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Ohio Nurse Practice Act: 1 Hour Category A

1.00 Contact Hour
This continuing nursing education activity was approved by the Ohio Nurses Association (OBN-001-91), an accredited approver by the American Nurses Credentialing Centers Commission on Accreditation. Approval valid through 1/30/2020. ONA #21358 has received ONA approval for 1 Category A contact hour.
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Authors:    Donna Thomas (RN, MSN, BSHEd) , David Tilton (RN, BSN)

Purpose/Outcomes

100% Learners will self-report that there knowledge of Ohio law and rules has improved.

Objectives/Outcomes

At the conclusion of this course, the learner will be able to:

  1. Discuss the application process to be a licensed nurse in Ohio.
  2. Discuss established standards of nursing practice in Ohio.
  3. Discuss the Ohio Board of Nursing provisions for LPN intravenous therapy
  4. Identify one client safety standard in the Ohio Nurse Practice Act.
  5. Define the steps for renewal of license with a focus on lifelong continuing professional education in the Ohio Nurse Practice Act.
  6. List two potential results that might occur as a result of disciplinary action to a nurse in Ohio.

Introduction

Are you a nurse? How do you know? It is only when you pick up the Nurse Practice Act written by the State Legislature of the state in which you are applying for licensure that you can know if you meet the specific definition of who may go by the title, nurse.

Each state governing body has the duty and obligation to its citizens to define who may be called a nurse, what the process is for achieving and maintaining that title, what a nurse may or may not do, who they are responsible to, and how correction of those who fail to comply with the state Nurse Practice Act (NPA) will be applied. Be aware while all NPAs discuss similar topics and share comparable content the Nurse Practice Acts of any two states will not be identical!

As a professional you are legally responsible to remain in compliance with the laws and regulations that govern you. Each licensed medical professional works under laws, statutes, and standards derived from local, state, and federal governing bodies in addition to the professional practice guidelines that apply.

Maybe it is time to dust off your copy of the Practice Act you have sworn, yes, sworn, to abide by. An application for professional licensure with acceptance is a legally binding contract to uphold your practice to the level mandated by that authorizing body. "The practice of nursing is a right granted by a state to protect those who need nursing care. Safe, competent nursing practice is grounded in the law as written in the state nurse practice act and its rules. The laws of the nursing profession can only function properly if nurses know the current laws governing practice in their state. Ignorance of the law is never an excuse." (NCSBN, 2013).

Well, no need to rush to a bookseller. Most states have copies of their Nurse Practice Acts on the internet, or available on request from your state board of nursing.

How about we start at the basics, picking an example NPA and looking at the high points? How about, Ohio:

Go to the state of Ohio nursing web page to access the most recent copy of the Ohio Nurse Practice Act: www.nursing.ohio.gov/LawandRule.htm

Ohio Meet the Board

The goal is safety. The NPA (chapter 4723 of the Ohio Revised Code (ORC), are statutes, with the expressed goal of protecting the public from unsafe care by ensuring that a minimum set of requirements are met and maintained by those whose practice is in that area the state defines as nursing. An Adjunct document is the Ohio Administrative Code (OAC) chapters 4723-1 though chapter 4723-27. The OAC is a set of rules that assist in implementation and interpretation of the ORC.

In Ohio the Board of Nursing acts as the administrative agency charged with implementing and interpreting the state's NPA. This authority is granted to the Board by the NPA itself. However, the Board has no actual control over the formation of the Act. That burden is the duty of the state legislature who listens to suggestions from the Board, professional organizations, legal counsel and the citizens of Ohio. In the end however, it is the state legislature that determines the contents of the NPA. As the Board of Nursing is the implementation aspect of the NPA governing nurses and nursing, some knowledge of how it is composed and formed may be helpful in understanding the rulings it makes, and how to appeal or question its decisions.

The Ohio Board of Nursing is composed of thirteen members picked by the Governor of Ohio specifically for this duty (ORC, 4723.02). Eight of the members are to be RNs. Of these at least one member must be a practitioner of a specialty such as; a certified nurse midwife, a clinical nurse specialist, a certified nurse practitioner, or a certified nurse anesthetist. Of the five remaining positions on the Board four of those seats are reserved for LPNs, with the last remaining seat being occupied by what is referred to as a 'consumer interest' representative (ORC, 4723.02).

Each of the LPN and RN members are required to have met certain minimum standards. Each must be a graduate of an approved nursing education program and hold a current license in the state of Ohio for the profession of nursing. Each of these board members must also have actively been in practice in their profession for the five years immediately prior to being selected for a position on the Board of Nursing.

That odd man out, the single citizen consumer interest representative, is forced to meet requirements that in many ways are the opposite of the nurses seated on the Board. The consumer representative is required to not be a member of any healthcare profession. Neither may they or anyone in their family be employed in healthcare. As a further requirement there can be no financial association related to financing or delivering health related items or services.

This group composing the Board of Nursing is charged with administering and enforcing the Nursing Practice Act and is equipped with an array of clearly defined powers, duties and responsibilities.

Now that we have an image of the players, we will take a look at the script they interpret, enforce and protect.

