soldiers

internal distress or moral injury (Delima-Tokarz, 2017).

The purpose of this article is to discuss and explore

the following questions: Can the same moral injury seen

in military veterans be seen in nurses that fight the battle

of COVID-19 and the regular day-to-day challenges in

healthcare? Are nurses at all levels of the healthcare

organization, at the bedside and in administration having

to face internal and external demands that compromise

quality care, or patient and individual safety that could

lead to moral injury? What recommendations can be

integrated to help identify and intervene early in actual or

potential moral injury dilemmas?

According to the Ohio Nurses Association (2020),

moral injury can be defined as “the feeling that occurs

when we are prevented from doing what we believe

is right. We feel compromised in our ability to practice

as moral agents according to our Code of Ethics.” The

Code of Ethics for Nurses is the profession’s public

expression of those central ethical values, duties, and

commitments (ANA, 2015). Finally, Dictionary.com

(2020) defined moral injury as concerning itself with

right and wrong principles of behavior.

Exactly who or what becomes the compass of

assessing moral principles to determine what is

acceptable behavior by an individual or society?

(Delima-Tokarz, 2017). Perhaps, it is an internal

moral guide that directs how we live our daily lives

and actions? On the other hand, Beard (2019) found

moral principles represent treating others the way the

individual wants to be treated (being treated fairly),

speaking truth and avoid telling a lie (building trust),

avoiding spending what you do not have (living a

personable affordable life), and avoiding taking what

does not belong to you (building honesty). The moral

code is comprised of building blocks that construct

society’s culture (Beard, 2019). If our individual moral

code is damaged, a moral injury has occurred (Delima-

Tokarz, 2017). Therefore, each nurse and nursing

leader can turn to the nursing process which is the

framework at the heart of the provision of nursing

practice to help identify and rectify situations causing

actual or potential moral injury. Utilization of the nursing

process allows the nurse to promptly assess, diagnose,

plan, implement, and evaluate issues directed at

themselves, the patient, co-workers or the organization.

Nurse Burnout Versus Moral Injury

Dean, Talbot, and Dean, (2019) posited that the

difference between burnout and moral injury must

be identified because a better understanding will

reframe the problem and the solutions. The term

burnout indicates that an individual cannot withstand

something in the work environment. “Over the last 10

years, burnout has become a significant psychosocial

problem that is caused by unsuccessfully managed

chronic stress in the workplace. It is a psychological

syndrome characterized by energy depletion, increased

mental distance from one’s work (i.e. cynicism or

negativism), and reduced professional efficacy”

(WHO; ICD-11; 2013; 2018 as cited in Raudenska et al.

(2020). Because burnout is an internal and individual

problem, then a solution to burnout is to fix the internal

deficiency. Alharbi et al. (2019) identified anxiety,

depression, decrease in satisfaction, diminished quality

of care, PTSD, and an increase in suicide rates as

prevalent in healthcare professionals experiencing

burnout. This is contrasted with moral injury, which is a

description of knowing what care is needed for patients

and being unable to offer the care or treatment, due to

barriers beyond the control of the nurse (Dean et al.,

2019).

The moral injury debacle of the COVID-19 pandemic

has placed extreme pressure on the nursing workforce

daily with morally challenging dilemmas (Duhig, 2020).

According to Duhig, the morally challenging dilemmas

are being described as: fear of not being able to

protect the patient or self because insufficient supplies

of personal protective equipment (PPE). Nurses are

not able to provide quality care to patients. Nurses

are taking on roles that they are inadequately trained

to implement. Moral injury can be caused by severe

understaffing, poor team communication, conflict with

physicians about patient care, physician-only input into

clinical decisions, and clashes between physicians

and nurses regarding inappropriate use of resources

(Duhig, 2020).

Moral injury is present among nurses when nurses

feel that high standards of patient care are not being

met, personal values cannot be lived up to, personal

negative feeling of being devalued and voiceless which

can lead to shame or guilt of and mistrust of colleagues

and organizational administrators. The long-term

effects of moral injury can lead to mental health threats

(National Center for PTSD, n.d.). Marquis and Houston

(2017) echoed this point by saying that “nurses are

often placed in situations where they are expected to

be agents for patients, physicians, and the organization

simultaneously, all of which may have conflicting needs,

wants, and goals” (p. 84). Nurse leaders and nurses

need to implement strategies to reduce the incidence of

moral injury.

Nursing Solutions for Moral Injury

Nurse leaders can support nursing teams by

presenting moral injury as a lens to talk about personal

experiences. This informal peer group can be referred

to as “soul repair” (Duhig, 2020, p.1) The overarching

goal of supporting nurses is to move from an analysis

of the problem to a vision of a positive outcome (Duhig,

2020). This change in perspective and shared vision

can lead the nursing organization through the following

recommendations by Duhig (2020) and Dean et al.,

(2019):

• The nurse leader should focus on what small

or large steps can be taken to obtain a sense of

fulfillment.

• The nurse leaders can also reevaluate workflow,

revise team communication, strive to identify and

eliminate episodes of poor time management,

eliminate inefficient use of resources, and curtail

ineffective processes in daily practice and

operations of the departments (Duhig, 2020).

The healthcare team and nursing administrators

must work together to identify the problems that prevent

clinicians and other healthcare team members from

building trust and providing optimal care. The quality

and safety of patient care must be changed to put the

patient first instead of letting business practices drive

treatment options (Dean et al., 2019).

In a recent article by Dean et al., (2019),

recommendations given to address moral injury are

summarized below:

• Invite and expose administrators to the

innerworkings of the clinical environment. The

administrators and the clinician’s make-up the

interprofessional healthcare team. These two

parties must engage each other on a common

ground. If administrators would work a shift with

a clinician in various areas such as a clinic or the

emergency room, they would be exposed to the

challenges experienced by the nurses. These

encounters would expose administrators to the

depth of the challenges that occur in the system.

Clinicians need to be open-minded to see

the challenges from the overall administrative

perspective. Having an understanding from both

perspectives is where commonality and happy

mediums are found, and shared visions are

explored.

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March 2021 Ohio Nurse Page 9

• Change the paradigm that links patient satisfaction

with clinician compensation to clinician satisfaction

with executive compensation.

• Clinicians must have the ability to impact lobbying

efforts. Clinicians, like physician leaders, chief

wellness officers, department chairpersons, and

nurse leaders must open lines of communication

with those who can impact healthcare change.

• Establish and maintain a sense of community

and collaboration among clinicians. This can

be implemented by offering and fostering a

more supportive, mentoring, and team building

environment/culture instead of one where there is

increased competition.

Conclusion

The year 2020 has taken nursing by a vast

storm, namely COVID-19. The year 2020 can even

be described as a landlock tsunami. The sweep

of devastation that the wrath of previous tsunami’s

has echoed is a reflection of death and destruction.

The familiar memories of death and destruction are

reflections of how nurses have carried the banners of

care, treatment, loss, and success stories.

