Chapter 1: Ohio Nursing Laws and Standards. 1.0 Contact Hour, Category A. Learning objectives. Introduction

Chapter 1: Ohio Nursing Laws and Standards 1.0 Contact Hour, Category A (This CE activity, OLN-I-1501-13, being offered by Elite CME, Inc. has been approved for 1.0 contact hour, Category A, by the Ohio Board of Nursing through the approver unit at the Ohio League for Nursing (OBN-006-92) and this program may be offered through February 5, 2015.) Learning objectives After completing this course, the student will be able to: Distinguish between the ORC and OAC. Describe the three main types of revisions to Nursing Rules in 2012. Explain the changes and limitations in Ohio Nursing Law regarding the authority of Advanced Practice Nurses to prescribe schedule II controlled substances. Define professional nursing in the state of Ohio. List the activities expected of a nurse under state law that define the practice of nursing by a registered nurse. List the activities expected of a licensed practical nurse under state law that defines the practice of nursing by a licensed practical nurse. Explain the differences in the scopes of practice and nursing processes for registered nurses and licensed practical nurses. List the rules for practice by licensed nurses that create a safe environment for clients. Identify which health care personnel may delegate nursing tasks. List the factors a licensed nurse must consider before delegating a nursing task. Introduction The State of Ohio requires Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) to complete continuing education courses in the laws, rules and guidelines governing professional practice, called for by Chapter 4723 of the Ohio Revised Code (ORC), also known as the Nurse Practice Act, and directly related to Rules of the Board of Nursing set forth in Chapter 4723-1 to 4723-27 of the Ohio Administrative Code (OAC), providing learning objectives regarding scope of practice for Registered and Licensed Practical Nurses, standards of safe practice, and nursing delegation as required by Rule 4723-14-03, Section (F)(2a). Each year, the State Legislature and the Board of Nursing, with the input of other interested parties, review amendments and revise the laws and rules governing Ohio Nursing Practice, setting new policy or educational requirements and/or removing outdated or inaccurate information. This course summarizes the most significant changes in laws and rule implemented in 2012. It s intended to increase awareness of the new information and alert nurses to provisions that affect them regarding changing requirements or standards in the field. All Laws and Rules associated with professional nursing in Ohio are contained in the Ohio Revised Code (ORC), and the Ohio Administrative Code (OAC). To refer directly to the ORC or OAC online, use the links that follow the definitions below: A. Ohio Revised Code: All statutes of a permanent and general nature of the state as revised and consolidated into general provisions, title, chapters and sections, including all bills passed. For nurses, see ORC Chapter 4723 at http:// codes.ohio.gov/orc/4723. Ohio Administrative Code: A codification of the administrative agencies of the state, including all rules filed with an effective date. The Ohio Board of Nursing is the agency charged with specifying rules and processes governing practices and standards that fulfill the requirements of the Nurse Practice Act. See OAC Chapter 4723-1 through 4723-27 at http://codes.ohio.gov/orc/4723. The course is presented in four parts: Part I: What s new? Part II: Scope of practice for Ohio licensed nurses The Nurse Practice Act and OAC outline specific boundaries of practice for nursing professionals. Part III: Standards of safe practice for Ohio licensed nurses The OAC includes specific rules for safe practice in nursing. These include rules that promote and protect client safety. Part IV: Laws and rules on delegation of nursing tasks The OAC outlines a number of specific rules for nurses when delegating nursing tasks to licensed and unlicensed health care workers. Page 1

Part I What s new? This section discusses changes to Ohio Nursing laws and rules in 2012. Rules State agencies, including the Ohio Board of Nursing, are required to examine and draft new rules for the discipline. In 2012, there were three main types of revisions; Two the Five Year Review and the Common Sense Initiative (CSI) were demanded by regulatory requirements, while the third category more directly addressed substantive changes relating to perceived needs or deficiencies in Ohio Nursing practice. The Five Year Rule Review was conducted according to provisions specified in Chapter 119.032 of the Ohio Revised Code, requiring the Board to eliminate obsolete, unnecessary, and redundant rules, avoid duplication, and ensure that new rules do not duplicate any existing Ohio regulation. Similarly, the Common Sense Initiative was established by Executive Order 2011-01K to promote transparency, consistency, predictability, and flexibility in regulatory activities. Agencies are encouraged to prioritize compliance over punishment and use plain language in the development of regulations. Both initiatives are intended to provide additional clarity and specificity in cases of outdated or complicated language, and rarely change significant aspects of the provision. For example, wording revisions to Rule 4723-14-01, Definitions, included the following changes and rationale: In new paragraph (G)(2), the current definition of continuing education (new paragraph G) was changed to read health care career goals instead of professional career goals, to prevent credit being awarded to someone taking a course non-related to their licensure, i.e., in pursuit of a career change or other field of study. Independent study was reworded as Independent study continuing education activity with the addition for which contact hours may be awarded. In new paragraph (G)(3), interdisciplinary was changed to interprofessional, to better reflect current Nursing practice and terminology. 