Ohio Nurse Practice Act: 2 Hour Category A

As a professional, you are legally responsible for remaining 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 and the professional practice guidelines. To find the NPA, go to the state of Ohio Board of Nursing web page to access the most recent copy: www.nursing.ohio.gov/laws-rules/.

No one can practice a nursing profession in Ohio without a license from the Ohio Board of Nursing. These professions include RN, LPN, CRNA, CNS, CNM, CNP, and APRN (ORC, 4723-03). The 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. 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 of acceptable for your requested credential. A criminal record background check and a testing date and location are also conducted. Once the testing is completed, the board issues a discipline-specific license and instructions on maintaining current licensure through board-approved continuing education courses.

Nurses who possess active licenses outside of Ohio who are requesting an Ohio nursing license, known as 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
• 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)

Foreign born applicants seeking a nursing license in Ohio that possess licensure out of the country must prove that they have passed the Test of English as a Foreign Language.

Do not despair. A 180-day temporary permit to practice nursing is available to those 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 too comfortable. You can only be issued that temporary permit once. APRN licensure includes prescriptive authority for all CNPs, CNSs, and CNMs who meet the requirements.

In Ohio, 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)):

• 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 areas of practice. This ability includes but is not limited to the following:
  • Consistent performance in all aspects of nursing care
  • The ability to assess health status to provide nursing care
  • Health counseling and teaching abilities
  • Skills for safe administration of medications/treatments and 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 and consult or refer when a complication arises

Duties that RNs are expected to complete within a "timely manner" include the following (ORC, 4723.01) (B)-(D)):

• Implementation of any order for a client unless the RN believes or should have reason to believe the order is: inaccurate, not properly authorized, not current or valid, harmful or potentially harmful to the client, and contraindicated by other documented information.
• Clarify any order for a client when the RN believes or should have reason to believe the order is: inaccurate, not properly authorized, not current or valid, harmful or potentially harmful to the client, and contraindicated by other documented information.

When it is necessary to clarify an order, the RN is expected to consult with an appropriate licensed practitioner promptly. If a decision is made not to follow the direction to administer the medication or treatment as ordered, it is up to the RN to notify the prescribing practitioner promptly and document the notification and the reason for not following the order. The most important thing is the mandate to act as needed to ensure the safety of the client.

An RN must report or consult whenever necessary with other health care team members and make referrals if 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 about what information may be communicated to others. This process includes using written consent permissions in all circumstances appropriate for their use.

It is expected that RNs practicing in Ohio maintain acceptable standards of safe nursing care in observation, advice, instruction, teaching, or evaluation. They are also expected to communicate information acceptably within the standards of safe nursing care. This communication includes identifying their title to the people involved in the communication. When providing direction to an LPN, it is up to the RN 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 LPN about their ability to perform specific needed functions or procedures
• The availability and accessibility of resources needed to safely perform the specified function or procedure

The eternal question "Vocational vs. Practical" is answered by the Ohio NPA. In Ohio, the title is LPN. The practice of an LPN means providing care to individuals and groups, requiring the application of basic knowledge of the biological, physical, behavioral, social, and nursing sciences. The LPN practices under the direction of an RN, physician, physician assistant, dentist, podiatrist, optometrist, or chiropractor. In Ohio, an LPN is expected to function within the limits of practice set 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 (B) – (D)).

It is an expectation that current knowledge of duties, responsibilities, and accountabilities necessary for safe nursing practice be maintained and that an LPN can demonstrate competence and accountability in the care they deliver. LPNs are also expected to possess the skills necessary to recognize, refer, seek consultation, or implement interventions that may be needed to manage complications that may arise.

In the state of Ohio, it is expected that an LPN will promptly implement any order or direction for a client unless the LPN believes or should believe the order is: inaccurate, not properly authorized, not current, valid, or contraindicated by other documented information.

An LPN must obtain clarification for any order or direction for a client when the LPN believes or should have reason to believe the order or direction is: inaccurate, not properly authorized, not current, valid, or contraindicated by other documented information. Clarification for an order or direction requires a timely consultation with an appropriate licensed practitioner. If the LPN decides not to follow the direction, or administer the medication or treatment as prescribed, they must notify the prescribing practitioner. Following administration, document that the practitioner was notified of the decision and the reason for that decision. The LPN is expected to act when needed to ensure the safety of the client.