Ignatavicius, Workman, and Rebar (2018) validated

that “patient and staff safety is a major priority for

professional nurses. Best safety practices reduce

error and harm through established protocols, memory

checklists, and systems such as bar-code medication

administration” (p. 4). Even though the year 2020 has

taken nursing by an unprecedented, unexpected,

unrelenting surprise with this pandemic, the healthcare

team, especially nurses, has exhibited a matchless

resiliency and perseverance for this cause.

Nurses have been at the front lines, the first

responders, and the supporters of health care

throughout this ordeal. Nurses have worked their

scheduled shifts and overtime which have now

become a way of life. The tragedy of loss has been

overwhelming but recovery cases have encouraged

nurses, with a sense of duty to an internal calling.

This internal calling is the nursing oath (Dean et al.,

2019) which promotes us to a higher standard even

in the midst of a pandemic. One helpful tool to keep

in mind in helping to educate nursing leadership

and nursing staff about the prompt identification of a

potential or actual moral injury is “RACK:” Recognize

what is happening, Act promptly, Consult with the

nursing leader by following the chain of command

(chief nursing officer, nursing director, nurse manager,

supervisor, charge nurse, etc.), Keep alert to signs

and symptoms of moral injury and avoid and mitigate

situations within your control from occurring that

can lead to ethical dilemmas (S. Gullo, personal

communication, December 6, 2020).

Research is needed on the identification, response,

overall impact and effective resolution of moral injury in

the nursing workforce to specifically assess, diagnose,

plan, implement and evaluate prompt and intentional

efforts to mitigate any and all episodes of moral injury.

Healthcare organizations, nursing administrators,

nursing regulatory agencies, and nurses themselves

must take a stand to prevent and protect themselves

and their patients, from moral injury. Nurses must act

now!

References

Alharbi J., Jackson, D.,& Usher, K.(2019). Compassion

fatigue in critical care nurses. An integrative review

of the literature. Saudi Med J. 40(11):1087–1097.

doi:10.15537/smj.2019.11.24569.

American Nurses Association (2015). Code of ethics

for nurses with interpretive statements, https://www.

nursingworld.org/practice-policy/nursing-excellence/

ethics/code-of-ethics-for-nurses/coe-view-only/

Beard, S. ( 2019). Deep ethics: The long-term quest to

decide right from wrong. Future. Retrieved from: https://

www.bbc.com/future/article/20190617-deep-ethics-thelong-term-quest-to-decide-right-from-wrong

Dean, W., Talbot, S., & Dean, A. (2019). Reframing

clinician distress: Moral injury not burnout. Federal

Practitioner: For the Health Care Professionals of the

VA, DoD, and PHS, 36(9), 400–402.

Delima-Tokarz, T. (2017). The psychiatric ramifications

of moral injury among veterans. The American

Journal of Psychiatry. https://doi.org/10.1176/appi.ajprj.2016.110505

Dictionary.com (2020). Retrieved from https://www.

dictionary.com/browse/moral?s=t

Duhig, S. (2020). Relias Institute. Retrieved from: https://www.

relias.com/blog/are-your-nurses-experiencing-moral-injury

Ignatavicius, D., Workman, M. & Rebar, C. (2018).

Medical-surgical nursing: Concepts for interprofessional

collaborative care (9thed.). Elsevier.

Marquis, B. L. & Houston, C. J. (2017). Leadership roles

and management functions in nursing: Theory and

application. (9th ed.). Wolters Kluwer.

National Center for PTSD (Posttraumatic Stress Disorder).

(n.d.). Advancing science and promoting understanding

of traumatic stress: Moral injury in healthcare workers

on the frontlines of the Coronavirus (COVID -19)

outbreak. U.S. Department of Veterans Affairs.

Retrieved from: https://www.theschwartzcenter.org/

media/Moral-Injury-Covid-19-Fact-Sheet-040420_

JH.pdf

Ohio Nurses Association (2020). Moral Injury Research

Application. Retrieved from https://onaapply.smapply.io/

prog/moral_injury_research_application_/

Raudenská, J., Steinerová, V., Javůrková, A., Urits, I.,

Kaye, A. D., Viswanath, O., & Varrassi, G. (2020).

Occupational burnout syndrome and post-traumatic

stress among healthcare professionals during the novel

coronavirus disease 2019 (COVID-19) pandemic. Best

practice & research. Clinical anaesthesiology, 34(3),

553–560. https://doi.org/10.1016/j.bpa.2 020.07.008

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Page 10 Ohio Nurse March 2021

(A) A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner

who holds a license to practice nursing issued under section 4723.42 of the

Revised Code may delegate to a person not otherwise authorized to administer

drugs the authority to administer to a specified patient a drug, unless the

drug is a controlled substance or is listed in the formulary established in rules

adopted under section 4723.50 of the Revised Code. The delegation shall be

in accordance with division (B) of this section and standards and procedures

established in rules adopted under division (O) of section 4723.07 of the

Revised Code.

(B) Prior to delegating the authority, the nurse shall do both of the following:

(1) Assess the patient and determine that the drug is appropriate for the

patient;

(2) Determine that the person to whom the authority will be delegated has met the

conditions specified in division (D) of section 4723.489 of the Revised Code.

Question:

I put my Ohio RN License on inactive status a few years ago, but I want

to help administer the COVID vaccine. Is there a way I can do this?

Nurse Jesse:

While those with an active nursing license can work safely to the highest

extent of that license, Ohio does have provisions for administering the vaccine

without a current, active license.

Currently, SB 310 authorizes RNs, APRNs, and LPNs who hold Ohio licenses

that lapsed or were placed on inactive status within the past five years, to

practice without reactivating or reinstating the license, through May 1, 2021. This

does not apply to revoked, surrendered, or suspended licenses.

In accordance with Ohio law and rules, it may be possible for you to

administer the vaccine without an active nursing license under proper, authorized

supervision by an authorized provider.

The Ohio Revised Code (Nurse Practice Act) Section 4723.48 states

[emphasis added]:

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This means that under current law, if one is a former Ohio registered nurse with an

inactive license chooses not to reactivate/reinstate the license, it is possible they could,

with training updates and competency determinations (see 4723.489 ORC below),

administer immunizations via applicable Delegation Rules if an APRN or physician is

on site.

APRNs must however comply with all requirements of Section 4723.48, ORC, and

Section 4723.489, ORC, including specific requirements as to the unlicensed person’s

documented education and demonstrated knowledge, skills, and ability to administer

the drug safely, and the requirement that the APRN is on site during the delegated

medication administration.

Sections 4723.489 ORC for reference [emphasis added]:

ORC Section 4723.489, Delegated authority to administer drugs.

A person not otherwise authorized to administer drugs may administer a drug to a

specified patient if all of the following conditions are met:

(A) The authority to administer the drug is delegated to the person by an advanced

practice registered nurse who is a clinical nurse specialist, certified nursemidwife,

or certified nurse practitioner and holds a license issued under section

4723.42 of the Revised Code.

