Nursing and Clinical Memos

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Read the memo: NCBON/OCPHN Joint Memo on Nursing Administration, Nursing Practice, and Nursing Supervision for LHDs

About this Memo

From the NCDHHS Office of the Chief Public Health Nurse

Dear Public Health leaders,

While the Registered Nurse (RN) maintains accountability for the delivery of nursing services whether rendered directly or indirectly, the NC Board of Nursing encourages that a system’s nursing organizational structure, such as found in local public health departments, have an established nursing chain of command. Nursing administration involves different executive-level nursing tasks that help ensure internal compliance with the NC Nursing Practice Act, G.S. 90-171.20 (7), and RN Rules, 21 NCAC 36.0224 Components of Nursing Practice for the Registered Nurse. Only an RN has accountability and responsibility to assure the appropriate allocation of human resources (staffing) for the delivery of nursing services, and to manage, supervise, and evaluate nursing care services and practice to promote safe and effective nursing care.

Agreement Addendum 110 requires that the local health department provide DPH with the name and contact information for the organization’s Senior Public Health Nurse Leader. The purpose of this requirement is two-fold; to promote communication between the Office of the Chief Public Health Nurse and local health departments regarding guidance, standards of practice, and other information related to nursing practice in the local health department setting, and to confirm that each health department has identified nursing administration and an established nursing chain of command to support the seamless communication of guidance, standards of practice, and other nursing practice information. Nursing administration may look different in each of North Carolina’s local health departments and may include more than one RN assigned to ensure internal compliance with the NC Nursing Practice Act and RN Rules.  Regardless of how this may look in your organization, only an RN has accountability and responsibility for nursing administration, including the supervision and evaluation of nursing personnel and nursing practice.

Nursing administrators provide tangible benefits to healthcare and public health systems in the following areas:

  1. Clinical Leadership: Nurse administrators provide clinical leadership and expertise. Their extensive nursing experience ensures your organization’s nursing staff delivers high-quality patient and population health care and services.
  2. Patient Safety: Nurse administrators play a pivotal role in ensuring patient safety. They develop and implement policies and practices that reduce medical errors, enhance patient and population outcomes, and prevent adverse events.
  3. Strategic Alignment: Nurse administrators align nursing services with the organization's overall mission and strategic goals. They ensure that nursing care is in sync with broader healthcare and public health strategies and outcomes.
  4. Quality Improvement: Nurse administrators are instrumental in quality improvement efforts. They oversee the development and implementation of evidence-based practices to improve patient care and population health quality and outcomes.
  5. Resource Management: Nurse administrators manage nursing resources efficiently, including staffing and budgeting, to provide cost-effective care without compromising quality.
  6. Interdisciplinary Collaboration: Nurse administrators foster collaboration among different healthcare and public health disciplines. This teamwork enhances patient and population-level care coordination and overall healthcare and public health effectiveness.
  7. Staff Development: Nurse administrators promote the professional growth and development of nursing staff. They create a culture of continuous learning, which leads to more skilled and motivated nurses.
  8. Staff Retention: Nurse administrators motivate their colleagues, setting the tone for a safe, civil workplace with a culture of high morale and job retention. 
  9. Innovation: Nurse administrators encourage innovation in nursing practice and technology adoption. This leads to the implementation of new and more effective healthcare and population/public health solutions.
  10. Advocacy: Nurse administrators advocate for the nursing profession and the interests of nurses within the organization. This includes addressing issues like nurse staffing levels and work environment.
  11. Patient- and Population-Centered Care: Nurse administrators prioritize patient- and population-centered care by ensuring that nursing staff provide evidence-based nursing care and services. These contribute to better patient experiences and population health outcomes.
  12. Regulatory Compliance: Nurse administrators are responsible for ensuring that the nursing division complies with healthcare regulations and accreditation standards. This helps in avoiding legal and financial consequences.
  13. Risk Management: Nurse administrators play a vital role in risk management by identifying potential risks in nursing care and implementing strategies to mitigate them.
  14. Adaptation to Change: Nurse administrators help public health agencies adapt to changes in healthcare, including advances in technology, new treatment modalities, and evolving patient and population needs.