To Be a Nurse in Ohio

No one is allowed to practice a nursing profession in Ohio without a license from the Ohio Board of Nursing. This includes RN, LPN, CRNA, CNS, CNM, CNP, APRN (ORC, 4723.03).

A NPA defines the conditions under which a person can be called by the professional title "nurse" (ORC, 4723.01). To be known as a nurse in Ohio, an application must be presented to the state Board of Nursing (ORC 4723.09). This application will serve as a request to take the licensing examination. (We will discuss transferring out-of-state licenses into Ohio later). For a fee, determined by the Board, the application for examination follows a process described in the NPA that will determine if the educational program you have attended meets the minimum level acceptable for your requested credential. A criminal record background check is also conducted and a testing date and location assigned. Once the testing is successfully completed a discipline specific license is issued by the Board, along with instructions on how to maintain up-to-date licensure by means of Board approved continuing education courses.

Nurses who possess active licenses outside of Ohio who are requesting an Ohio nursing license, known as by licensure by endorsement, may apply to the board to grant them Ohio licensure. Ohio's board of nursing is willing to grant endorsement provided a clean criminal and disciplinary action background check comes back and the applicant provides proof of graduation from an education program approved either by Ohio (or a fellow member of the national council of state boards of nursing), along with documentation of completion of at least two contact hours of continuing education directly related to the laws and rules that govern the practice of nursing in Ohio (ORC 4723.09) (OAC, 4723-7-05). Foreign born applicants seeking a nursing license in the state of Ohio that possess licensure out of the country are required to provide proof that they have passed the Test of English as a Foreign Language (TOEFL) (OAC, 4723-7-04).

Don't despair. A one-hundred-eighty day temporary permit to practice nursing is available to those who are having trouble getting their documentation together as long as they have a current license from a recognized state or national nursing board. However, do not get complacent either. You can only be issued that temporary permit once.

HB 216 requires that APRNs practicing with the designation of CRNA, CNP, CNS or CNM be “licensed” in Ohio rather than just certi?ed. The transition to becoming licensed for APRNs who hold a Certi?cate of Authority (COA) began July 1st as part of the 2017 COA renewal/APRN license issuance process. Any person who wishes to continue to practice in Ohio as an APRN with a designation of CRNA, CNP, CNS or CNM obtain licensure in Ohio no later than the statutory deadline of December 31, 2017.

Licensure includes prescriptive authority for all CNPs, CNSs, and CNMs who meet the requirements of HB 216.

Ohio Standards of Practice

The Legislature in each state may set in place rules and standards separate from any professional organization. For health professionals the acts they may or may not do (as well as a minimum standard for measuring professional competency) are defined by the state in which they choose to practice or be employed.

The intent of a NPA is to protect the public from unsafe practitioners, with the ultimate goal of competent, quality nursing care provided by qualified practitioners. The NPA also protects you, the nurse, by defining what is and what is not a responsibility or duty required from you!

Standards for a Registered Nurse

In Ohio, Registered Nurses (RNs) are expected to provide nursing care in a manner defined by the Board of Nursing, as stipulated within the NPA. What is expected, at a minimum, is composed of the following (ORC, 4723.01 (B)-(D)), (OAC, 4723-4-03):

  • Maintenance of current knowledge in the areas of duties, responsibilities and accountabilities required for safe nursing practice.
  • The ability to demonstrate both competence and accountability in all of the areas of practice in which that nurse is engaged. This includes, but is not limited to the following;
    • Consistent performance in all aspects of nursing care.
    • The ability to assess health status for the purpose of providing nursing care.
    • Health counseling and teaching abilities.
    • Skills for safe administration of medications, treatments, executing regimens appropriate for a nurse's professional practice.
    • The ability to teach, administer, supervise, delegate and evaluate nursing practice.
    • The ability to recognize and intervene appropriately when a complication arises, as well as the ability to refer or consult when needed.

Duties that registered nurses are expected to complete within a "timely manner" include the following:

  • Implementation of any order for a client unless the registered nurse believes or should have reason to believe the order is;
    • Inaccurate
    • Not properly authorized
    • Not current or valid
    • Harmful or potentially harmful to that client
    • Contraindicated by other documented information
  • Clarify any order for a client when the registered nurse believes or should have reason to believe the order is;
    • Inaccurate
    • Not properly authorized
    • Not current or valid
    • Harmful or potentially harmful to that client
    • Contraindicated by other documented information

When it is necessary to clarify an order the registered nurse is expected to (in a timely manner) consult with an appropriate licensed practitioner. If a decision is made not to follow the direction or administer the medication or treatment as ordered it is up to the registered nurse to notify the prescribing practitioner (again in a timely manner) and document the notification along with the reason for not following the order. The most important thing however is the mandate to take actions as needed to assure the safety of the client.

The NPA requires a registered nurse to report or consult whenever necessary with other members of the health care team, as well as make referrals if that seems appropriate. While doing so, care must be taken to maintain client confidentiality and limit the communication of nonessential information to other health professionals as much as possible. What would be optimal is to involve the client by allowing consent decisions regarding what information may be communicated to others. This includes the use of written consent permissions in all circumstances appropriate for their use.