(B) The drug is not listed in the formulary established in rules adopted under

section 4723.50 of the Revised Code, is not a controlled substance, and is not

to be administered intravenously.

(C) The drug is to be administered at a location other than a hospital inpatient care

unit, as defined in section 3727.50 of the Revised Code; a hospital emergency

department or a freestanding emergency department; or an ambulatory

surgical facility, as defined in section 3702.30 of the Revised Code.

(D) The person has successfully completed education based on a recognized body

of knowledge concerning drug administration and demonstrates to the person’s

employer the knowledge, skills, and ability to administer the drug safely.

(E) The person’s employer has given the advanced practice registered nurse

access to documentation, in written or electronic form, showing that the person

has met the conditions specified in division (D) of this section.

(F) The advanced practice registered nurse is physically present at the location

where the drug is administered.

Amended by 131st General Assembly File No. TBD, HB 216, §1, eff. 4/6/2017.

Note: What a physician is authorized to delegate and under what circumstances, etc.,

is governed by law and rule enforced by the Board of Medicine. https://med.ohio.gov/

How to Volunteer

The Ohio Responds Volunteer Registry (https://www.ohioresponds.odh.ohio.

gov) is the State of Ohio’s online system for managing public health and healthcare

professionals who wish to volunteer. This site supports a variety of personnel who may

be called to action during disasters, all-hazards response efforts, and public health

activities. Ohio Responds is the system used to notify volunteers of the specific events

happening in their community.


March 2021 Ohio Nurse Page 11

The Year of the Nurse and the Midwife –

An Interview with Penny Marzalik, PhD, APRN-CNM, IBCLC

Jeri A. Milstead, PhD, RN, NEA-BC, FAAN,

ANA Hall of Fame

Introduction

The World Health Organization designated 2020

as the Year of the Nurse and Midwife. The COVID-19

pandemic curtailed many celebrations world-wide, so

WHO extended the honor through June 2021. The

designation is to advance nurses’ and midwives’ vital

position in transforming healthcare around the world

as well as honor the 200th anniversary of Florence

Nightingale’s birth. In this interview, Penny Marzalik

discusses the role and education of the U.S. midwife

and provides a perspective of midwives globally.

JM: What do midwives do?

PM: The Ohio Board of Nursing determines

the legal scope of practice for this state. The

role includes primary health care for individuals

from adolescence through menopause and care

during pre-conception, prenatal, labor and birth.

Postpartum and lactation care as well as gynecology

and family planning services are provided. CNMs

support pregnancy, birth, and menopause as normal

physiologic processes and support non-intervention

in the absence of complications. CNMs prescribe

medications and repair episiotomies and lacerations

as needed. Newborn care for the first 28 days of life

is required in midwifery education but is not within

Ohio scope of practice for Certified Nurse-Midwives

(CNMs).

The American College of Nurse-Midwives

(ACNM) is the national professional specialty

organization for CNMs and CMs representing 12,000

professionals who attend 9% of U.S. births. The

Core Competencies for Basic Midwifery Practice as

disseminated by ACNM define the professional scope

of practice. Certified Nurse-Midwives (CNMs) are

recognized as Advanced Practice Registered Nurses

(APRNs) and are licensed to practice and prescribe in

all 50 states, territories, and the District of Columbia.

There are 431 CNMs in Ohio. Certified Midwives

(CMs) are not nurses but have the same scope of

practice as CNMs and practice in six states (DE, HI,

ME, NJ, NY, RI). The Certified Professional Midwife

(CPM) is recognized in 34 states and the District of

Columbia. CPMs practice in the State of Ohio but

are not recognized by any government board. The

International Confederation of Midwives represents

two million midwives around the globe including in the

United States.

Most CNMs in Ohio attend births within a

hospital setting although some provide care in

birthing centers and the patient’s home. The

support of physiologic birth is provided no matter

the setting and evidence-based care as well as

person-centered care are hallmarks of midwifery

practice. If desired by the patient or required by

the circumstance, the CNM can consult with

the nurse-anesthetist or anesthesiologist for

an epidural for labor and birth. Midwives work

in the community at Federally Qualified Health

Centers, private practices, and outpatient clinics.

An important component of midwifery education

is understanding and reducing increased risks,

barriers to care, and disparities in health outcomes

faced by many marginalized communities.

JM: What education is required to become a

midwife?

PM: A graduate degree is required to be eligible

for board certification as a Certified Nurse-Midwife

(CNM) or Certified Midwife (CM). The nurse-midwife

in the U.S. is an RN with a specialized master’s

degree. There are three academic graduate

programs located in Ohio: Case Western Reserve

University, University of Cincinnati, and The Ohio

State University. I had the pleasure of serving as

Director of the OSU program from 2016 to 2020.

In addition to these programs, several institutions

outside of Ohio offer distance education with

students attending classes online and completing

clinical experiences throughout the state. The

Certified Professional Midwife (CPM) is educated

through an independent apprenticeship prior to a

written examination and portfolio evaluation.

JM: What is different in the global education

and role of midwives?

PM: Globally, nursing and midwifery are two

distinct professions with separate education

pathways and clinical expectations. The International

Confederation of Midwives provides Global

Standards for Midwifery Education that serves

as a benchmark for the preparation of midwives.

The role of midwives outside the United States

and the Certified Professional Midwife within

the U.S. includes pre-pregnancy and antenatal

care, care during labor and birth, and ongoing

care of women and newborns. Primary care

such as annual examinations for cervical cancer

screening or acute care for cystitis are typically

not within the role.

JM: What is one of your best memories

about your midwifery career?

PM: The ultimate compliment I received

about half-way through my 37-year career as

a CNM was during a six-week postpartum

visit. As the new mother recounted her birth

story, she explained that when I arrived at her

labor, she knew everything was going to be ok.

She continued to explain that “ok” meant that

whatever happened I would be there to guide

her. I became a midwife for exactly that reason

and continue to strive to be a guide to every

patient and student I encounter.

The Year of the Nurse and Midwife officially

ends June 20, 2021, but the contributions made

by these two professions are at a pinnacle that

must be sustained. Recognition of midwives will

continue in the U.S. with National Midwifery Week

which is celebrated the first week of October each

year. International Midwives’ Day will be May 5th,

2021.

So, let’s acclaim and cheer on this important

group of nurses—seek out a midwife and

congratulate her/him (0.6% of U.S. midwives are

males) for a successful career. Mail a card…send

an email note…make a phone call…bring flowers

or chocolate…celebrate!!


Page 12 Ohio Nurse March 2021

CONTINUING EDUCATION

The Nurse as Educator: The Role of the Nurse in Patient & Family Education

Disclosures

There is no conflict of interest among anyone

with the ability to control content for this activity.

Criteria for Successful Completion: Read entire

study, complete case study and evaluation

question, and pass post-test with a score of

80% or greater.