In summary, every healthcare system that has a nursing organizational structure must adhere to the NC Nursing Practice Act and the RN rules.  Having an identified nursing administrator(s) is crucial for supporting public health agencies to ensure that nursing services are of the highest quality, safe, and aligned with the organization's goals. Nursing administrators bring a unique blend of clinical expertise, leadership, and strategic thinking that is essential for delivering excellent patient, family, community, and population care.

Please see the Joint Memo for clarification of the scope of practice of the nurse administrator.

Should you have any follow up questions, please do not hesitate to contact your OCPHN Nurse Consultant. 

Susan Haynes Little, DNP, RN, CPHN, PHNA-BC, CPH, FAAN
Chief Nursing Officer, Divisions of Public Health, and Child & Family Well-Being
Head, Local Technical Assistance and Training Branch, Division of Public Health

Read the memo: Joint Memo on Credentialed Emergency Medical Services (EMS) Providers Working in Local Governmental Public Health Settings and Nursing Delegation

About this Memo

From the NCDHHS Office of the Chief Public Health Nurse

Dear Public Health leaders,

Credentialed EMS (Emergency Medical Services) providers and licensed nurses often work together collaboratively to provide comprehensive patient care. In the public health setting, Credentialed EMS providers and licensed nurses can work together to address various healthcare needs in the community and respond effectively to community health challenges, promote wellness, and protect the public’s health. Their combined expertise and teamwork could be one approach to effect the capacity of public health systems to serve and safeguard communities.

The Joint Memo on Credentialed Emergency Medical Services (EMS) Providers Working in Local Governmental Public Health Settings and Nursing Delegation from the Chief, Office of Emergency Medical Services and Chief Public Health Nurse serves to clarify the role of Credentialed Emergency Medical Services (EMS) Providers working in local public health settings and addresses delegation by the licensed nurse to Credentialed EMS Providers. The memo is intended to address EMS providers who are working in positions requiring the Credentialed EMS provider credential. If a person credentialed as an EMS provider is working in a position not requiring  EMS credentials, such as unlicensed assistive personnel (UAP) positions which may include Nurse Aide I, Nurse Aide II, Medical Office Assistant, Medical Assistant, etc., their scope of practice would fall under the scope of the position and the delegation of nursing care activities to UAP standards provided by the NC Board of Nursing, addressed in the memo, would need to be followed. 

Should you have any follow up questions, please do not hesitate to contact your OCPHN Nurse Consultant. 

Susan Haynes Little, DNP, RN, CPHN, PHNA-BC, CPH, FAAN
Chief Nursing Officer, Divisions of Public Health, and Child & Family Well-Being
Head, Local Technical Assistance and Training Branch, Division of Public Health

Read the memo: Standing Orders for Nursing Practice in the Local Health Department Clinical Setting

About this Memo

From the NCDHHS Office of the Chief Public Health Nurse

Dear NC PHN leaders,

Please review the new Standing Orders for Nursing Practice in the Local Health Department Clinical Setting memo. It should replace all standing order memos sent by previous chief nurses.  

Materials referenced in the memo:

Please reach out to your PHNPDU Nurse Consultant if you have any questions.

Susan Haynes Little, DNP, RN, CPHN, PHNA-BC, CPH, FAAN
Chief Nursing Officer, Divisions of Public Health, and Child & Family Well-Being
Head, Local Technical Assistance and Training Branch, Division of Public Health

Read the memo: Changes to RN Dispensing in Local Health Departments Rule Effective 10/01/2022

About this Memo

From the NCDHHS Office of the Chief Public Health Nurse

Dear Public Health leaders,

G.S. 90-85.34A Public Health Pharmacy Practice sets out the conditions under which a registered nurse in a local health department clinic may dispense drugs and devices. Subparagraph (a)(3) limits the dispensing of drugs and devices.  Effective October 1, 2022, 21 NCAC 46 .2403 Drugs and Devices To Be Dispensed will be repealed and the nurse dispensing formulary will be managed through DHHS and the Board of Pharmacy proceedings, making it easier to adjust. The full formulary is now posted on the Board of Pharmacy website.  