It is expected that registered nurses practicing in Ohio maintain acceptable standards of safe nursing care in the areas of observation, advice, instruction, teaching, or evaluation. They are also expected to communicate information in an acceptable manner within the standards of safe nursing care. This includes identifying their title to the person with whom they are communicating.

When providing direction to a licensed practical nurse, it is up to the registered nurse to first assess:

  • The condition of the client, including their stability
  • The type of nursing care required by the client
  • The complexity and frequency of any nursing care needed
  • The training, skill and ability of that licensed practical nurse in relation to their ability to perform specific needed functions or procedures
  • The availability and accessibility of resources needed in order to safely perform the specified function or procedure

Standards for a Licensed Practical Nurse

The eternal question "Vocational vs. Practical" is answered by the Ohio NPA. In Ohio, the title is LPN Licensed Practical Nurse.

The practice of nursing as a licensed practical nurse" means providing to individuals and groups nursing care requiring the application of basic knowledge of the biological, physical, behavioral, social, and nursing sciences at the direction of a registered nurse or any of the following who is authorized to practice in this state: a physician, physician assistant, dentist, podiatrist, optometrist, or chiropractor (ORC 4723.01(6)(f).

The Standards of Practice for a Licensed Practical Nurse is the LPN is expected to function within the limits of practice set out by the Ohio Revised Code as well as by any rules by the Board of Nursing, applicable laws, rules and professional standards (ORC, 4723.01(E)-(F)), (OAC, 4723-4-04):

It is an expectation that current knowledge of duties, responsibilities and accountabilities necessary for safe nursing practice be maintained, and that a licensed practical nurse is able to demonstrate competence and accountability in the care that they deliver. Licensed Practical Nurses are also expected to possess the skills necessary to recognize, refer, seek consultation or implement interventions that may be needed to handle complications which may arise.

In the state of Ohio, it is expected that a licensed practical nurse will, in a timely manner, complete the following:

  • Implement any order or direction for a client unless the licensed practical nurse believes or should have reason to believe the order is;
    • Inaccurate
    • Not properly authorized
    • Not current or valid
    • Contraindicated by other documented information
  • Obtain clarification for any order or direction for a client when the licensed practical nurse believes or should have reason to believe the order or direction is;
    • Inaccurate
    • Not properly authorized
    • Not current or valid
    • Contraindicated by other documented information

Clarification for an order or direction requires a timely consultation with an appropriate licensed practitioner and notification of the prescribing practitioner should the licensed practical nurse decide not to follow the direction or administer the medication or treatment as prescribed. This must be followed with documentation that the practitioner was notified of the decision as well as the reason for that decision. Above all, the licensed practical nurse is expected to act when needed to assure the safety of the client.

A licensed practical nurse is expected to report to and consult with other nurses or members of the health care team in a timely manner. They are also expected to make referrals for the client as appropriate. When discussing client information with other health providers the licensed practical nurse must maintain client confidentiality to the greatest extent possible. As much as possible it is desired that the client has the right to give or withhold consent regarding the release of information. This includes the use of written consents when appropriate or in all circumstances identified by law.

In those instances, in which a licensed practical nurse is directed to observe, advise, instruct, or evaluate the performance of a nursing task they are expected to use acceptable standards of safe nursing care as a basis. Any information they communicate should be within the acceptable standards of safe nursing care.

Licensed Practical Nurses (LPNs) in Ohio may be eligible for Intravenous Therapy privileges after licensure in the state (ORC, 4723.18), (OAC, 4723-18), If this is desired they must demonstrate successful completion of a Board approved course of study in the safe performance of Intravenous Therapy. The laws for IV therapy by LPNs are very specific.

When a licensed practical nurse authorized by the board to perform intravenous therapy performs an intravenous therapy procedure at the direction of a registered nurse, the registered nurse or another registered nurse shall be readily available at the site where the intravenous therapy is performed, and before the licensed practical nurse initiates the intravenous therapy, the registered nurse shall personally perform an on-site assessment of the adult patient who is to receive the intravenous therapy. (OAC, 4723-18 (2)(C)(1)).

There are special requirements for LPNs to perform intravenous therapy procedures (OAC, 4723-18 (2)(D)- 4723.181(5)).
An LPN shall not initiate or maintain any of the following:
  • Blood or blood components;
  • Solutions for total parenteral nutrition; Any cancer therapeutic medication including, but not limited to, cancer chemotherapy or an anti-neoplastic agent;
  • Solutions administered through any central venous line or arterial line or any other line that does not terminate in a peripheral vein; except that a licensed practical nurse authorized by the board to perform intravenous therapy may maintain the solutions specified that are being administered through a central venous line or peripherally inserted central catheter;
  • Any investigational or experimental medication.