Exp. Date: 11/1/2022

This study was written by Jessica Dzubak,

MSN, RN

The Ohio Nurses Association is accredited as

a provider of nursing continuing professional

development by the American Nurses

Credentialing Center’s Commission on

Accreditation. (OBN-001-91)

Visit ce4nurses.org to view the full study and

references, and to complete the post-test and

evaluation to earn 1 contact hour.

A critical but sometimes overlooked aspect

of registered nursing care is patient and family

education. This education comes in many forms and

occurs in all care settings. No matter what specific

nursing role a nurse holds, assessing patient and

family educational needs should be a part of their

daily (or nightly) routine.

Ohio Law

Per the Ohio Revised Code (ORC) Chapter

4723.01, “providing health counseling and health

teaching” is part of the “practice of nursing as a

registered nurse” (Ohio Revised Code, 2003, rev.

2017).

(B) “Practice of nursing as a registered nurse” means

providing to individuals and groups nursing care

requiring specialized knowledge, judgment, and

skill derived from the principles of biological,

physical, behavioral, social, and nursing

sciences. Such nursing care includes:

(1) Identifying patterns of human responses to

actual or potential health problems amenable

to a nursing regimen;

(2) Executing a nursing regimen through the

selection, performance, management, and

evaluation of nursing actions;

(3) Assessing health status for the purpose of

providing nursing care;

(4) Providing health counseling and health

teaching;

Code of Ethics

ANA Code of Ethics: 1.4 - Right to Self-Determination

Patients have the right to be fully informed about

every aspect of their care. Registered nurses play

an integral role in educating patients and families

about various aspects of the care and treatment

plans (American Nurses Association [ANA], 2015).

While it is important to note that obtaining informed

consent for procedures is not within the scope of

practice for registered nurses in Ohio, nurses can

answer additional questions and provide detail

when appropriate (Ohio Revised Code, 2000, rev.

2017). Nurses often spend more time with patients

than physicians or surgeons, so there are multiple

opportunities for the nurse to assess any additional

questions the patient or family may have. These

crucial conversations can sometimes lead to changes

in the treatment plan or, as will be discussed later,

other resources or interprofessional referrals.

Reflection Questions: Have you ever had an

instance where patient education led to a change

in the care plan? Have you ever discovered through

teaching that the patient misunderstood or had

critical questions about their care or treatment plan?

What is Patient Education?

While the concept remains the same, patient

education looks different from patient to patient.

Nurses have the expertise to teach on various health

concepts, from basic health promotion, providing

anticipatory guidance, or explaining complex disease

processes. Depending on the nurse’s practice setting,

education will look different, as will the methods they

use to educate. For example, school nurses provide

a very different patient education type than intensive

care unit nurses or occupational health nurses.

Like the nursing process, patient teaching

includes “assessment, planning, implementation and

evaluation” (Flanders, 2018, pg. 55). The purpose

of patient teaching, whether formal or informal, is to

assist patients in applying “health-related knowledge

to their lives” (Flanders, 2018, pg. 55).

Informal patient education

- Often used at the bedside or upon discharge

- Quick delivery instruction

- Promote self-directed learning

- Focus on specific tasks

All based on the needs of the patient. (Dunn &

Milheim, 2017, pg. 18). Whether they are receiving

care in the inpatient or outpatient setting, patients

and their families often have many learning needs

related to their care.

Common examples of patient education:

• Discharge teaching

• Anticipatory guidance

• Prenatal and infant care

• New medications

• Pre- and post-operative

• Diet and lifestyle changes

• Home medical equipment usage

The literature demonstrates the impact of the quality

of patient education on patient health outcomes. A

2018 article opens with, “the value of patient education

cannot be over-emphasized” (Flanders, 2018, para. 1).

Other cited benefits of patient education include:

• Patient empowerment

• Enhanced knowledge and quality of life

• Improved self-care

• Reduced hospital re-admissions

• Improved medication adherence (as cited in

Flanders, 2018)

A 2019 study discussed the impact patient education

by nurses can have on the use of non- pharmacologic

pain management modalities, stating, “findings suggest

that patient education about [non-pharmacologic

modalities] NPMs has the potential to motivate patients

to try these modalities, which may increase overall

use” (Andrews Cooper & Kozachik, 2019, para. 5).

By providing patients with accurate information and

strategies to manage their health, nurses can empower

patients to take a more active role in their care.

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March 2021 Ohio Nurse Page 13

Reflection: Recall an experience you or a loved

one had with a healthcare provider. Maybe it was

after a procedure or a new diagnosis. What kind of

education did you or your loved one receive? When

you look back at the experience, how important was

that education? Did it make you feel better or worse?

Did you leave feeling empowered and confident or

scared and overwhelmed?

Health Literacy

What is Health Literacy?

“The Patient Protection and Affordable Care

Act of 2010, Title V, defines health literacy as the

degree to which an individual has the capacity to

obtain, communicate, process, and understand basic

health information and services to make appropriate

health decisions” (Centers for Disease Control and

Prevention, 2020, para. 1).

Before engaging in any patient education, nurses

must assess health literacy. Thinking back to

nursing school care plans, nurses are familiar with

the category of nursing diagnoses that begin with

‘knowledge deficit’ and understand that ‘readiness

for enhanced knowledge’ should be part of the

plan of care. The first step in preparing to educate

is to ensure the patient is ready and willing to

comprehend the information.

Health literacy isn’t just about a patient’s

readiness to learn, but it also considers their

capability to understand. Language barriers, hearing/

communication difficulties, cultural considerations,

reading/education levels, and levels of basic health

understanding are all factors to be considered when

assessing a patient’s health literacy.

Considering health literacy isn’t just about

assessing overt barriers to comprehension. Highly

educated, well-spoken native English speakers

may still have great difficulty understanding

complex medical and health-related information.

“It is important to remember that even people

with good literacy skills find that understanding

healthcare information is a challenge” (Cornett,

2009, pg. 2). Add that with the stress and anxiety

that most people experience in the hospital

or healthcare setting, and it can often be a

challenging environment for real learning to occur.

Stress impacts our ability to comprehend and

remember (Cornett, 2009). Additionally, many

patients, especially those with poor health literacy,

may be embarrassed to admit it and hesitate to

ask providers to repeat information or even ask

questions (Cornett, 2009).

Signs of Poor Health Literacy (Cornett, 2009, pg. 4):

• Patients often make excuses when asked to

read or fill out forms. Examples include: “I don’t

have my glasses,” “I’m too tired to read,” and “I’ll

read this when I get home.”

• Poor readers often lift text closer to their eyes

or point to the text with a finger while reading.

Many times, their eyes wander over the page

without finding a central focus.

• Patients may provide an incomplete medical

history or check items as “no” to avoid follow-up

questions.

• Poor readers often miss appointments and

make errors regarding their medication.

• Patients with low health literacy become skilled

at listening, and they often take instructions

literally to avoid mistakes. To identify their

medications, they look at the pills for color, size,

and shape since they can’t read the labels.