In addition, effective Sept. 1, the Pharmacy Board approved the addition of folic acid for the prevention of neural tube defects and other related conditions and low-dose aspirin for prevention or delayed onset of preeclampsia in pregnant individuals with increased risk of preeclampsia as defined by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. The full formulary as of Oct. 1, 2022:

  1. Anti-tuberculosis drugs, as recommended by the North Carolina Department of Health and Human Services in the North Carolina Tuberculosis Policy Manual, when used for the treatment and control of tuberculosis;
  2. Anti-infective agents used in the control of sexually transmitted diseases as recommended by the United States Centers for Disease Control in the Sexually Transmitted Diseases Treatment Guidelines;
  3. Natural or synthetic hormones and contraceptive devices when used for the prevention of pregnancy;
  4. Topical preparations for the treatment of lice, scabies, impetigo, diaper rash, vaginitis, and related skin conditions;
  5. Vitamin and mineral supplements;
  6. Opioid antagonists prescribed pursuant to G.S. 90-12.7;
  7. Epinephrine auto-injectors prescribed pursuant to G.S. 115C-375.2A; 
  8. Over-the-counter nicotine replacement therapies;
  9. Folic acid for prevention of neural tube defects and other related conditions; and
  10. Low-dose aspirin for prevention or delayed onset of preeclampsia in pregnant individuals with increased risk of preeclampsia as defined by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (criteria available at ACOG Practice Advisory).

Sample Standing Order templates:

Please share this memo with affected staff in your departments.

Susan Haynes Little, DNP, RN, CPHN, PHNA-BC, CPH, FAAN
Chief Nursing Officer, Divisions of Public Health, and Child & Family Well-Being
Head, Local Technical Assistance and Training Branch, Division of Public Health

Memo: Clarification of Licensed Professional Nurse (LPN) practice in Public Health Settings

From the NCDHHS Office of the Chief Public Health Nurse

View as PDF: Clarification of LPN practice in Public Health Settings Memo

Pursuant to a meeting with the NC Board of Nursing (NC BON) and review of appliable laws and practice authorities, we have again verified that the licensed practical nurse's (LPN) scope of practice prohibits them from functioning as public health nurses.  

Public health nursing (PHN) is a specialty practice within nursing and public health. It requires independent nursing practice and judgment, application of theory and evidence, assessment skills, primary prevention focus, and system-level perspectives to meet the needs of individuals, families, communities, and populations, all of which fall within the scope and licensure of a registered nurse. The NC Nursing Practice Act defines the LPN scope of practice as limited and focused, dependent and directed. LPNs are required by licensure to remain in a dependent and directed practice environment. An agency/employer, including a registered nurse or physician employer, may restrict the nurse’s practice but never expand the practice beyond the legal scope as defined.[i]  According to the NCBON (2017), the LPN Scope of Practice in all steps of the nursing process is limited and focused because, by law, it is a dependent and directed scope of practice. LPN practice requires assignment or delegation by and performance under the supervision, orders, or directions of a registered nurse (RN), physician, dentist, or other person authorized by State law to provide the supervision.[ii] The NC BON defines supervision as the provision of guidance or direction, evaluation, and follow-up by the licensed nurse for accomplishment of an assigned or delegated nursing activity or set of activities.[iii] However, The NC Nursing Practice Act and RN Rules clearly authorize only RNs to supervise, teach and evaluate licensed nurses.[iv] Non-nurses do not possess the education or licensure to supervise the nursing practice of a licensed nurse.

