The Importance of Title Protection in Healthcare and Evaluation

Learner Outcome: Learners will have an increased knowledge of the current state of title protection in healthcare and its implications for practice.

This independent study was developed by: Tiffany Bukoffsky, MHA, BSN, RN, Jessica Dzubak, MSN, RN, Amy Rossio, MN, RN-BC, CCRN-K, Kelli Schweitzer, MSN, RN-BC

Disclosures
0.7 Contact Hour will be awarded with successful completion.

Criteria for Successful Completion: Complete the pre-work survey, read the entire study, complete the evaluation.
Expiration: 9/30/2021

There is no conflict of interest among anyone with the ability to control content of this activity.

The Ohio Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. (OBN-001-91)

Click Here to Complete the Pre-Work Survey

The Importance of Title Protection in Healthcare

By: Tiffany Bukoffsky, MHA, BSN, RN, Jessica Dzubak, MSN, RN, Amy Rossio, MN, RN-BC, CCRN-K, Kelli Schweitzer, MSN, RN-BC

History of the word “Nurse”

What do you think of when you hear the word nurse?
“A person who cares for the sick or infirm”
“A licensed health-care professional…who is skilled in promoting and maintaining health”
(Merriam-Webster, n.d.)

The word nurse (ners) has origins from the latin nutricius, meaning person that nourishes. Nursing comes from “to nourish” (Online etymology dictionary, 2019). Today the word is used in reference to nursing an infant child as well as to the practice of nursing. In both uses, you can see the applicability of its origin, to nourish. Nursing mothers are providing their infant with nourishment and food to grow and thrive. Those practicing nursing are nourishing their patients in a variety of ways not just by tending to their wounds and alleviating their pain, but by nourishing their soul through compassionate care, empathy and emotional support.

Nurses today work in a variety of settings, more than ever before. Not only are nurses caring for the sick, but they are aiding in health promotion, disease prevention and management, health literacy and education.

According to the American Nurses Association (ANA), Registered Nurses (RNs):
• Perform physical exams and health histories before making critical decisions
• Provide health promotion, counseling and education
• Administer medications and other personalized interventions
• Coordinate care, in collaboration with a wide array of health care professionals (American Nurses Association, n.d.)

The word nurse carries significant respect and honor. The public has awarded nursing as the most trusted profession for 17 years in a row (Brenan, 2018). Nurses have worked hard for years to earn that title and to proudly display RN, Registered Nurse, on their name badge.

The title ‘nurse’ is not currently protected across America. According to ANA, “At least 39 states are known to have language in their Nurse Practice Act; either explicit in restricting use of the title “nurse” to only those who are licensed or implicit language restricting use of any words implying the individual is a licensed nurse” (ANA, 2013).

Title identification and protection is important because a profession’s standards and scope of practice hinge on not only education and preparation, but also statute and rules that surround it. The title of nurse is no exception. Legislation continues to pop up across the United States that is related to title protection and more specifically, those who can call themselves nurses.

Senate Bill (SB) 131 was introduced in the Ohio state Senate by Senator Steve Huffman (R- Tipp City) on April 18, 2019, with the intent to change the title of veterinary technician to veterinary nurse. SB 131 was referred to the Senate Agriculture and Natural Resources Committee on May 29, 2019 and had its first hearing on June 26, 2019. The bill is a reintroduction of similar legislation (HB 501 and SB 337) from the last Ohio General Assembly that successfully reported out of committee, passed the House floor, but did not advance through the Senate prior to the end of the last legislative session.

Individuals have asked why Ohio was targeted as one of the first states to introduce legislation to change a registered veterinary technician to registered veterinary nurse. It was introduced in Ohio because our state statute does not protect the title “nurse”. “Registered Nurse”, “RN”, “Advanced Practice Registered Nurse”, “APRN”, “Licensed Practical Nurse”, and “LPN” are all protected titles, however, “nurse” on its own is not.

The Ohio Nurses Association (ONA), along with 36 other state nurses’ associations and the American Nurses Association, continue to adamantly oppose SB 131 and any language that threatens to weaken the title of nurse. Association opposition comes from a longstanding belief that title protection safeguards the public. “Restricting use of the title “nurse” to only those individuals who have fulfilled the requirements for licensure as outlined in each state’s nurse practice act is a protection for the public against unethical, unscrupulous, and incompetent practitioners. Nurse practice acts describe entry level qualifications such as education, practice standards and code of conduct for continued privilege to practice nursing” (American Nurses Association, 2013, para. 3).

