After completing this course, nurses will be able to practice within the perimeters of the Ohio Nurse Practice Act.
At the conclusion of this course, the learner will be able to:
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:
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.
Before you reach for the migraine relief kit, be assured that much of what we as a society consider being a nurse (singular) and nursing (the field of endeavor) is consistent from state to state. The National Council of State Boards of Nursing (NCSBN) has even developed a 'Model Nursing Practice Act' to help government stay abreast of the profession and assist in the crafting of suitable laws and statutes. Details will vary however, and the amount of difference from one state to another can catch a professional by surprise!
|To encourage consistency across state lines, the National Council of State Boards of Nursing developed a Model Nursing Practice Act. This is available at; http://www.ncsbn.org.|
One area of considerable variance is in that entity commonly known as the state Board of Nursing. 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.
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.
Certifications are recognized in nursing by the NPA (ORC, 4723.24). Proof of successful completion of an approved program specific for that certification and specialty, along with proof of current acceptance by the nationally approved certifying body for that specialty (along with the proper application and fee) allow those individuals consideration by the Board for specialty licensure. No set testing regimen is required, however a criminal record check, continuing education, and maintenance of national certification are mandatory.
Prescriptive authority for APNs may be granted by the Board in compliance with specific criteria in the NPA (ORC, 4723.071) (OAC 4723-8).
To gain the ability to prescribe certain types of medications and/or therapies, a certified nurse practitioner, clinical nurse specialist or certified nurse-midwife must provide proof of 'Collaboration' with a physician with whom they have a standard care arrangement. Proof must be provided that guidance and communication is continuously available in person, by phone, radio or other form of communication. Completion of an approved advanced pharmacology program and a closely supervised 'externship' as detailed in the NPA must also accompany the application for prescriptive authority.
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!
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):
Duties that registered nurses are expected to complete within a "timely manner" include the following:
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 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:
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 make a decision 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 take action 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 have 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. The following are those requirements (OAC, 4723-18 (2)(D)- 4723.181(5))
QRC Sec. 4723.181.
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 the following Advance Practice Nurses (APN) (ORC, 4723.01(G)-(J)), (OAC, 4723-4-05):
In addition to meeting the qualifications laid out in section 4723.01 of the Ohio Revised Code along with the rules of the Board of Nursing, these APNs are held to a higher standard of practice should that individual hold a certificate to prescribe medications.
In essence, these sections of the NPA set a standard by which these advanced care providers may be evaluated, and describes the process of evaluation along with who will provide that service (collaborating physician, specialist, or nurse holding a similar current certificate of authority). These advanced nurse practitioners must provide proof of education from a recognized body of knowledge relative to the nursing care they will provide as well as demonstrating appropriate knowledge/skills/abilities and the ability to maintain satisfactory documentation as set forth by the Board of Nursing for their specialty.
Advance care providers are required to have a standard care arrangement (OAC, 4723-8-01). This arrangement is a written, formal guide for planning and evaluating a patient's health care that is developed by a collaborating physician or podiatrist and a certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist,
HB 341 imposes new 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, 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, pg. 6).
Recent amendments to the Ohio Nurse Practice Act permits APRNs with prescriptive authority to delegate the administration of certain drugs under specified conditions. This new delegation authority became effective October 15, 2015 through the enactment of Senate Bill 110 (131st General Assembly). Section 4723.48, Ohio Revised Code (ORC), permits the holder of a certificate to prescribe (CTP), to 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 specified in division (D) of Section 4723.489, ORC. Section 4723.489, ORC, specifies the conditions under which the delegation may occur. 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, pg. 14).
4723-8-04 [Effective 2/1/2016] Standard care arrangement for a certified nurse-midwife, certified nurse practitioner, and clinical nurse specialist.
4723-8-05 [Effective 2/1/2016] Quality assurance standards.
4723-8-06 [Effective 2/1/2016] National certifying organizations.
4723-8-07 [Effective 2/1/2016] Initial certificate of authority.
4723-8-08 [Effective 2/1/2016] Certificate of authority renewal; notification of national recertification.
4723-8-09 [Effective 2/1/2016] Certificates of authority for a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist practicing in another jurisdiction.
A certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist who is practicing in another jurisdiction may apply for a certificate of authority to practice in Ohio if the nurse meets the requirements for approval for a certificate of authority set forth in section 4723.41 of the Revised Code and this chapter. An applicant from another jurisdiction shall:
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:
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.
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:
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:
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!
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!
NCSBN, (2013). "Nurse Practice Act, Rules & Regulations". National Council of State Boards of Nursing. Retrieved from (Visit Source), Sept. 17, 2013.
Ohio Administrative Code (2015) OAC chapters 4723-1 to 4723-27. Retrieved 11/9/15 from (Visit Source).
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).
Ohio Revised Code, (2016). "ORC Title 47 Occupations Professions, Chapter 4723: Nurses". Retrieved from (Visit Source), Sept 17, 2016.
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)
CPD: Promote Professionalism and Trust, Legal & Regulatory, Ohio Requirements