Ohio Nurse - March 2021

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
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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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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
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address changes to the Ohio Board of Nursing:
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Columbus, OH 43215
614-466-3947
www.nursing.ohio.gov
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in this publication express the opinions of the
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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
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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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“If Nursing is not at the table when
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nursing will never be heard.”
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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.
Education and Nursing Care
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care and patient education are interconnected. Thus,
by improving patient education, the quality of nursing
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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
right to that perfect NURSING JOB!
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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/
publications