The title “nurse” has always been linked to the care of humans—and prior to 1903, anyone could call themselves a nurse and practice nursing in the United States. Moreover, nurses in Ohio formed the Ohio Nurses Association in 1904 so we would have a powerful platform for the protection, promotion and advancement of our profession, beginning with Ohio’s Nurse Practice Act. For over one-hundred years, nurses have fought to establish standards of practice and licensure. Through these regulatory efforts, the nursing profession has protected the public and nurses’ credibility. Furthermore, licensure through state statutes limits the use of the title “registered nurse” and “licensed practical nurse”. In Ohio, the Nurse Practice Act, Ohio Revised Code 4723.03 (A), explicitly states that:

“(A) No person shall engage in the practice of nursing as a registered nurse, represent the person as being a registered nurse, or use the title “registered nurse,” the initials “R.N.,” or any other title implying that the person is a registered nurse, for a fee, salary, or other consideration, or as a volunteer, without holding a current, valid license as a registered nurse under this chapter.” It also states in ORC 4723.03 (E): “No person shall use the titles or initials “graduate nurse,” “G.N.,” “professional nurse,” “P.N.,” “graduate practical nurse,” “G.P.N.,” “practical nurse,” “P.N.,” “trained nurse,” “T.N.,” or any other statement, title, or initials that would imply or represent to the public that the person is authorized to practice nursing in this state” except for licensed nurses.

Furthermore, immediately after defining the term “registered nurse”, the Ohio Revised Code 4723.01 states:

(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 [emphasis added] 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;
(5) Administering medications, treatments, and executing regimens authorized by an individual who is authorized to practice in this state and is acting within the course of the individual’s professional practice;
(6) Teaching, administering, supervising, delegating, and evaluating nursing practice.

Additionally, 4723.03 of the Revised Code discusses unlicensed practice:
(A) No person shall engage in the practice of nursing as a registered nurse, represent the person as being a registered nurse, or use the title “registered nurse,” the initials “R.N.,” or any other title implying that the person is a registered nurse, for a fee, salary, or other consideration, or as a volunteer, without holding a current, valid license as a registered nurse under this chapter.

ONA believes that the definitions explicitly defined in the Ohio Revised Code 4723 protect the practice of nursing and changing the title of veterinary technician to veterinary nurse would undermine title protections and the “practice of nursing” that have been secured through Ohio’s state statute. While actively opposing SB 131, ONA is proactively discussing potential sponsors to introduce language that would strengthen our current title protection and reserve the title “nurse” to individuals who provide human care.

What’s in a Title?

Titles & Credentials:
Nurse Practitioner                                                                   CNP, APRN
Nurse Anesthetist, Nurse Anesthesiologist*                       CRNA
Doctor                                                                                        DNP, PhD, MD, DO, PsyD, EdD, DDS, DVM (and                                                                                                        more)
Physician *title protected                                                       MD, DO
Nurse                                                                                         RN, LPN, LVN
Nurse-Midwife                                                                         CNM
Registered Nurse *title protected                                        RN

While these may seem like just letters or titles, there are serious implications for practice. Healthcare professionals must be diligent in clarifying their position and credentials. For example, when you hear the term, doctor, what do you think of? How do you know if it’s a nurse researcher, with his PhD? Or a surgeon with her MD?

Now imagine how confusing this could be for patients and non-healthcare professionals. As healthcare professionals we know there is a significant difference between a psychologist with a PhD and a psychiatrist with an MD, for example. A patient, however, may not be familiar with the key differences between the two.

As stated above, those not licensed as a nurse may not refer to themselves as one, but we must be just as careful with the rest of the titles in order to make sure our patients and clients understand. It is our duty to explain who we are and what we are here to do, each and every time we encounter a patient.

There has been much discussion on the issue in recent years as more nurses are obtaining doctoral degrees. According to the American Association of Colleges of Nursing, from 2017-2018 the number of DNP graduates increased from 6,090 to 7,039 (American Association of Colleges of Nursing, 2019). In 2011, the percentage of nurses holding a doctorate degree was less than 1%, with a forecast and goal to double that number by 2020 (Feeg & Nickitas, 2011). With both the number of programs and graduates increasing, nurses are increasingly obtaining doctorate degrees and earning the privilege of being called “Doctor”.

A nurse practitioner, who obtains a doctoral degree such as a PhD or DNP, may be referred to as “Doctor”. In a 2013 position statement, the Emergency Nurses Association (ENA) stated: “This title in the discipline of nursing is central to establishing collegial, collaborative relationships with all members of the healthcare team by recognizing a higher educational level that nurses bring to the arena” (Emergency Nurses Association, 2013, p. 1).

However, the American Medical Association (AMA) argues about “misrepresentation” in passed Resolution 211, stating that doctoral-prepared nurses referring to themselves as doctor will only confuse patients and mislead them into believing their care is being provided by a physician (Klein, 2007). The important takeaway from this is that nurses, regardless of credential, are responsible for clearly communicating their role and credentials with each patient encounter. Clear identification of roles and credentials is essential to safe, effective patient care. Each role should be respected for its individual contribution to the healthcare team.