• Patients often show signs of nervousness,

confusion, frustration, and even indifference.

They may withdraw or avoid situations where

complex learning is required.

• Patients often give incorrect answers when

questioned about what they have read.

In addition to assessing and considering health

literacy, it is also imperative for nurses to determine

an appropriate time for teaching. Immediately after

a painful procedure or receiving bad news may

not be the best time to discuss medications or diet

instructions. Finding a time that works for the patient

and their family can make for a more effective

teaching session and better retention of knowledge

when they can devote their full attention to learning.

How to

While there are many patient teaching methods,

providing patient education should always include an

individual approach for maximum effectiveness (Smith

& Zsohar, 2013). Patient education should never be

‘one size fits all,’ since every patient has different

knowledge, experiences, and circumstances. Including

motivational interviewing in the nurses’ assessment

of health literacy can help nurses learn what factor(s)

motivate the patient, their personal learning goals,

and keep the approach patient-centered (Smith &

Zsohar, 2013). Additionally, by assessing what the

patients already know, nurses can tailor the education

to the actual knowledge gaps and address any

misconceptions or inaccuracies (Wolters Kluwer, 2017).

There are a variety of effective methods for

delivering patient and family education. For

maximum effectiveness, the learning should engage

patients and family members (Smith & Zsohar, 2013).

Teaching Methods to Engage Patients and Families:

• Demonstration

• Return demonstration

• “Teach-back” (Smith & Zsohar, 2013).

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Some tips for using the teach-back method from

the Agency for Healthcare Research and Quality

[AHRQ] (2020):

• Keep in mind this is not a test of the

patient’s knowledge. It is a test of how well

you explained the concept.

• Plan your approach. Think about how you will

ask your patients to teach back the information.

For example:

o “We covered a lot today and I want to make

sure that I explained things clearly. So let’s

review what we discussed. Can you please

describe the three things you agreed to do to

help you control your diabetes?”

• “Chunk and Check.” Don’t wait until the end

of the visit to initiate teach-back. Chunk out

information into small segments and have your

patient teach it back. Repeat several times

during a visit.

• Clarify and check again. If teach-back uncovers

a misunderstanding, explain things again using

a different approach. Ask patients to teach-back

again until they are able to correctly describe

the information in their own words. If they parrot

your words back to you, they may not have

understood.

For more information and videos on how to do the

teach-back method:

• The Always Use Teach-Back! Toolkit describes

principles of plain language, teach-back,

coaching, and system changes necessary

to promote consistent use of teach-back. Its

45-minute Interactive Teach-Back Learning

Module includes key content and videos of

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Page 14 Ohio Nurse March 2021

CE continued from page 13

clinicians using teach-back. The module can

be used by clinicians, staff members, in a group

setting, or as a self-directed tutorial.

• 5-Minute Teach-Back Video. This 5-minute

video gives two examples for clinicians of how

to use teach-back with medicine changes.

(AHRQ, 2020)

When considering which teaching method to use,

nurses must evaluate the content of the teaching and

expected outcomes to choose the appropriate method.

For example, to teach how to administer insulin at

home, an effective teaching method should include

return demonstrating as this is a learned skill. If the

nurse is teaching about a new medication’s side effects,

the ‘teach-back’ method will allow the nurse to assess

how much information the patient comprehended.

“Studies have shown that 40-80% of the medical

information patients are told during office visits

is forgotten immediately, and nearly half of the

information retained is incorrect” (Agency for

Healthcare Research and Quality, 2020).

Nurses can reinforce education with supplemental

materials such as hand-outs and pamphlets. Patients

should be encouraged to take notes when possible,

and critical information should always be given to the

patient in printed form in their most proficient language.

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Resources and Referrals

Sometimes during patient education, the nurses

identify that additional resources or assistance is

needed. Nurses may determine that the patient does

not have the resources to be compliant with care,

or perhaps there is a concern over the patient’s

ability to take care of themselves outside of the

care setting. In these cases, the nurse has the

responsibility to seek out additional resources or

referrals.

Interprofessional Resources

• Pharmacists

• Physical / Occupational Therapists

• Nutritionists

• Social Workers

• Wound Care Nurses

Documenting Patient Education

As with any other nursing care, it is critical to

document when patient education takes place.

Per OAC 4723-4-07, documentation is an integral

part of applying the nursing process as a registered

nurse:

(A) A registered nurse shall apply the nursing process

in the practice of nursing as set forth in division

(B) of section 4723.01 of the Revised Code and

in the rules of the board. The nursing process is

cyclical in nature and requires that the nurse’s

actions respond to the patient’s changing status

throughout the process. The following standards

shall be used by a registered nurse, using clinical

judgment, in applying the nursing process for each

patient under the registered nurse’s care:

(1) Assessment of health status:

The registered nurse shall, in an accurate

and timely manner:

(a) Collect data. This includes:

(i) Collection of subjective and objective

data from the patient, family,

significant others, or other members

of the health care team. The registered

nurse may direct or delegate the

performance of data collection; and

(ii) Documentation of the collected data.

And

(5) Evaluation:

The registered nurse shall, in an accurate

and timely manner:

(a) Evaluate, document, and report the

patient’s:

(i) Response to nursing interventions;

and

(ii) Progress towards expected outcomes

Documentation of assessing health literacy

and completing patient education is part of this

process. It is another form of collecting subjective

and objective data on the patient, evaluating the

patient response after teaching and describing how

it is contributing to the patient meeting identified

outcomes. As with any other component of the

nursing process, thorough documentation is critical.

Critical Components of Documentation:

• The education that was given, in detail.

• The method. Did you use the teach-back

method? Did the patient return demonstrate

something? How did you, as the nurse,

evaluate whether the patient/family understood

the information?

• The patient’s response. Did the patient

verbalize understanding? Did the family

member receive the information?

• Any additional resources utilized. Did you make

any referrals? What was the response? Did the

physician or pharmacist need to come to speak

with the patient? What was the outcome?

Case Study

The physician prescribes a blood thinner on a

patient following the diagnosis of a blood clot. You

provide education on the importance of taking

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March 2021 Ohio Nurse Page 15

the medications, the side effects, and the risk of stopping the medication. The

patient responds and re-stated the information indicating that he understands.

Which is the best example of the documentation?

A) Checking the ‘Patient education completed’ box in the EMR

B) This RN discussed XYZ medication’s purpose, explaining it is used to prevent

more blood clots and prevent stroke. Explained the side effects including

bleeding, but that the risk of not taking this medication is greater than potential

excess bleeding. Patient verbalized understanding, stating “I know I have to take

this medicine, even though you and the doctor both said I might bleed a little

more. I will call the doctor if the bleeding gets too much. But I will take it; I don’t

want to have a stroke.”

C) Discussed medication and risks with patient.

While all of them are technically correct, B is the best option as it is the most

detailed and includes specifics and quotes directly from the patient. This example

also includes the critical components of the education, such as the purpose of the

medication and the risks of not taking it.