4723-3-01 Definition of terms. The following definition was added: (J) Patient means the recipient of nursing care or dialysis care, which may include an individual, a group, or a community. While these definitions were removed: (B) Client means the recipient of nursing care or dialysis care, which may include an individual,a group, or a community. (E) Endorsement means the process by which: (2) A certificate to practice as an Ohio certified dialysis technician is issued by the board in accordance with section 4723.75 of the Revised Code and Chapter 4723-23 of the Administrative Code; (3) A certificate to practice as a community health worker issued by the board in accordance with section 4723.84 of the Revised Code and Chapter 4723-26 of the Administrative Code. Chapter 4723-14 Continuing nursing education. Continuing education that does not conform to requirements specified in this Chapter could result in an advisory letter, disciplinary action, or a delay in licensure renewal. 4723-14-03 Continuing education requirement for licensed nurses. Paragraph (E) specifies the following revisions: a nurse who is inactive or lapsed less than two years, or who holds a current, valid license in another jurisdiction, is not be required to complete the detailed course content provided in (E)(2) (a) through (e). If the nurse does not hold a current, valid license in another state, and is lapsed/inactive for two years or more, then the detailed course content provided in (E)(2) (a) through (e) is required. The third category of changes is composed of revisions that fundamentally alter a rule s provisions and are more likely to affect you as a Nursing professional. Some of the following revisions to Chapters 4723-1 to 27 OAC may be relevant to you. 4723-1-03 Board records and documents. Section (E) specifies that Wall certificates or other documents issued by the Board as evidence of licensure, certification, or other authorization to practice must not be falsified or altered, but may now be reproduced, duplicated, photocopied, or converted to electronic media. Rule 4723-14-07 Continuing education audit. Chapter 4723-14, OAC, authorizes the Board to grant a waiver, a one-time exception from meeting a continuing education requirement set forth in Section 4723.24 of the Revised Code and rules 4723-14-03, 4723-23-06, and 4723-26-05 of the Administrative Code. Rule 4723-14-07 was revised to include section (E), preventing a licensee/certificate holder from invoking this one-time waiver in response to an audit notice. Page 2

Laws Authority to prescribe schedule II controlled substances. Senate Bill 83 (SB 83), which became law on June 8, 2012, expanded the scope of schedule II prescribing for Advanced Practice Nurses (APNs) who hold a certificate to prescribe (CTP), or certificate to prescribe externship (CTP-E). Its main provisions are summarized below. Prescribing from specified locations The law provides that an advanced practice nurse (APN) who holds a certificate to prescribe is not subject to three restrictions in continuing law governing an APN s authority to prescribe schedule II controlled substances, but only when the APN issues a prescription to a patient from specified locations [R.C. 3719.06 and 4723.481(C)(2)]. A schedule II controlled substance is a drug or other substance that (1) has a high potential for abuse, (2) has a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions, and (3) may lead to severe psychological or physical dependence if abused [21 United States Code (U.S.C.) 812(b)]. Examples include hydrocodone, oxycodone, morphine, and methamphetamine [21 Code of Federal Regulations (C.F.R.) 1308.12]. When prescribing from a location that is not one of those specified in the law, the APN remains subject to the following three restrictions in continuing law: (1) the patient must have a terminal condition, (2) the APN s collaborating physician must have initially prescribed the drug for the patient, and (3) the prescription must be for an amount that does not exceed the amount necessary for the patient s use in a single 24-hour period [R.C. 4723.481(C)(1)]. The locations from which the law authorizes an APN to prescribe a schedule II controlled substance without being subject to the three restrictions are the following [R.C. 4723.481(C)(2)(a) to (m)]: 2. A hospital registered with the Department of Health; 3. An entity owned or controlled, in whole or in part, by a hospital or by an entity that owns or controls, in whole or in part, one or more hospitals; 4. A health care facility operated by the Department of Mental Health or Department of Developmental Disabilities; 5. A nursing home licensed by the Department of Health or a political subdivision; 6. A county home or district home that is certified under the Medicare or Medicaid program; 7. A hospice care program; 8. A community mental health agency; 9. An ambulatory surgical facility; 10. A freestanding birthing center; 11. A federally qualified health center; 12. A federally qualified health center look-alike, which is a not-for-profit health center that meets the eligibility requirements for, but does not receive, a federal public health services grant; 13. A health care office or facility operated by a board of health or an authority having the duties of a board of health; Page 3 14. A site where a medical practice is operated, but only if the practice is comprised of one or more physicians