An LPN shall not Initiating intravenous therapy in any vein, except that a licensed practical nurse authorized by the board to perform intravenous therapy may initiate intravenous therapy in a vein of the hand, forearm, or antecubital fossa;

An LPN cannot perform any of the following procedures:

  1. Discontinuing a central venous, arterial, or any other line that does not terminate in a peripheral vein;
  2. Initiating or discontinuing a peripherally inserted central catheter;
  3. Mixing, preparing, or reconstituting any medication for intravenous therapy, except that a licensed practical nurse authorized by the board to perform intravenous therapy may prepare or reconstitute an antibiotic additive;
  4. Administering medication via the intravenous route, including all of the following activities:
    1. Adding medication to an intravenous solution or to an existing infusion, except that a licensed practical nurse authorized by the board to perform intravenous therapy may do any of the following:
    2. Initiate an intravenous infusion containing one or more of the following elements: dextrose 5%;, normal saline;, lactated ringers;, sodium chloride .45%;, sodium chloride 0.2%;, sterile water.;
    3. Hang subsequent containers of the intravenous solutions vitamins or electrolytes, if a registered nurse initiated the infusion of that same intravenous solution.
  5. Initiate or maintain an intravenous piggyback infusion containing an antibiotic additive;.
  6. Injecting medication via a direct intravenous route, except that a licensed practical nurse authorized by the board to perform intravenous therapy may inject heparin or normal saline to flush an intermittent infusion device or heparin lock including, but not limited to, bolus or push.
  7. Changing tubing on any line including, but not limited to, an arterial line or a central venous line, except that a licensed practical nurse authorized by the board to perform intravenous therapy may change tubing on an intravenous line that terminates in a peripheral vein;
  8. Programming or setting any function of a patient controlled infusion pump.

At the direction of a physician or a registered nurse, a licensed practical nurse authorized by the board to perform intravenous therapy may perform the following activities for the purpose of performing dialysis:

The routine administration and regulation of saline solution for the purpose of maintaining an established fluid plan;

The administration of a heparin dose intravenously;

The administration of a heparin dose peripherally via a fistula needle;

The loading and activation of a constant infusion pump or the;

The intermittent injection of a dose of medication physician for dialysis that is administered via the hemodialysis blood circuit and through the patient's venous access.

No person shall employ or direct a licensed practical nurse to perform an intravenous therapy procedure without first verifying that the licensed practical nurse is authorized by the board to perform intravenous therapy.

A may perform on any person any of the intravenous therapy procedures without receiving authorization to perform intravenous therapy from the board of nursing, if both of the following apply:

(1) The licensed practical nurse acts at the direction of a registered nurse or a licensed physician, dentist, optometrist, or podiatrist and the registered nurse, physician, dentist, optometrist, or podiatrist is on the premises where the procedure is to be performed or accessible by some form of telecommunication.

(2) The licensed practical nurse can demonstrate the knowledge, skills, and ability to perform the procedure safely.

The intravenous therapy procedures that a licensed practical nurse may perform are limited to the following:

Verification of the type of peripheral intravenous solution being administered;

Examination of a peripheral infusion site and the extremity for possible infiltration;

Regulation of a peripheral intravenous infusion according to the prescribed flow rate;

Discontinuation of a peripheral intravenous device at the appropriate time;

Performance of routine dressing changes at the insertion site of a peripheral venous or arterial infusion, peripherally inserted central catheter infusion, or central venous pressure subclavian infusion.

Standards for APRNs

The nursing process and dedicated nurses have been shown to be valuable in every area of health care. The state of Ohio in its NPA recognizes that nurses can be found everywhere, doing many different tasks at all levels of care. For that reason, it has specifically addressed the standards it expects from Advance Practice Nurses (APRN) (ORC, 4723.01(G)-(J)), (OAC, 4723-4-05):

  • Certified Nurse Midwife
  • Certified Nurse Practitioner
  • Certified Registered Nurse Anesthetist
  • Clinical Nurse Specialist

4723-8-04 Standard care arrangement for a certified nurse-midwife, certified nurse practitioner, and clinical nurse specialist.

Before beginning practice, a standard care arrangement shall be entered into with each physician or podiatrist with whom the certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist collaborates. The standard care arrangement can be revised to add or delete a physician or podiatrist within that employment setting instead of making a new arrangement. A new standard care arrangement is needed when the nurse is employed at a different setting and engages in practice with different collaborators. The collaborating physicians or podiatrists practice must be the same or similar to the nurse's practice.

A clinical nurse specialist without a certificate to prescribe whose nursing specialty is mental health or psychiatric mental health is not required to enter into a standard care arrangement.

A standard care arrangement includes at least:

signatures of each nurse, and each collaborator, indicating review of and agreement to abide by the terms of the standard care arrangement.

The date when the arrangement is initially executed

The date of the most recent review of the arrangement

The complete name, specialty and practice area, business address, and business phone number or number at which the individual can be reached at any time for all participants.

A statement of services offered by the nurse or holders of a certificate to prescribe, including a description of the scope of prescriptive practice.

A plan for incorporation of new technology or procedures.