10A NCAC 46.0301[v] requires each local health department to employ a full-time public health nurse. The agency’s lead public health nurse holds overall responsibility for all the administrative, supervisory, and technical components of public health services and programs with a nursing component and ensures consistency in the organization's practice standards.  This authority supports the concept of local health departments as “Public Health Nursing driven systems of care” (previously referred to as “public health being a ‘nursing delivery systems’”).  In this nurse-driven healthcare system, LPNs must practice under the direction of a PHN in NC local public health departments. Rationale for this includes that a PHN would have hired and trained the LPN on what activities are within the LPN’s scope to carry out in the local health department setting.  A PHN would ensure that policies and procedures are in place allowing the activities to be carried out by the LPN and would ensure those activities are consistent with the LPN’s job description.  A PHN would also ensure the LPN has received education and documentation of competency in performing the activities.[vi] The NC Nursing Practice Act supports that a PHN must retain overall responsibility for managing outcomes and consequences of patient care actions and assessing client care needs, health status, response to treatment, and establishing the plan of care.  The local health department must ensure that a PHN familiar with the policies, procedures, standing orders, and client population(s) is continuously available to the LPN for consultation regarding patient evaluation and care planning decisions whenever an LPN is working[vii]. The LPN can never be the highest-level licensed nurse working in a local health department.  Please refer to Guidance Related to LPN Practice in NC Local Health Departments for more information about LPNs practicing in the local health department setting.

10A NCAC 46.0301 also clarifies that all local health department nurses must have a nursing degree from an accredited baccalaureate nursing school. Those nurses who do not hold a baccalaureate degree in nursing must complete an introductory course in principles and practices of public health and public health nursing (PPPHN) sponsored by the Department within one year of employment. LPNs do not qualify to attend the PPPHN course because they have not completed the required minimum education to be eligible to practice as a PHN, nor do they possess the legal scope to function as a registered nurse. 

i NC Board of Nursing (2017). LPN scope of practice – Clarification: Position statement for RN and LPN practice. 
ii ibid. 
iii NC Board of Nursing (2017). Delegation and assignment of nursing activities: Position statement for RN and LPN practice.
iv NC Board of Nursing (2015). Who’s your supervisor or manager? Nursing practice: The management and supervision of nursing services.
v 10A NCAC 46 .0301 MINIMUM STANDARD HEALTH DEPARTMENT: STAFFING. 
vi NC Board of Nursing (2018). Scope of practice decision tree for the RN and LPN. 
vii NC Board of Nursing (2018). Nurse-in-charge assignment to LPN: Position statement for RN and LPN practice. 

Susan Haynes Little, DNP, RN, CPHN, PHNA-BC, CPH, FAAN
Chief Nursing Officer, Divisions of Public Health, and Child & Family Well-Being
Head, Local Technical Assistance and Training Branch, Division of Public Health

Memo: Use of Unlicensed Assistive Personnel in NC local health department clinical settings

From the NCDHHS Office of the Chief Public Health Nurse

View as PDF: Use of Unlicensed Assistive Personnel in NC local health department clinical settings

This memo provides general guidance regarding the supervision and oversight of unlicensed assistive personnel (UAP), appropriate roles for UAP, and delegation of nursing activities by PHNs in NC local health department (LHD) clinical settings.

Public Health Nurses (PHN) comprise a versatile nursing specialty in which they lead, manage, direct, coordinate, delegate, assign, and provide care as well as supervise clinical care teams in the local public health clinics PHNs also provide essential services in community settings through activities such as home visiting, jail health, care coordination, health education, and population health interventions. As a licensed Registered Nurse, the PHN's duty is to protect the public and is required by law as codified in the Nursing Practice Act[1] to use the nursing process, a scientific method for decision-making. NC LHDs function as PHN-driven systems of care[2]. If an LHD is facing a staffing crisis and considering hiring unlicensed assistive personnel (UAP) to supplement the PHN staff, certain actions must be taken by the PHN and LHD leadership to ensure patient outcomes and safe and legal provision of care.