who are also owners of the practice, the practice is organized to provide direct patient care, and the APN providing services at the site has a standard care arrangement and collaborates with at least one of the physician owners who practices primarily at that site. (Entering into a standard care arrangement and practicing in collaboration are requirements of ongoing law governing the practice of APNs.) Immunity from liability for pharmacists The law provides that a pharmacist who acts in good faith reliance on a prescription issued by an APN at a location specified above is not liable for or subject to any of the following for relying on the prescription: (1) damages in any civil action, (2) prosecution in any criminal proceeding, or (3) professional disciplinary action by the State Board of Pharmacy [R.C. 4723.481(D)]. Convenience care clinics The law prohibits an APN from prescribing any schedule II controlled substance to a patient in a convenience care clinic. The prohibition applies even if the convenience care clinic is owned or operated by an entity that is one of the locations from which an APN, under the law, may prescribe schedule II controlled substances without being subject to the three restrictions that otherwise apply when an APN prescribes a schedule II controlled substance [R.C. 4723.481(C)(3)]. Prescribing in collaboration with a podiatrist The law authorizes an APN to prescribe schedule II controlled substances in collaboration with a podiatrist by eliminating the prior law provision that prohibited an APN from doing so [R.C. 4723.481(C) (prior law)]. Rulemaking The law requires the Board of Nursing to adopt rules as necessary to implement the law s provisions pertaining to an APN s authority to prescribe schedule II controlled substances. The rules must conform to the recommendations submitted by the Committee on Prescriptive Governance [Section 4]. With respect to the Board s rules establishing criteria for APN standard care arrangements with physicians and podiatrists, the law requires the rules to include components that apply to the authority to prescribe schedule II controlled substances [R.C. 4723.50(B)(3)]. Transition provisions The law specifies that an APN s authority to prescribe schedule II controlled substances, as established by the law, begins on the law s effective date. The law requires, however, that an APN complete at least six contact hours of instruction specific

to schedule II controlled substances if the APN s certificate to prescribe was issued either (1) before the law s effective date or (2) before the Board of Nursing implements the law s provisions pertaining to instruction in schedule II controlled substances. Satisfactory evidence of completing the six hours of instruction must be submitted to the Board as a condition of eligibility for renewal of the APN s certificate to prescribe or, in the case of an APN participating in an externship, as a condition of receiving a new certificate [Section 3]. Advanced pharmacology course of study The law requires an APN seeking prescriptive authority to complete a course of study in advanced pharmacology and related topics consisting of at least 45 contact hours. Prior law referred instead to instruction in advanced pharmacology and related topics and did not specify a minimum number of contact hours [R.C. 4723.482(B)(2)]. The law maintains requirements that (1) the course of study be approved by the Board of Nursing in accordance with standards adopted by the Board in rules and (2) the content be specific to the applicant s nursing specialty [R.C. 4723.482(B)(2)]. The law increases to 36 (from 30), the minimum number of contact hours of instruction an APN seeking prescriptive authority must complete in advanced pharmacology and related topics that includes pharmacokinetic principles and clinical application and the use of drugs and therapeutic devices in illness prevention and maintenance of health. Prior law referred to the instruction as training. Rules adopted by the Board prior to the law required this portion of the instruction to consist of a minimum of 36 hours, so the law makes the statutory requirement consistent with the requirement in those rules [Ohio Administrative Code 4723-09-02]. Instruction specific to schedule II drugs The law adds a requirement that the course of study in advanced pharmacology include instruction specific to schedule II controlled substances, including all of the following: 1. Indications for the use of schedule II controlled substances in drug therapies; 2. The most recent guidelines for pain management therapies, as established by state and national organizations such as the Ohio Pain Initiative and the American Pain Society; 3. Fiscal and ethical implications of prescribing schedule II controlled substances; 4. State and federal laws that apply to the authority to prescribe schedule II controlled substances; 5. Prevention of abuse and diversion ofschedule II controlled substances, including identification of the risk of abuse and diversion, recognition of abuse and diversion, types of assistance available for prevention of abuse and diversion, and methods of establishing safeguards against abuse and diversion [R.C. 4723.482(B)(5)(d)]. Former pilot program participants The law repeals a provision under which an APN who participated in one of the three former APN pilot programs that were operated in medically underserved areas of Ohio could apply for a certificate authorizing the APN to prescribe anywhere in Ohio without having to complete an externship or another course of study in advanced pharmacology. The repealed provision applied to APNs with prescriptive authority under the pilot programs as of May 17, 2000 [R.C. 4723.482(A)(2)]. If any