Quality assurance provisions:

  1. Review and reapproval of the standard care arrangement every two years. Criteria for referral of a patient by the nurse to a collaborating physician or podiatrist.
  2. A process for the nurse to obtain consultation from a physician or podiatrist;
  3. A procedure for regular review of referrals made by the nurse.
  4. A process for chart review if the nurse's practice includes any direct patient care, education, or management.
  5. A policy for care of infants up to age one and recommendations for collaborating physician visits for children from birth to age three, if the nurse is providing services to infants.
  6. A plan for coverage of patients in instances of emergency or planned absences of the nurse or collaborators.
  7. A process for resolution of disagreements regarding matters of patient management
  8. An arrangement regarding reimbursement under the medical assistance program
  9. For nurses with a current valid certificate to prescribe, the following quality assurance provisions shall include at least:
  10. Provisions to ensure timely direct, personal evaluation of the patient with a collaborating physician or the physician's designee when indicated
  11. Additional prescribing parameters for those drugs or therapeutic devices established in the formulary, including provisions for use of:
    1. drugs with non-food and drug administration (FDA) approved indications
    2. drugs approved by the FDA and reviewed by the committee on prescriptive governance subsequent to the date of the standard care arrangement
    3. drugs previously reviewed by the committee on prescriptive governance but approved by the FDA for new indications subsequent to the date of the standard care arrangement
    4. schedule II controlled substances.
    5. opioid analgesic to a minor if prescribing to minors.
    6. for obtaining and reviewing OARRS reports, and engaging in physician consultation and patient care consistent.
    7. a quality assurance committee periodic review, at least semiannually, of:
      1. A representative sample of prescriptions written by the nurse;
      2. A representative sample of schedule II prescriptions written by the nurse
    8. ensure that the nurse is meeting all the requirements of rule 4723-9-12 of the Administrative Code related to review of a patient's OARRS report, consultation with the collaborating physician prior to prescribing based on the OARRS report and signs of drug abuse or diversion as set forth in rule 4723-9-12 of the Administrative Code, and documentation of receipt and assessment of OARRS report information in the patient's record.

The most current copy of the standard care arrangement, and any legal authorization signed by a physician must be available upon request at each site where practice of the occurs. Upon request of the board, the nurse must provide a copy of the standard care arrangement to the board. Retain copies of previously effective standard care arrangements for three years.

When a hospital negotiates a standard care arrangement the review and approval of the standard care arrangement must be in accordance with the policies and procedures of the hospital governing body and the bylaws, policies, and procedures of the hospital medical staff.

A nurse must notify the board of the identity of a collaborating physician or podiatrist any change in the name and business address of a collaborating physician or podiatrist within 30 days.

A clinical nurse specialist who does not hold a certificate to prescribe and whose nursing specialty is mental health or psychiatric mental health shall identify one or more physicians with whom they collaborate, but a standard care agreement is not required.

An APN may practice without a collaborating physician or podiatrist for notmore than 120 days if the physician or podiatrist terminates the collaboration beforethe standard care arrangement expires.

Certified Nurse Midwives are now authorized to treat their female patients’ male partners only to the extent of issuing or providing the prescription or the drug to treat chlamydia, gonorrhea, or trichomoniasis and to provide the related health care information as provided in Section 4723.4810, ORC.

An advanced practice registered nurse may delegate the administration of medication to an unlicensed person

HB 341 imposes legal requirements for CTP holders. CTP holders who hold appropriate DEA certification and prescribe opioid analgesics or benzodiazepines. Before initially prescribing or personally furnishing an opioid analgesic or a benzodiazepine, The APRN must request patient information from OARRS that covers at least the previous 12 months, and make periodic requests for patient information from OARRS if the course of treatment continues for more than 90 days. Exceptions to the requirement to check OARRS under these circumstances include drugs prescribed to hospice or cancer patients, drugs to be administered in hospitals or long-term facilities, drugs to treat acute pain from surgery or a delivery, and drug amounts for use in seven days or less.

The law further requires the Nursing Board to verify that licensees prescribing in this manner are registered and using OARRS appropriately. Violations of these legal requirements may subject licensees to discipline (OBN Momentum, winter 2015).

APRNs with prescriptive authority may delegate to a person not otherwise authorized to administer drugs, the authority to administer drugs to a specified patient. Prior to delegating this authority, the CTP holder is required to assess the patient, determine that the drug is appropriate for the patient, and determine that the person to whom the authority will be delegated has met the conditions Section 4723.489, ORC. For example, a CTP holder is limited to delegating only the administration of drugs that the CTP holder may prescribe him/herself, and the CTP holder is prohibited from delegating the administration of intravenous drugs and controlled substances. There are also restrictions on the locations where the authority to administer drugs may be delegated by a CTP holder. Section 4723.489(C), ORC, prohibits the delegation from occurring in hospital inpatient care units, hospital emergency departments, freestanding emergency departments, or ambulatory surgery facilities. The CTP holder must be physically present at all locations where a drug is administered through CTP holder delegation. Prior to delegating, the CTP holder must determine that the individual who will administer the drugs has successfully completed drug administration education based upon a recognized body of knowledge, and that the individual has demonstrated to their employer the knowledge, skills, and ability to safely administer the drug(s). All of this must be documented and made available to the delegating CTP holder to determine whether the delegation is appropriate for patient safety and well-being. (OBN Momentum, fall 2015).

4723-9-10 Formulary; standards of prescribing for advanced practice registered nurses designated as clinical nurse specialists, certified nurse-midwives, or certified nurse practitioners.