Say the patient later does stop taking XYZ medication without consulting the

physician and goes on to suffer from a stroke. Consider which documentation

option will most effectively describe the encounter and provide the most details in an

adverse event where the nurse will need to defend their actions and thus protect their

nursing license.

Conclusion

In summary, delivering patient education is a crucial aspect of nursing

care. Empowering patients and their families with accurate information about

their health can significantly impact their compliance and ability to manage

their care. Nurses are in a unique position to assist patients in obtaining and

understanding information about their care and condition(s) and connecting them

with appropriate resources. By taking the time to deliver meaningful education

to patients and their families, nurses can improve the patient experience and

provide patients the tools to be successful and healthy.

• To complete the course and receive your certificate visit

CE4Nurses.org and register for the course titled “The Nurse as

Educator: The Role of the Nurse in Patient & Family Education.”

You will find this course listed in the catalog.

• References available within the www.CE4Nurses.org course.

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Page 16 Ohio Nurse March 2021

Ask any nurse and he/she will tell you: nurse

fatigue is a very real component of unsafe nurse

staffing, and when nurses are fatigued, patients

aren’t receiving the top-level care they deserve.

Research not only points to dissatisfied patients,

but also increased errors and higher patient

readmissions when nurses aren’t safely staffed.

Prioritizing safe nurse staffing benefits everyone:

hospitals, nurses and patients.

Bipartisan and companion bills, Senate Bill 129

and House Bill 163, sponsored by Representatives

Cutrona and Sweeney and Senators Antonio

and Schaffer, respectively, aim to make Ohio the

19th state to prohibit nurse mandatory overtime.

Curtailing the use of mandatory overtime will not

only help cut down on nurse fatigue, but also

increase safe nurse staffing through proper nurse

staffing plans that don’t rely on forced overtime

to fill regular staffing gaps. Should the need for

overtime arise, nurses should use their professional

judgment to determine whether it is safe to continue

working. Nurses should never be forced to work

overtime or threatened with discipline if they voice

concerns.

This is the third consecutive Ohio General

Assembly to consider nurse mandatory overtime

legislation. Previous bills passed the House of

Representatives, but were eventually stalled in the

senate. This simultaneous two-chamber approach

aims to move the legislation more efficiently through

the legislative process.

See the full press release (right):

Nurse Mandatory Overtime Companion Bills Introduced

Happy Volunteer Month!

Did you know? April is National Volunteer Month!

ONA wants to recognize all our members who volunteer:

• Board and Commission Members

Nurse Peer Reviewers

• Local Unit and District Officers

• Content Contributors

• Advocates

• Mentors

• Event Planning Committee Members

• First Book Volunteers

• Council, Caucus, and Committee Members

• CE Presenters

Despite the challenging circumstances of the past

twelve months, ONA members continue to show

up and dedicate their time and expertise. Social

responsibility is one of ONA’s Core Values, including

advocacy and service which our members exemplify

daily. ONA strives to be a leader in state and national

advocacy, partnering with its national affiliates

American Nurses Association (ANA) and American

Federation of Teachers (AFT). Some of our members

volunteer at the national level and are highly involved in

ANA and AFT programs and activities. We are proud of

the service our members provide to their communities,

in addition to the hard work they do each day in their

practice settings.

Curious about volunteer opportunities with ONA?

Visit ohnurses.org to learn more about becoming

a member and joining one of our many volunteer

opportunities!

NursingALD.com can point you

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March 2021 Ohio Nurse Page 17

American Nurses Foundation Launches National Well-being Initiative for Nurses

Reprinted with permission Nebraska Nurse,

February 2021

In response to the growing burden of stress and

moral distress on the nation’s nurses as they valiantly

care for patients on the frontlines of the pandemic,

the American Nurses Foundation (the Foundation),

the philanthropic arm of the American Nurses

Association (ANA), announced the launch of the

national Well-being Initiative designed specifically

for nurses across the U.S. These new resources

will help nurses build resilience and take necessary

steps to manage the stress and overcome the

trauma caused by COVID-19.

The Well-being Initiative gives nurses access to

digital mental health and wellness-related sources, tools

and more to support their emotional well-being while

taking care of those affected by the virus. Developed

‘for nurses by nurses,’ the Foundation partnered with

the American Nurses Association (ANA), the Emergency

Nurses Association (ENA), the American Association

of Critical-Care Nurses (AACN), and the American

Psychiatric Nurses Association (APNA).

Nurses are putting their physical and mental

health on the line to protect us all during this

pandemic. Every day they confront traumatic

situations while they face their own worries about

the risks to themselves and their families,” said

Kate Judge, executive director, American Nurses

Foundation. “Nurses are always there for us and we

owe it to them to support their well-being during this

crisis and in the future.”

Recognizing individuals process stress, trauma

and anxiety differently, nurses will have the option to

join virtual groups, express thoughts through writing

workshops or talk one-on-one. The comprehensive

offering includes both responsive measures (peerto-peer

conversations, warmlines, hotlines, cognitive

processing techniques) and preventive actions

(stress reduction, mindfulness and educational

materials):

Nurses Together: Connecting through Conversations

– there is significant value in peer support during

times of crisis and these virtual voice and/or video

calls provide nurses a safe space to openly talk about

self-care and wellness, recovery and resilience, care

dilemmas and bereavement. Led by the ENA these are

one-hour, volunteer-led calls for nurses.

Narrative Expressive Writing – writing

is a proven and effective tool for building

resilience, improving mindfulness, and reducing

psychological distress. In this five-week program,

nurses respond anonymously to COVID-19-related

writing prompts. A certified responder reads

individual’s submissions and provides confidential

feedback.

Happy App – emotional support is critical,

especially for nurses tackling anxiety, stress,

daily life and death decisions, fear, and isolation

during the COVID-19 pandemic. This easy-to-use

smart phone app connects nurses one-on-one to

a Support Giver team member 24/7.

Moodfit Mobile App – self-care is critical for

nurses, even more as work and life stresses mount

during the COVID-19 pandemic. This mobile app,

customized for nurses, will support them with

wellness goals and activities. Nurses can set and

track their own goals for sleep, nutrition, exercise,

mindfulness and other activities.

Self-Assessment Tool – an important part

of self-care for nurses is understanding and

connecting with their mental health needs. This

evidence-based tool recommended by APNA will

help nurses identify symptoms, understand if they

need to seek help, and direct them to relevant

resources.

Hotlines and Provider Resources – evaluated

and recommended by the Foundation and its

partners, these resources include instructions

for finding mental health providers, how to get a

referral, and what to look for in a provider.

A 2017 study found 63% of hospital nurses

reported burnout. During the COVID-19 pandemic

the rate of burnout is expected to increase even

more as the mental and physical strain and moral

distress take its toll on nurses. This underscores

the essential need for these tools and resources.