An LPN is expected to promptly report to and consult with other nurses or healthcare team members. They are also expected to make referrals for the client as appropriate. When discussing client information with other health providers, the LPN must maintain client confidentiality to the greatest extent possible. The client has the right to give or withhold consent regarding the release of information. This consent includes written consent when appropriate or identified by law.

In those instances in which an LPN 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.

In Ohio, the 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 advanced practice registered nurses in Chapter 4723-8 (OAC 4723). These standards apply to the following titles: Certified nurse midwife, Certified nurse practitioner, Certified registered nurse anesthetist, 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. Instead of making a new arrangement, the standard care arrangement can be revised to add or delete a physician or podiatrist within that employment setting. A new standard care arrangement is needed when the nurse is employed in a different setting and engages in practice with different collaborators. The collaborating physician's or podiatrist's practice must be the same or similar to the nurse's practice (ORC 4723.431).

A standard care arrangement includes at least (ORC 4723.431 (B)):

• Signatures of each nurse, and collaborator, indicating a review and agreement to abide by the terms
• 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, a certificate to prescribe, and a description of the scope of prescriptive practice
• A plan for incorporation of new technology or procedures
• Quality assurance provisions (ORC 4723.50):
  • Periodic review and reapproval of the standard care arrangement and criteria for client referral by the nurse to a collaborating physician or podiatrist
  • Collaborating physician or podiatrist must be within an acceptable travel time between their location and the APRN's location when the APRN prescribes medications
  • Other criteria recommended by the committee on prescriptive governance

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 the practice of the APRN occurs. Upon request of the board, the nurse must provide a copy of the standard care arrangement to the board and 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 follow the policies and procedures of the hospital governing body and the bylaws, policies, and procedures of the hospital medical staff. The nurse must notify the board of the identity of a collaborating physician or podiatrist or any change in the name and business address of a collaborating physician or podiatrist within 30 days.

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 the practice in the nurse's specialty area
2. The prescription is consistent with the terms of a standard care arrangement
3. The prescription would not exceed the prescriptive authority of the collaborating physician
4. The individual drug or subtype or therapeutic device is not one excluded by the formulary
5. The prescription meets the requirements of state and federal law
6. A valid prescriber-client relationship exists. This relationship may include but is not limited to:
   1. Obtaining a thorough, relevant history of the client
   2. Conducting a physical or mental examination of the client
   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 client's medical records

An advanced practice registered nurse may delegate medication administration to an unlicensed person. Before delegating this authority, the APRN with prescriptive authority must assess the client, determine that the drug is appropriate for the client, and determine that the person to whom the authority will be delegated has met the conditions (ORC 4723.489). An APRN with prescriptive authority has many requirements and limitations. These include:

• Limitation on prescribing Schedule II controlled substances (ORC 4725.48)
• Limitations on prescribing controlled substances
• Limitation on the delegation to administer medication (ORC 4723.489)
• An exclusionary formulary species
• Authority may not exceed the prescriptive authority of the collaborating physician or podiatrist.

The exclusionary formulary is on the Board website at https://www.nursing.ohio.gov/practice-resources/prescribing-resources/ (ORC 4723.431 (E) and ORC 4723.27). The Ohio Automated RX Reporting System is a resource available to APRNs by the State of Ohio Board of Pharmacy. The Morphine equivalent daily dose (MED) helps calculate a client's opioid intake. The MED converts various opioid analgesics to a morphine equivalent dose using accepted conversion tables provided by the state board of pharmacy. The calculator can be found at www.ohiopmp.gov/MED_Calculator.aspx.

No person shall employ or direct an LPN to perform an intravenous (IV) therapy procedure without verifying that the board authorizes the LPN to perform IV therapy. LPNs in Ohio may be eligible for IV therapy privileges after licensure in the state if they complete a Board-approved course of study on the safe performance of IV therapy. Laws for IV therapy by LPNs are very specific. In this section, the term authorized LPN applies to LPNs authorized by the Board to perform IV therapy.

There are special requirements for LPNs to perform IV therapy procedures (ORC 4723.18). An RN shall be readily available at the IV therapy site when an authorized LPN has been directed an IV therapy procedure. Before the LPN initiates the IV therapy, the RN shall personally perform an on-site assessment of the adult client to receive the IV therapy. 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 antineoplastic agent
• Solutions are administered through any central venous line or arterial line, or any other line that does not terminate in a peripheral vein; except that an LPN authorized by the board to perform IV 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 initiate IV therapy in any vein, except that an IV-authorized LPN may initiate IV therapy in a vein of the hand, forearm, or antecubital fossa.