The Board adopted an exclusionary formulary, based upon the recommendation of the Committee on Prescriptive Governance (CPG). The exclusionary formulary speci?es that CNSs, CNPs and CNMs shall not prescribe any drug in violation of federal or Ohio law. It further states that the prescriptive authority of a CNS, CNP and CNM shall not exceed the prescriptive authority of the collaborating physician or podiatrist. The exclusionary formulary is on the Board website at www.nursing.ohio.gov/Practice-Prescribing.htm.

Sections 4723.431(E) and 4731.27, ORC

Morphine equivalent daily dose (MED) means a conversion of various opioid analgesics to a morphine equivalent dose by the use of accepted conversion tables provided by the state board of pharmacy at: www.ohiopmp.gov/MED_Calculator.aspx.

A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner may;prescribe any drug or therapeutic device in any form or route of administration if:

  1. The ability to prescribe the drug or therapeutic device is within the scope of
  2. practice in the nurse's specialty area
  3. The prescription is consistent with the terms of a standard care arrangement
  4. The prescription would not exceed the prescriptive authority of the collaborating
  5. physician
  6. The individual drug or subtype or therapeutic device is not one excluded by the
  7. Formulary
  8. The prescription meets the requirements of state and federal law
  9. A valid prescriber-patient relationship exists. This relationship may include, but is not limited to:
    1. Obtaining a thorough relevant history of the patient;
    2. Conducting a physical or mental examination of the patient;
    3. Rendering a diagnosis
    4. Prescribing medication, ruling out the existence of any recognized contraindications
    5. Consulting with the collaborating physician when necessary
    6. Documenting these steps in the patient's medical records

A nurse may prescribe or personally furnish a drug to not more than a total of two individuals who are sexual partners of the nurse's patient. If the patient is a family member, acceptable and prevailing standards of safe nursing care require that a nurse maintain detached professional judgment. The nurse shall not prescribe to a family member unless:

  1. The nurse is able to exercise detached professional judgment in reaching diagnostic or therapeutic decisions
  2. The prescription is documented in the patient's records

For drugs that are a controlled substance:

  1. The prescription indicates the ICD-10-CM medical diagnosis code of the
  2. primary disease or condition that the controlled substance is being used
  3. to treat.
  4. The prescription indicates the intended days' supply of the controlled
  5. substance prescription. The intended days' supply is calculated by
  6. dividing the total quantity prescribed by the maximum intended number
  7. of tablets or doses per day;
  8. The patient is not a family member; and
  9. The nurse shall not self-prescribe a controlled substance

A schedule II controlled substance can only be prescribed in situations where all of the following apply:

  1. A patient has a terminal condition;
  2. A physician initially prescribed the substance for the patient; and
  3. The prescription is for a quantity that does not exceed the amount necessary for the patient's use in a single, seventy-two hour period
  4. The patient is in one of the following settings:
    1. hospital
    2. entity owned or controlled, in whole or in part, by a hospital
    3. health care facility
    4. nursing home
    5. county home or district home
    6. hospice care program;
    7. community mental health agency
    8. ambulatory surgical facility
    9. freestanding birthing center
    10. federally qualified health center
    11. federally qualified health center look-alike,
    12. health care office or facility operated by the board of health of a city or general
    13. health district
    14. site where a medical practice is operated, but only if the practice is comprised of one or more physicians who also are owners of the practice; the practice is organized to provide direct patient care
    15. residential care facility

a schedule II controlled substance cannot be prescribed from a convenience care clinic even if the clinic is owned or operated by one of the above entities. Extended-release or long-acting opioid analgesics shall not be prescribed for thetreatment of acute pain.

Before prescribing an opioid analgesic, the nurse shall first consider nonopioidtreatment options. If opioid analgesic medications are required asdetermined by history and physical examination, the prescription should be forthe minimum quantity and potency needed to treat the expected duration ofpain, with a presumption that a three-day supply or less is frequently sufficient. For adults, not more than a seven-day supply with no refills; for minors, not more than a five-day supply with no refills. The seven-day limit for adults and five-day limit for minors may be exceeded for pain that is expected to persist for longer than sevendays based on the pathology causing the pain. In this circumstance, the reason that the limits are being exceeded and the reason that a non-opioid analgesic medication was not appropriate to treat the patient's condition shall be documented in the patient's medical record.

The total morphine equivalent dose (MED) of a prescription for opioid

analgesics for treatment of acute pain shall not exceed an average of thirty

MED per day. To exceed this MED of thirty, the patient's treating physician has entered a standard care arrangement with the advanced practice registered nurse that states the understanding of the physician as to when the nurse may exceed the thirty MED average, and when the nurse must consult with the physician prior to exceeding the thirty MED average.

The prescription guidelines for acute pain do not apply when an opioid analgesic is prescribed:

  1. To an individual who is a hospice patient or in a hospice care program;
  2. To an individual who is receiving palliative care;
  3. To an individual who has been diagnosed with a terminal condition; or
  4. To an individual who has cancer, or a condition associated with the individual's cancer or history of cancer.
  5. for the treatment of opioid addiction utilizing a controlled substance

Drugs approved by the FDA but not yet reviewed and approved by the committeeon prescriptive governance may be prescribed, unless later disapproved by the

committee on prescriptive governance, if:

  1. The drug type or subtype is not excluded on the formulary,
  2. The collaborating physician has agreed in the standard care arrangement that the nurse may prescribe drugs approved by the FDA, that have not yet been reviewed and approved by the committee on prescriptive governance.