UAP include, but are not limited to, the following specific job titles: Nurses’ Aides (NA), Certified Nursing Assistants (CNA), Patient Care Aides (PCA) /Home Health Aides (HHA)/Patient Care Technicians (PCT), Medical Office Assistants (MOA), Medical Assistants (MA), Medication Aides (Med Aide), and Medication Technicians (Med Tech).[3] UAPs cannot contribute the same level of care as a PHN because they do not have the educational preparation or possess the licensure to do so legally. However, they can and do function as an integral part of the healthcare team as supplemental staff to the PHN workforce, provided they have the training, support, oversight, and supervision required to ensure safe and legal practice in protection of the patient and public.

In the PHN-driven system of care characteristic of NC local health departments, where PHNs direct and manage care patients receive, the PHN is legally accountable by the NC Nursing Practice Act to retain overall responsibility for managing outcomes and consequences of patient care related nursing actions. The PHN’s responsibilities include determining nursing care tasks that are appropriate to delegate to UAP, based on client assessment and criteria established in the NC Board of Nursing (NCBON) Decision Tree for Delegation to UAP.[4] The PHN retains accountability for assessing client care needs, health status, response to treatment, establishing the plan of care, and evaluating the care given. The PHN, in accordance with 21 NCAC 36 .0224 Components of Nursing Practice for the Registered Nurse[5] and the Nursing Practice Act, may delegate nursing care activities to UAP that are appropriate to the level of knowledge, skill, and validated competence of the unlicensed personnel. The PHN is held accountable for their delegation decisions and their specific actions/directions related to UAP.[6] Experienced PHNs are best utilized when they assume leadership roles in public health including program management, coordination, supervision, and clinic oversight roles. PHNs are the most well-prepared to oversee the proper and safe use of supplemental UAP in the local public health clinical setting and are appropriately trained to validate the competence of UAP prior to the UAP carrying out any delegated tasks. PHNs carrying out UAP oversight roles must be competent to ensure safe patient care when UAP provide supplemental patient care as part of the patent care team. When realizing the use of UAP in the LHD setting, care must be taken to ensure the UAP understands the “why” of what is being delegated and has communicated willingness to perform such duties. Care must also be taken to verify that UAP are not being asked to carry out any tasks for which they have not received training and competency evaluation.

LHDs considering hiring UAP to supplement the clinical work of the PHNs must ensure that a PHN who is knowledgeable about the programs and interventions being carried out, including policies, procedures, standing orders, and client population(s), will be continuously available to supervise the UAP following the guidance provided in the NC BON’s Decision Tree for Delegation to UAP, specifically Step 3 of 4: Supervision and Monitoring.[7] The organizational chart and job descriptions must also clearly reflect the PHN’s responsibilities for teaching, delegating to, and supervising UAP within the RN scope of practice.[8] For these reasons, when considering hiring UAP, PHNs must be involved in evaluating what impact adding supplemental UAP to the patient care team will have on clinic processes, deciding what role(s) UAP will perform, and in final decision-making regarding the value of adding UAP to the clinical practice environment.

The memo also contains program-specific tables created by DPH program nursing experts to support the safe and effective use of UAP in the LHD clinic setting. These tables include the roles of PHNs followed by the roles of LPNs and UAP supplement the PHN care provided in multiple clinical settings. 

  • Child Health
  • School Health Activity
  • Tuberculosis Activity
  • Women’s Health Clinic

Please contact your regional nurse consultant for each program for program-specific questions. If you have a practice question not specific to a program, please reach out to your Public Health Nursing and Professional Development Unit nurse consultant.