The rules governing nursing in the state of Ohio, OAC 4723-4-06, states:
(C) At all times when a licensed nurse is engaged in nursing practice and interacting with the patient, or health care providers on behalf of the patient, through any form of telecommunication, the licensed nurse shall identify to each patient or health care provider the nurse’s title or initials set forth in division (E) of section 4723.03 of the Revised Code to identify applicable licensure as a registered nurse, licensed practical nurse, certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist.

Title Protection: Not Just for Registered Nurses

Title protection has been in the news lately regarding more than just the title of ‘nurse.’ The American Association of Nurse Anesthetists (AANA), the national professional association of nurse anesthetists, recently voted and approved the use of “nurse anesthesiologist” (The Committee For Proper Recognition for CRNAs, 2019) (American Society of Anesthesiologists, 2019). While some states have approved this descriptor, it is not widely accepted across the country.

There is much discussion around the importance of titles and what it implies to the public. CRNAs strive to make their role clear to patients and believe by changing their title to nurse anesthesiologist they can do so. However, opponents of the change argue that this does not do an effective job of differentiating nurse anesthesiologists from anesthesiologist that are physicians. (The Committee For Proper Recognition for CRNAs, 2019). The American Society of Anesthesiology adamantly opposes this change and calls it “misleading” and an effort to “dismantle the successful and proven anesthesia care team model at both state and federal levels” (American Society of Anesthesiologists, 2019, para. 1).

Where do we go from here? The Future of Nursing
Safeguarding the title of nurse provides professionals, as well as the community at-large, needed security in knowing what is meant by that term. With the healthcare industry drastically changing, people should know what to expect when being cared for by a nurse. This is especially true since the role of the nurse has rapidly evolved over the years and is expected to continue on this trajectory of growth and change.

In 2008, the Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM) began a study on the Future of Nursing. This was a two-year initiative to report on recommendations for the Nursing profession. Of the four main messages that resulted, three were directly impacted by how we define the word “nurse.” They are:
1) That nurses should practice to the full extent of their education and training,
2) That nurses should be full partners with physicians and other health care professionals in redesigning health care in the United States,
3) And that effective workforce planning and policy making will require nurses to collect better data and information (Institute of Medicine, 2011).

The committee that was established for this study recognized that the nursing profession is the largest of the health care workers. For that reason, they stated that nurses have an opportunity to be leaders in improving the system. They prioritized future demands for care to be safe, patient-centered, accessible, affordable, and have quality outcomes. Primary care and prevention would be the focus, giving rise to needed systematic changes in healthcare. Nursing are moving from acute care to new roles such as coaches for chronic conditions, care coordinators for transitional care, and other front-line positions in public health. Nurses are expanding their roles regarding informatics and technology.

Nurses will continue to be, as described by the business world, “disruptive innovators”, forcing nurse leaders to become more “innovator-friendly” and accommodate this rise in nurse entrepreneurs and inventors (Fuller & Hansen, 2019). Nurses are creating improvements in the healthcare industry that may start out small, but end up changing the way patients receive care. An example of this is Nurse Practitioners setting up clinics in unconventional locations such as Walmart to increase access to care in lower socioeconomic communities (Fuller & Hansen, 2019). It worked so well that these clinics are now seen in a myriad of places.

Many things must take place for this growth in nursing to be seamless. Such things as effective leadership would be needed to empower nurses to deal with the pressures of these changes (Institute of Medicine, 2011). Unique nurse identifiers will have to be created and used in electronic health records to demonstrate nurses’ contributions in the value-based reimbursement (Sensmeijer, et al., 2019). Nurses in Informatics will have to be data specialists to interpret the vast amount of information collected regularly (Carroll, 2019). Nurses will need to continue using their voice in policies, procedures, regulatory and accreditation standards to influence systems. As the world becomes more global, nurses will need to focus on this globalization. No matter the country, this profession shares the desire to make changes so that our communities are healthier (Cipriano, 2018).

There is no doubt that nursing roles are definitely evolving. One basic concept of what is yet to come, however, is that nurses need to protect their title so that the understanding of the word is consistent throughout our communities.

As you can see, it is imperative that now more than ever, nurses must advocate for title protection. Nurses must emphasize that nursing is the care of humans in a variety of settings. Our profession is unique and needs to be recognized as such.