An APRN shall not prescribe any drug or device to perform or induce an abortion.

The APRN may prescribe or personally furnish naloxone.

Client Safety Standards in Ohio

It is all about safety really. A NPA serves as a dividing line between what is recognized as a safe level of client care, and what is not. In OAC, 4723-4-06 delineates minimum standards for client safety. One of which is that the title (or initials representing the title) of each nurse offering care be displayed as a means of identifying that person's relevant licensure. This process of identifying level of credential does not stop at a nametag. Whenever engaged in a telephone (or any other means of distance) conversation related to nursing practice each nurse holding a valid Ohio licensure is required to identify their title to the person they are conversing with (OAC, 4723-4-06).

Reporting and documenting complete, accurate and timely nursing assessments is an essential part of client safety. As is documenting the care provided by the nurse for that client and the following response of the client to that care. The process of reporting includes relaying to the appropriate practitioner any errors or deviations from current valid orders. Record management emphasizes truth in reporting and falsifying records or altering documents is strongly discouraged.

The Ohio NPA encourages nurses to implement measures that promote a safe environment for each client and discourages behaviors that cause or may cause physical, verbal, mental or emotional abuse.

Property belonging to a client should not be misappropriated. Nor should there be any behaviors enacted to seek or obtain personal gain at the client's expense. The presence of behavior that may be reasonably interpreted as an attempt to seek personal gain at the client's expense also warrants a caution.

Personal relationships of an inappropriate kind or even the appearance of such relationships is also specifically warned against in the Act. Special attention is paid to care of clients considered incapable of giving free, full or informed consent. Each nurse licensed in Ohio is warned against even the appearance of the following:

  • Sexual conduct with a client.
  • Conduct in the course of practice that may be reasonably interpreted as sexual.
  • Verbal behavior of the seductive or sexually demeaning type.
  • Verbal behavior that to the client may be reasonably interpreted as seductive or sexually demeaning.

It is an expectation in Ohio that each nurse delineates, establishes and maintains professional boundaries with each client. As a routine matter of care the nurse should provide privacy during examination or treatment, and treat each client with courtesy, respect and with full recognition of dignity.

The Nursing Process in Ohio

One of the most consistently productive instruments available to health care is the Nursing Process. The OAC, 4723-4-07 recognizes the importance of the nursing process and defines it as steps which are "cyclical in nature so that the nurse's actions are directed by the client's changing status throughout the process" (OAC, 4723-4-07).

The nurse collaborates with client, family, significant others, as well as other members of the health care team in applying the steps of the nursing process. Licensed practical nurses provide a valuable role in obtaining data, implementing strategies, and collaborating during the entire course of care. Registered nurses and advanced care nurses introduce critical thinking and clinical judgment into the application of the following steps:

  • Assessment
    • Collect data both subjective and objective from all involved persons either in person or by delegation.
    • Document the collected data.
    • Report data as appropriate to other health team members.
  • Analysis
    • Identify, organize and interpret relevant data.
    • Establish, accept or modify a nursing diagnosis to be used as a basis for nursing interventions.
  • Planning
    • Develop, maintain, or modify the nursing component of the plan for care including establishing desired client outcomes and interventions.
    • Communicate the nursing component of the plan for care and all modifications of the plan to appropriate members of the health team.
  • Implementation
    • Execute any current valid orders or directions by those authorized to practice in Ohio as is within the course of that individuals professional practice.
    • Provide direct nursing care commensurate to education, knowledge, skills and abilities.
    • Assist with care of the client.
    • Delegate or direct tasks if appropriate.
  • Evaluation
    • Evaluate, document and report response to nursing interventions.
    • Evaluate, document, and report progress toward expected outcomes of the plan for care.
    • Reassess the client's health status, revise the nursing diagnoses or nursing component of the plan for care, and make any changes in nursing interventions as is appropriate.

License Renewal and Education Requirements

Many states require proof of ongoing professional learning as a condition for gaining and renewing a license to practice nursing in their jurisdiction. As an example, we will look at the continuing professional education expectations as outlined in the Ohio NPA.

License renewal for nurses in Ohio is on a two year cycle. Every two years nurses must complete and possess documentation that they have completed twenty-four contact hours of professional level nursing continuing education, one hour of which must be a category A level training.

For those who come to a renewal date after holding an Ohio licensure for one year or less there is a lessened expectation of twelve hours of professional level nursing continuing education. If an individual has held an Ohio license for more than one year, they are held to the higher renewal standard of twenty-four hours.

Each applicant for renewal must attest that they have completed the required number and levels of continuing education within the two year time window. Documented evidence of completion must be available on request by the board. Should evidence of completion be lacking and the applicant fail to provide proof to the board before the end of the renewal period the license will lapse.

To reactivate or reinstate a lapsed license the nurse applicant will need to complete twenty-four contact hours of continuing education, with one of the hours being a category A, and possess documentation that completion occurred during the twenty-four month period immediately before their reapplication date.