An LPN cannot perform any of the following procedures:

• Discontinuing a central venous, arterial, or any other line that does not terminate in a peripheral vein
• Initiating or discontinuing a peripherally inserted central catheter
• Mixing, preparing, or reconstituting any medication for IV except that an IV authorized LPN may prepare or reconstitute an antibiotic additive
• Administering medication via the IV route, including all the following activities:
  • Adding medication to an IV solution or an existing infusion except that an IV authorized LPN may initiate an IV infusion containing one or more of the following elements: Dextrose 5%, normal saline, lactated ringers, sodium chloride 45%, sodium chloride 0.2% and sterile water
  • Hang subsequent containers of the IV solutions, vitamins, or electrolytes, if an RN initiated the infusion of that same IV solution
  • Initiate or maintain an IV piggyback infusion containing an antibiotic additive
  • Inject medication via a direct IV route, except that an IV authorized LPN heparin or normal saline to flush an intermittent infusion device or heparin lock
  • Change tubing on any line including, but not limited to, an arterial line or a central venous line, except that an IV authorized LPN may change tubing on an IV line that terminates in a peripheral vein
  • Program or set any function of a client-controlled infusion pump

Any LPN may perform on any client some IV therapy procedures without receiving authorization to perform IV therapy from the board of nursing if both of the following apply:

1. The LPN acts under the direction of an RN or a licensed physician, dentist, optometrist, or podiatrist. The RN or a licensed 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 LPN demonstrates the knowledge, skills, and abilities to perform the procedure safely.

The IV therapy procedures that any LPN may perform are limited to the following:

• Verification of the type of peripheral IV solution being administered
• Examination of a peripheral infusion site and the extremity for infiltration
• Regulation of a peripheral IV infusion according to the prescribed flow rate
• Discontinuation of a peripheral IV 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

At the direction of a physician or an RN, an authorized LPN may perform the following activities to perform dialysis:

• The routine administration and regulation of saline solution to maintain an established fluid plan
• The administration of a heparin dose IV
• The administration of a heparin dose peripherally via a fistula needle
• The loading and activation of a constant infusion pump or the intermittent injection of a dose of medication for dialysis are administered via the hemodialysis blood circuit and through the client's venous access point

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 outlined in the Ohio NPA. License renewal for nurses in Ohio is on a two-year cycle. Every two years, nurses must complete and retain documentation that they completed 24 contact hours of continuing education.

• one hour category A must be directly related to the statutes and rules pertaining to the practice of nursing in the state of Ohio
• At least 12 of the 24 contact hours for APRNs must include continuing education in advanced pharmacology (ORC 4723.24)

Category A is defined as training related to the rules of the Ohio Nurse Practice Act, as described in rule 4723 of the Ohio Revised Code and is approved by the Ohio Board of Nursing, an OBN approver, or is offered by an OBN approved provider.

For those who come to a renewal date after holding an Ohio licensure for one year or less, there is a lessened expectation of 12 contact hours of continuing education. If individuals have held an Ohio license for more than one year, they are held to the higher renewal standard of 24 contact 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 fails to provide proof to the board before the end of the renewal period, the license will lapse (ORC 4723.14). To reactivate or reinstate a lapsed license, the nurse applicant will need to complete 24 contact hours of continuing education, with one of the hours being a category A, and possess documentation that completion occurred during the 24 months immediately before their reapplication date.

It is an assigned duty for the board to investigate evidence showing a violation has occurred (ORC 4723.28). The NPA spells out the process by which the board investigates evidence having the appearance that a license or certificate holder has failed to practice following acceptable standards of safe practice. Once the 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 (ORC 4723.28).

Powers held by the board include the ability to (ORC 4723.28):

• Deny, revoke, suspend or place restrictions on any nursing license or dialysis technician certificate issued by the board
• Reprimand or otherwise discipline a holder of a nursing license or dialysis technician certificate
• Impose a fine of not more than five hundred dollars per violation

Disciplinary proceedings that occur after an investigation may appear before a hearing examiner, or a consent agreement may resolve them. When findings indicate that an individual's 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.