For more information on how you can get involved, visit http://ohnurses.org/advocacy/

References
American Association of Colleges of Nursing. (2019, March). DNP Fact Sheet. Retrieved August 16, 2019, from AACN: https://www.aacnnursing.org/News-Information/Fact-Sheets/DNP-Fact-Sheet

American Nurses Association. (2013). Title “Nurse” Protection. Retrieved August 14, 2019, from ANA: https://www.nursingworld.org/practice-policy/advocacy/state/title-nurse-protection/

American Nurses Association. (n.d.). What is Nursing. Retrieved August 14, 2019, from ANA: https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/

American Society of Anesthesiologists. (2019). AANA’s Anti-Team-Based Anesthesia-Care Campaign. Retrieved August 23, 2019, from American Society of Anesthesiologists: https://www.asahq.org/in-the-spotlight/defending-physician-led-care

Brenan, M. (2018, December 20). Nurses Again Outpace Other Professions for Honesty, Ethics. Retrieved from Gallup: https://news.gallup.com/poll/245597/nurses-again-outpace-professions-honesty-ethics.aspx

Carroll, W. (2019). Putting the “N” in STEM: A call for nurse data scientists. Online Journal of Nursing Informatics, 23(2). Retrieved from www.himss.org/ojni

Cipriano, P. (2018). The Nursing Now campaign launches. American Nurse Today.13(5). Retrieved from https://www.americannursetoday.com/nursing-now-campaign-launches/

Emergency Nurses Association. (2013). Appropriate Credential Use/Title Protection for Nurses with Advanced Degrees. Retrieved from https://www.ena.org/docs/default-source/resource-library/practice-resources/position-statements/appropriatecredentialuse.pdf?sfvrsn=b464e4ca_14

Feeg, V., & Nickitas, D. (2011). Doubling the Number of Nurses with a Doctorate by 2020: Predicting the Right Number or Getting it Right? Nursing Economics, 29(3). Retrieved from https://www.nursingeconomics.net/necfiles/news/MJ_11_Editorial.pdf

Fuller , R., & Hansen, A. (2019). Navigating and leading the future of nursing. Nursing Administration Quarterly, 43(3), 212-221. doi:10.1097/NAQ.0000000000000354

Institute of Medicine. (2011). The future of nursing: leading change, advancing health. Retrieved from Institute of Medicine: www.nap.edu/catalog.php?record_id=12956

Klein, T. (2007, October 11). Are Nurses With a Doctor of Nursing Practice Degree Called “Doctor”? Retrieved from Medscape: https://www.medscape.com/viewarticle/563176

Merriam-Webster. (n.d.). nurse. Retrieved August 14, 2019, from Merrian-Webster Dictionary: https://www.merriam-webster.com/dictionary/nurse

Online etymology dictionary. (2019). Nurse. Retrieved from https://www.etymonline.com/word/nurse

Sensmeijer, J., Androwich, I., Baernholdt, M., Carroll, W., Fields, W., Fong, V., . . . Rajwany, N. (2019). The value of nursing care through the use of a unique nurse identifier. Online Journal of Nursing Informatics, 23(2). Retrieved from www.himss.org/ojni

The Committee For Proper Recognition for CRNAs. (2019). NURSEANESTHESIOLOGISTINFO. Retrieved August 21, 2019, from NURSEANESTHESIOLOGISTINFO: https://www.nurseanesthesiologistinfo.com

Emergency Nurses Association. (2013). Appropriate Credential Use/Title Protection for Nurses with Advanced Degrees. Retrieved from https://www.ena.org/docs/default-source/resource-library/practice-resources/position-statements/appropriatecredentialuse.pdf?sfvrsn=b464e4ca_14

Feeg, V., & Nickitas, D. (2011). Doubling the Number of Nurses with a Doctorate by 2020: Predicting the Right Number or Getting it Right? Nursing Economics, 29(3). Retrieved from https://www.nursingeconomics.net/necfiles/news/MJ_11_Editorial.pdf

Fuller , R., & Hansen, A. (2019). Navigating and leading the future of nursing. Nursing Administration Quarterly, 43(3), 212-221. doi:10.1097/NAQ.0000000000000354

Institute of Medicine. (2011). The future of nursing: leading change, advancing health. Retrieved from Institute of Medicine: www.nap.edu/catalog.php?record_id=12956

Klein, T. (2007, October 11). Are Nurses With a Doctor of Nursing Practice Degree Called “Doctor”? Retrieved from Medscape: https://www.medscape.com/viewarticle/563176

Merriam-Webster. (n.d.). nurse. Retrieved August 14, 2019, from Merrian-Webster Dictionary: https://www.merriam-webster.com/dictionary/nurse

Online etymology dictionary. (2019). Nurse. Retrieved from https://www.etymonline.com/word/nurse

Sensmeijer, J., Androwich, I., Baernholdt, M., Carroll, W., Fields, W., Fong, V., . . . Rajwany, N. (2019). The value of nursing care through the use of a unique nurse identifier. Online Journal of Nursing Informatics, 23(2). Retrieved from www.himss.org/ojni

The Committee For Proper Recognition for CRNAs. (2019). NURSEANESTHESIOLOGISTINFO. Retrieved August 21, 2019, from NURSEANESTHESIOLOGISTINFO: https://www.nurseanesthesiologistinfo.com

Click Here to Take the Evaluation