Reactivation of Lapsed License (ORC, 4723.07(G)-(P)), (OAC, 4723-7-09(H))

Applicant must complete 24 Contact Hours during the twenty-four month period immediately before the application date.

If the license of a registered nurse or licensed practical nurse has been inactive or lapsed in Ohio less than two years, or the applicant holds a current, valid license in another jurisdiction, the continuing education shall be 24 Contact Hours of continuing education that includes one hour of category "A".

If the license of a registered nurse or licensed practical nurse has been inactive or lapsed in Ohio for two years or more, and the applicant does not hold a current, valid license in another jurisdiction, the continuing education must consist of 24 Contact Hours and must include all of the following:

(a) Two contact hours of category A with learning outcome that address scopes of practice for registered and licensed practical nurses, standards of safe practice, and nursing delegation;

(b) Six contact hours with learning outcome that address application of the nursing process and critical thinking, clinical reasoning, or nursing judgment related to patient care;

(c) Six contact hours in pharmacology with learning outcome that include drug classifications, medication errors, and patient safety;

(d) Two contact hours that include learning outcome related to clinical or organizational ethical principles in health care; and

(e) Eight contact hours that include learning outcome related to an area relevant to the nurse's practice.

Taking Care Seriously in Ohio

Remember the Board? The Board of Nursing is the implementation aspect of the Ohio NPA. You might choose to think of it as the end with the teeth.

You need to know the NPA from the governing body you are responsible to! Do not wait until it is too late. "Ignorance of the law is no excuse!"

The NPA spells out the process by which the Board investigates evidence having the appearance that a licensee or certificate holder has failed to practice in accordance with acceptable standards of safe practice. Once evidence has been gathered a review by the Board determines wrongdoing, lack of wrongdoing, or the presence of a deficiency in practice without actual harm or risk of imminent serious harm (for which a less stringent correction alternative may be offered by the NPA) (ORC, 4723.28).

Powers held by the Board include the ability to deny a license or certificate to practice within the state. License or certificates can also be suspended or revoked; the holder reprimanded, fined, or forwarded for criminal prosecution in instances of extreme neglect or suspected abuse (ORC, 4723.02).

Not all reasons for discipline are major violations. The Board oversees all aspects of nursing practice within the area of its jurisdiction, and may choose to investigate and discipline such things as reports of a nurse license holder not using universal and standard infection control precautions (OAC, 4723-07), offering to 'waive' client fees/co-payments or otherwise alter billing records as applies to nursing services (ORC, 4723.28), or even reports of a nurse supplying more than a 72-hour quantity of sample medications or therapeutic devices (ORC, 4723.481).

It is an assigned duty for the Board to investigate evidence that appears to show a violation has occurred. Disciplinary proceedings that take place after an investigation may either appear before a hearing examiner or they may be resolved by a consent agreement. When findings indicate that an individuals practice is substandard yet not posing a serious risk, the Board can recommend participation in the state guided practice intervention and improvement program (PIIP) rather than formal disciplinary action (OAC, 4723-6).

It is possible to request a hearing from the Board and agreeing to monitored progress while participating in the PIIP may be an option for those willing to work with the Board to correct minor practice deficiencies, or the appearance of deficiency. However, it is considered to be the wisest practice to be aware of the standards set concerning nursing practice by your state, and make sure your own practice lays far over onto the smiling side of the line!

Summation

NPAs are the definition set by a state for what a nurse is, and what requirements they must meet in order to practice within that state. The Practice Act is put in place for the protection of the public and when we seek initial licensure or renewal of license from a state we are agreeing to practice our profession in such a manner as to meet or exceed the level of care that they have set for us.

In Ohio we have seen an example of a well-crafted NPA. An Act that recognizes the many functions, and levels at which a professional nurse might practice. Recognition of professional nursing practice, in particular, as a specific and special means for the provision of nursing care indicates understanding of what nurses are, and what nurses do.

Do you know what you are supposed to be? What you are allowed to do?

You may. Yet I challenge you to take that extra step to be sure. Read YOUR NPA! You may be surprised by what you find there.

Just maybe, at some time to come, you might be very glad you took the time to find out what your state expects of you!

Reference

Ohio Revised Code, (2016). "ORC Title 47 Occupations Professions, Chapter 4723: Nurses". Retrieved from (Visit Source), 12/26/17.

Ohio Administrative Code (2015) OAC chapters 4723-1 to 4723-27. Retrieved 12/29/17 from (Visit Source).

Ohio Board of Nursing Momentum, (2016) 2016 Administrative Rule Update. Winter 2016, Vol. 14, Issue 1.

Ohio Board of Nursing Momentum, (2015) Legislative initiatives, Winter 2015, Volume 13, Issue, Retrieved on 1/17/16 from (Visit Source).

Ohio Board of Nursing Momentum, (2015) New APRN Law: Delegation of Authority to Administer Drugs, Fall 2015, Volume 13, Issue 4, Retrieved on 1/17/16 from (Visit Source).


This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Registered Nurse (RN)

Topics:

CPD: Promote Professionalism and Trust, Legal & Regulatory, Ohio Requirements


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