If you are a nurse and want to join the peerto-peer

conversations, download the apps or

use the tools; visit the Well-being Initiative at

https://bit.ly/35qLV7x.


Page 18 Ohio Nurse March 2021

Hospital Licensure May Finally Come to Ohio

A priority issue of the Ohio Nurses

Association for years, hospital licensure is

finally getting the attention it deserves this

general assembly thanks to Governor DeWine.

After the 2019 Nurses Day at the Statehouse,

Governor DeWine stated his intent to pursue

hospital licensing in Ohio. Plans were derailed

once the pandemic hit, but the governor is now

addressing hospital licensure through House Bill

110, also known as the state’s budget bill. The

Ohio Nurses Association was proud to provide

proponent testimony to make Ohio the last state

to license its hospitals.

The following testimony was read before the

Ohio Senate Finance Committee by Tiffany

Bukoffsky, RN, BSN, MHA, ONA’s Director of

Health Policy, on March 11, 2021:

Good morning Chairman Oelslager, Vice Chair

Plummer, Ranking Member Crawley and Members

of the House Finance Committee. My name is

Tiffany Bukoffsky, and I am a registered nurse as

well as the Director of Health Policy for the Ohio

Nurses Association. Thank you for allowing me to

be here today to testify in support of HB 110. ONA

believes the Governor’s Executive Budget makes

important investments in public health both at

the state and local level, efforts to combat health

disparities, infant mortality, as well as necessary

COVID-19 mitigation and prevention initiatives. We

urge the Legislature to maintain those worthwhile

investments as you continue your review of HB 110.

However, I would like to focus my testimony today

on the provisions in House Bill 110 that would create

an Ohio hospital licensing system through the Ohio

Department of Health (ODH). Many of you may not

be aware that Ohio is the only state in the country

that does not have a hospital licensing requirement.

While Ohio hospitals are currently required to

register with ODH and several service lines are

subject to individual unit licensure requirements,

hospital themselves are not required to hold a

license. ONA fully supports a statewide hospital

licensing system and would like to see additional

regulation and inspection requirements that ensure

all hospitals are meeting appropriate standards of

patient service and safety.

To begin, I’d like to address accreditation

standards and ODH oversight authority. Ohio

hospitals are required to register and report data to

ODH annually, in accordance with section 3701.07 of

the Ohio Revised Code. As a part of the registration

process, hospitals are required to complete and

submit the Annual Hospital Registration and Planning

Report (AHR) by March 1st of each calendar

year. Additionally, hospitals may be accredited by

organizations like the Joint Commission, that have

been approved by the Centers for Medicare and

Medicaid Services (CMS) and are deemed to meet

conditions of participation for Medicare program

participation. Almost all Ohio hospitals are required

to comply with accreditation standards and thus do

not fall under the jurisdiction of the Ohio Department

of Health for survey and certification, however they

can still be inspected by ODH. On the other hand,

non-accredited hospitals are surveyed by ODH.

When a complaint is filed against an accredited

hospital, CMS may direct ODH to conduct the

complaint investigation survey or may refer the

complaint to the accrediting organization. According

to the ODH hospital website:

CMS directs the standard survey of

approximately 1 to 3% of Ohio’s accredited

hospitals each year to validate the continued

meeting of Medicare standards through

accreditation surveys. The hospitals to be

surveyed under the “validation” program are

selected by CMS. Non-accredited hospitals

are surveyed at an interval not to exceed five

years to maintain a three-year average for all

non-accredited hospitals in the state.

While ONA appreciates the current process in

place for registration, surveying, reporting, and

complaint investigations, we do not believe CMS

oversight for accredited hospitals, and the current

non-accredited survey process is enough to hold our

hospitals accountable to standards our state deems

safe for all Ohioans. Additionally, ONA believes

hospital oversight, operation and regulation should

be managed and dictated by the state and not the

federal government and/or third-party accreditor.

Ohio loses out on the opportunity to tailor its

standards appropriately and set its own high-quality

indicators by giving up that authority to federal

regulators. The first line of defense for Ohio hospital

accountability should not be the federal government.

In addition, in reviewing hospital licensing

systems in other states comparable to Ohio,

we believe there are a few additional layers of

transparency and safety Ohio could strive for that

would ensure we don’t fall behind other states in

patient care. For example, Illinois has a Hospital

Licensing Board of fourteen members representing

various sectors of the healthcare delivery

spectrum. This Board develops, establishes,

and enforces standards for Illinois hospitals in

partnership with the health department head.

ONA believes a licensing oversight board that is

representative of all practitioners in the hospital

space would be an effective check on the licensure

process and allow for frontline expert voices to

have a say in the process. In addition, all hospitals

in Illinois are required to report the following to the

Secretary of Health and Human Services: nurse

staffing levels, prevention of infection measures,

and hospital acquired infections data. These,

in turn, must be made available to the public in

published hospital report cards. ONA believes

we could benefit from a similar system in which a

public-facing interface holds statewide hospital

report card data, including hospital safety plans,

incidents of workplace violence, detailed nurse

staffing plans per unit and shift, and the number

of hours staff are working. Any proprietary or

confidential information would of course be

excluded from this data, but the intent would

be to add much-needed transparency in these

important staffing areas, which directly impact

patient care. Patients should be able to make

informed decisions when it comes to hospitals and

publicizing this data will likely incentivize improved

hospital performance and quality standards.

Along with a hospital report card, ONA would

also like to see a statewide reporting system

through which employees and patients of hospitals

could report unsafe staffing levels, workplace

violence incidences, equipment functionality, and

safety plan compliance. Many times, this type of

reporting is the best way to identify deficiencies

in these areas and draw management’s attention

to the problem. Nurses working in some Ohio

hospitals currently use an “Assignment Despite

Objection” form to file and report workplace safety

concerns. ONA believes a similar form should be

created and used throughout the state. We believe

the Ohio Department of Health should collect

these forms and actively track workplace safety

concerns on behalf of hospital employees and

patients. Again, these types of issues are key to a

safe and well- functioning hospital environment that

adequately serves patients and protects its critical

workforce.

ONA also believes Ohio should expand the

application of “Certificates of Need” beyond

long-term care facilities. A “Certificate of Need”

(CON) is a certification that numerous states

require before approving hospital construction,

expansion, changes in bed capacity, conversion,

sale, purchase, or lease. The CON is intended

to control healthcare facility costs and facilitate

the coordination of adding new services and/

or facilities. Thirty-five states currently maintain

some form of a CON program, including Indiana,

Michigan, Florida, and Illinois. In Michigan, the CON

process is triggered when a healthcare facility does

any of the following: seeks to acquire an existing

facility; begins operation of a healthcare facility;

makes a change in the bed capacity within a facility;

initiates, replaces or expands a covered clinical

service; or makes a covered capital expenditure.

However, ONA believes that a truly effective and

protective CON program should also be triggered

by a reduction in services, since that has a direct

negative impact on availability and accessibility

of care. ONA believes any reduction in services

provided should be included in Ohio’s hospital CON

requirements.