1 NC Nursing Practice Act
2 Little, S. (June, 14, 2021). Clarification of Licensed Professional Nurse (LPN) practice in Public Health Settings [memorandum].
3 NC Board of Nursing (n.d.). Nurse Aides: Information and Rules. 
4 
5 21 NCAC 36 .0224 Components of Nursing Practice for the Registered Nurse. 
6 
7 
8 

Susan Haynes Little, DNP, RN, CPHN, PHNA-BC, CPH, FAAN
Chief Nursing Officer, Divisions of Public Health, and Child & Family Well-Being
Head, Local Technical Assistance and Training Branch, Division of Public Health

Read the memo: NCBON/OCPHN Joint Memo on Nursing Administration, Nursing Practice, and Nursing Supervision for LHDs

About this Memo

From the NCDHHS Office of the Chief Public Health Nurse

Dear Public Health leaders,

 

Should you have any follow up questions, please do not hesitate to contact your OCPHN Nurse Consultant.

Susan Haynes Little, DNP, RN, CPHN, PHNA-BC, CPH, FAAN
Chief Nursing Officer, Divisions of Public Health, and Child & Family Well-Being
Head, Local Technical Assistance and Training Branch, Division of Public Health

Memo: Distribution of Over the Counter (OTCs) Meds by Registered Nurses (RNs)

To: Directors of Nursing, Nursing Supervisors and Public Health Nurses and DPH Nurse Consultants

From: Phyllis M. Rocco, MPH, BSN, RN, Chief Public Health Nurse

This memo is to clarify the rules regarding recommendation and distribution of over-the-counter meds by registered nurses.

  • Based on the NC BON Position Statement it is within the RN scope of practice to recommend OTC pharmaceutical products and non-prescriptive devices for an identified health-related need of an individual or client provided the agency’s policies/procedures permit the RN to perform this activity, and the nurse has the knowledge to make such nursing decisions safely according to accepted standards and to monitor the outcomes of her/his actions.
  • Based on the NC BON Position Statement it is not within the LPN scope of practice to recommend OTC pharmaceutical products and non-prescriptive devices for an identified health-related need of an individual or client.

However, when it comes to the question “May the RN distribute an OTC drug?” neither the Board of Pharmacy (BOP) nor the NC Board of Nursing (BON) regulate the distribution of OTCs. After consultation with the NC BON, the DPH Pharmacist and the NC BOP, our best practice recommendation is to:

  • Develop a policy and procedure re: which meds you have on site for distribution and guidelines re: to whom they should be offered and for what purposes.
  • Develop a “distribution log,” just in case there is ever a drug recall. Do not merge with the dispensing log. Labeling of OTC meds is not required if they are distributed as packaged nor do you need to have the client sign for the OTC.
  • Document in the medical record that an OTC was distributed due to xxxx. Use per manufacturer’s instructions.
  • Store all OTC meds in a safe place away from children. There is no law that requires OTC meds to be locked however Accreditation will want to see that all meds are secured from client access.

Examples:

  • A common side effect of immunizations is a local reaction at the injection site, including running a low-grade fever. A RN should know this information if he/she is the nurse administering immunizations and based on his/her knowledge should be able to safely recommend and provide a client with an unopened package of ibuprofen, acetaminophen or naproxen sodium with the recommendation to take this OTC following the manufacturer’s instructions for soreness and fever.
  • Client comes in for birth control pill pickup. Reports having some cramps around the time of her periods. The nurse should have the knowledge that cramping is a normal experience for some females with menses, and can recommend taking an OTC pain reliever such as naproxen sodium or ibuprofen and provide the client with a bottle of one or the other if the agency chooses to stock that med.
  • Prenatal Vitamins
    • OTC prenatal vitamins may be distributed to pregnant clients by a RN because the nurse has the understanding and knowledge that pregnant women often are deficient in getting all the daily vitamin and iron requirements through food intake alone.
    • Prescription prenatal vitamins must be ordered for the client either individually by the provider or through a standing order and must be DISPENSED by the RN.

Remember: Any re-packaging or re-labeling of an OTC med would be considered “dispensing” and a Standing Order would be required and all BOP rules re: labeling and dispensing must be followed. Only RNs who have taken the nurse dispensing course may dispense medications from the approved formulary.