During the investigation, the board can compel the subject of the investigation to submit to a mental or physical examination. If the board finds that an individual is impaired, the individual may have to submit to care, counseling, or treatment as a condition for initial continued, reinstated, or renewed authority to practice. The individual shall be allowed to demonstrate to the board that the individual can begin or resume the individual's occupation in compliance with acceptable and prevailing standards of care under the provisions of the individual's authority to practice.

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
• Offering to 'waive' client fees/co-payments or otherwise alter billing records as applies to nursing services (ORC 4723.28)
• Reports of a nurse supplying more than a 72-hour quantity of sample medications or therapeutic devices (ORC 4723.481)

Activities that may result in disciplinary action are listed at codes.ohio.gov/ohio-revised-code/section-4723.28 (ORC 4723.28).

In response to the COVID-19 pandemic, the Ohio Revised Code was updated to allow for synchronous or asynchronous technology to provide services within the professional's scope of practice (ORC 4723.09). Telehealth services are defined as the use of technology by the healthcare professional to provide services to a client at a site other than the provider's location. The standard of care for such services must be equal to the standard of care for in-person services. When a client consents to receive telehealth services, the health care provider is not liable for damages under any claims made that the services provided do not meet the same standard of care that would apply if the service was provided in person.

An initial in-person visit is required when prescribing a schedule II-controlled substance; however, this requirement is waived if the client is receiving palliative or hospice care. The requirement is also waived for a client who meets any of the following: medication-assisted treatment or any other medication for opioid-use disorder, who is a client with a mental health condition, or who, as determined by the clinical judgment of a health care professional, is in an emergency (ORC 4723.09).

Telehealth services may be denied, and the health care professional may require the client to attend in-person visits only. If the client is present in another state, Ohio allows the healthcare provider to complete the visit if permitted by the laws of the state in which the client is located.

During morning rounds, Jane RN assessed her clients, including stability, nursing care needed, complexity and frequency of care, and availability of unit stock. It is a busy day, and one of the staff is an LPN from another unit. Jane does not know the training, skills, or ability of the LPN. Jane would like to direct some IV responsibilities to this LPN.

Intervention/Strategies:

Jane RN called the unit's nurse manager the LPN came from to identify IV training. The nurse manager is not available. She speaks with the charge nurse, who says the LPN is authorized to do IV therapy. The charge nurse does not have the documentation but has observed the LPN performing IV therapy. Jane decided not to direct any IV therapy to the LPN from another unit except for discontinuation of peripheral lines, which any LPN can do.

Discussion of outcomes:

Jane was busy and could have used the LPN to do IV therapy, but Jane directed other tasks to the LPN. Jane could have taken the charge nurse's confirmation that the LPN is authorized for IV therapy; however, Jane does not know the charge nurse and would be more comfortable discussing the situation with the nurse manager who has access to the LPN's competency file. Jane felt she did not have any more time to commit to identifying the LPN's authorization for IV therapy.

Strengths and weaknesses of the approach used in the case:

Another 15 minutes of questioning could have identified a supervisor or manager who could confirm the LPN's authorization for IV therapy. Jane did not want to spend any more time on the issue. Had Jane taken the extra time, she could have directed IV responsibilities that amounted to more than 15 minutes. Directing the search for authorization for IV therapy to the supervisor or her nurse manager would have been a better use of time. Jane is responsible for knowing the training, skill, and ability of that LPN about their ability to perform specific needed functions or procedures, time was short, and resources limited. Jane made a safe decision. Jane also knew that resources were available, but accessibility to resources is limited for someone who has not oriented to the unit.

When a nurse seeks initial licensure or renewal of license from a state, they agree to practice their profession in such a manner as to meet or exceed the level of care that they have set. In Ohio the NPA recognizes the many functions and levels at which a professional nurse might practice. Recognition of professional nursing practice as a specific and special means for providing nursing care indicates an understanding of what nurses are and what nurses do.

• Ohio Board of Nursing (2016). Administrative rule update. Momentum. 2016; 14(1). Visit Source.
• Ohio Revised Code. Chapter 4723. Nurses. (2022). Visit Source.
• Ohio Revised Code. Chapter 4743. Standards for telehealth services. (2022). Visit Source.
• Ohio Board of Nursing. (2022) New APRN law: Delegation of authority to administration of drugs. Momentum.2022; 4(13). Visit Source.