To provide context for the CON and the need

for implementing this process in acute care

settings, I want to share a case ONA worked on

extensively in July and August of 2020. ONA filed

a federal lawsuit against the Ashtabula County

Medical Center and its Board of Trustees due to

the hospital closing its maternity unit, only a few

weeks after the hospital made the announcement

of its planned closure. Unfortunately, the judge did

not grant the emergency injunction and the unit

did close on August 1st, leaving the entire county

of Ashtabula without a maternity unit for their

expectant mothers. Within three weeks of the unit

closure, two laboring mothers entered the ACMC

emergency department and both had to wait an

hour and a half for ambulances to transport them

to Hillcrest, a hospital over 50 miles away.

Unfortunately, ACMC is not the only hospital in

the state to close its doors to expectant mothers,

and over 84 maternity units have either been

closed or acquired by a larger hospital system

over the last two decades. It is not news that Ohio

ranks 44th in the country with our infant mortality

rates, yet we have experienced 84 maternity unit

license closures over the last two decades. The

Ohio Equity Institute was created in 2012 and

collaborates with the Ohio Department of Health

to address racial disparities in birth outcomes

and population data to target areas of outreach

and services to nine counties with the largest

disparities. Of the nine counties identified, four

counties have the highest number of maternity

license closures in the state, including Cuyahoga

(11 of 84), Lucas (8 of 84), Mahoning (6 of 84), and

Stark (6 of 84). From our research, ONA believes

there is a correlation between mortality rates and

maternity closures over the last two decades. If our

state had a Certificate of Need program in place,

triggered by a reduction in services, perhaps Ohio

could have prevented some maternity unit closures

and our infant mortality rates would look starkly

different.

Lastly, ONA would recommend changes

to language within HB 110 that would allow

hospitals to avoid inspections for initial licensure

or a renewal if the hospital submits a copy of

the hospital’s most recent on- site survey report

from an accrediting body demonstrating that

the hospital is in deemed status. Most states

recognize something like “deemed status” that

exempts hospitals from numerous state licensure

requirements if they are certified by a recognized

accrediting body. While on-site surveys may

cover many important quality standards, ONA

believes that Ohio’s licensing system should

not provide opportunities for hospitals to evade

regular check-ins. Furthermore, Ohio should not

yield oversight authority over its own hospitals to

a third party. ONA believes that yearly hospital

inspections are an important part of ensuring

full accountability and compliance with critical

quality standards. In addition, to ensure the

inspections accurately reflect hospital conditions,

the state should have the authority to conduct

its inspections unannounced. Hospitals should

have no concerns about this if they are correctly

abiding by all licensure standards. Conducting

annual inspections will also ensure all hospitals

are up-to-date on submitting their Annual

Hospital Registration and Planning Report. For

example, Mount Carmel East Hospital’s last

accreditation survey took place on August 11th,

2017. And currently nineteen Ohio hospitals are

not registered with ODH and are listed as “noncompliant.”

ONA believes this information shows

a lack of accountability for hospitals to remain

compliant and illustrates the deficiencies in the

current system.

We understand creating a statewide hospital

licensing system will take time and that the

rulemaking process will be just as extensive.

ONA looks forward to the continued work with the

legislature and the administration to address the

future of health care and the hospital licensing

system. The Ohio Nurses Association fully

supports hospital licensing, as proposed in the

Executive Budget, HB 110, and we hope you will

take our recommendations to further strengthen

the system under consideration.

Thank you for allowing me to testify and I would

be happy to answer any questions you may have.


March 2021 Ohio Nurse Page 19

The 1st Annual ONA Human Trafficking Awareness Symposium

Increased Exposure -> Heightened Awareness -> Greater Impact -> Healthier Ohio

Are You Re-Licensure Ready?

RNs, it is a re-licensure year! Ohio RNs renew their

licenses on odd-numbered years.

While all nurses wish education about human

trafficking wasn’t necessary, unfortunately it is,

and ONA plans to keep addressing it until there

is no longer a need. Education is instrumental in

increasing identification of victims, raising awareness

of the problem, and working towards the abolition of

human trafficking.

The ONA Human Trafficking Awareness Symposium

was virtual this year due to the pandemic and followed

a sold-out inaugural symposium in 2020. While we

were disappointed we could not gather in-person, we

were grateful that the virtual environment eliminated an

attendance maximum, which led to a larger audience

than last year! Fingers crossed we will be back to an inperson

event with an even larger crowd for 2022.

Gracehaven, a non-profit that serves domestic

minor trafficking victims, partnered with ONA to provide

the weekly education, along with other experts from

the community. All profits from the registration of the

event were donated to Gracehaven, which they will

use to continue their outreach through education, case

management, and their group home for survivors.

The Mid-Ohio District Nurses Association

(MODNA) donated an extra $4,000 that was

divided between the anti-human trafficking

organizations who chose to be virtual exhibitors

at the event, a free opportunity provided by ONA.

Thank you MODNA for choosing to support these

community organizations serving those in need!

For more information about these organizations,

visit www.CE4Nurses.org/HTAS through the end of

April 2021.

Thank you to those who attended and learned

along with us. We look forward to hearing how you

will use the information to create a difference in the

lives of those devastated by human trafficking.

Important Dates to Remember:

• July 1, 2021: Re-Licensure Period Opens

• September 15, 2021: Last Day to Renew Without

Late Fee

• October 31, 2021: Last Day to Renew. *If RN

licenses are not renewed by this date, they

become expired and the nurse may not practice

until it is re-instated.

To prepare for re-licensure:

• Assure your name and address are accurate

with the Ohio Board of Nursing, OBN

• Confirm that you have/or will obtain at least 24

contact hours of nursing continuing professional

development, including 1 Category A Contact

Hour, by October 31st. Remember, you do not

have to have all of your CE completed when

you renew your license; you will attest on the

renewal application that you will have the 24

required contact hours by October 31, 2021.

• Be sure at least one contact hour is Category

A, or Ohio nursing law and rules. The content

of a Category A activity must directly relate to

ORC 4723 (the Ohio Nurse Practice Act) and/

or OAC 4723 (Ohio nursing rules). To verify

if an activity is Category A, check your CE

certificate or contact the CE provider.

• Remember ONA is approved by the Ohio Board of

Nursing to provide Category A education. ONA’s

professional development website, CE4Nurses.

org, offers over 10 different Category A courses,

and new activities are continuing to be added.

CE4Nurses.org offers a wide-range of topics,

including pharmacology, advocacy, leadership,

human trafficking, workplace violence, and more.

ONA members have access to almost all the

activities free, included with their membership! For

more information, visit CE4Nurses.org. We are

proud to be able to serve our nurses to meet their

nursing professional development needs.

Maintaining your license is important for your

professional practice and the safety of your

patients.

To access electronic copies of

Ohio Nurse, please visit

http://www.NursingALD.com/

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