pilot program participant has not since obtained a certificate to prescribe, the APN under the law must complete the same requirements as any other APN seeking a certificate to prescribe. Professional discipline for using schedule I controlled substances The law permits the Board of Nursing to take professional disciplinary action, such as license revocation or suspension, against a nurse or dialysis technician for self-administering or otherwise taking into the body any schedule I controlled substance [R.C. 4723.28]. A schedule I controlled substance is a drug or other substance that (1) has a high potential for abuse, (2) has no currently accepted medical use in treatment in the United States, and (3) has a lack of accepted safety for use under medical supervision [21 U.S.C. 812(b)]. Examples include heroin and marijuana [21 C.F.R. 1308.11]. Answers to frequently asked questions about APN and schedule II prescribing Ohio law requires that the standard care arrangement include the APN s scope of prescribing practices. APNs with a CTP or CTP-E who intend to begin prescribing schedule IIs according to the expanded authority set forth in the law will need to update this section of their standard care arrangement, as indicated, before prescribing schedule IIs. The law also requires that an APN s collaborating physician s practice involve the care and treatment of patients who may require schedule II controlled substances. These requirements have existed for some time and are not new requirements. The following are frequently asked questions relate to requirements for CTP or CTP-E holders and new applicants. Questions for current CTP or CTP-E holders 1. How did the bill change the prescribing of schedule II controlled substances? As of June 8, 2012, a CTP or CTP-E holder who is practicing in a location specified in the bill is no longer subject to the 24-hour supply restrictions in the pre-existing law governing an APN s authority to prescribe schedule II controlled substances. However, CTP and CTP-E holders who are not practicing in one of the specified locations must follow the restrictions: prescribing of schedule II controlled substances is limited to a 24-hour emergency supply of medications, prescribed to terminally ill patients with respect to whom the collaborating physician has previously prescribed the medication. 2. Where can I find detailed information regarding 2012 formulary revisions? Refer to: Formulary Revisions Reflecting Schedule II Prescribing Parameters (Effective June 8, 2012), at: http://www.nursing. ohio.gov/pdfs/advpractice/schedule%20ii%20 parameters.pdfformulary with Index for CTP Holders (Effective November 19, 2012), available at: http://www. nursing.ohio.gov/pdfs/advpractice/formulary_11-19-12.pdf Page 4

3. Are there any locations specified in SB 83 where CTP or CTP-E holders may NOT prescribe schedule II controlled substances? CTP or CTP-E holders are prohibited from prescribing a schedule II controlled substance from a convenience care clinic even if the clinic is owned or operated by an entity specified in the list above, with the exception of prescriptions limited to a 24-hour supply as set forth in preexisting law. CTP and CTP-E holders who are not engaged in practice in one of the listed locations are limited in their prescribing of schedule II controlled substances to a 24-hour emergency supply of medications to terminally ill patients with respect to whom the collaborating physician has previously prescribed the medication. 4. I m not sure if the facility in which I prescribe is a location covered by the bill? If you are not certain whether your practice location falls within those identified in this law, contact the facility or organization s administrator or legal counsel to advise you. As an APN with prescriptive authority, you are ultimately responsible for knowing and practicing according to the applicable laws and administrative rules. 5. When is the effective date of the rule changes? The effective date was November 5, 2012. 6. Is there anything that I need to do with my current DEA registration before I begin prescribing schedule II drugs? It depends on your current DEA registration. If your current DEA registration limits you to prescribe schedule III - V controlled substances and you plan to incorporate the prescribing of schedule IIs into your practice, you will need to contact the DEA for further instruction on how to revise your registration to include the prescription of schedule II drugs. The DEA website is www.deadiversion.usdoj.gov. If you are authorized to use the DEA number for the hospital where you work, you should contact the hospital for answers to questions related to the use of this number. Questions related to continuing education required for CTP holders to renew their CTP 1. Since I am currently an APN with a CTP, must I take the required continuing education (CE) course prior to prescribing in accordance with the new law? CTP holders are not required to complete the CE course prior to prescribing schedule IIs according to the new law. However, all CTP holders must complete the CE no later than August 31, 2013. 2. The facility where I practice is requiring me to complete the CE course prior to allowing me to prescribe in accordance with the new law. Employers or institutions that grant APNs practice privileges may establish their own policies and APNs need to know and follow their employer or institution s policies. 3. Can I take any controlled substance prescribing course for purposes of meeting the CE requirement by August 31, 2013? You must take a CE course that includes the content included in the new law and Rule 4723-9-13, OAC. Also, Page 5 all CE courses must meet the requirements for CE set forth in Rule 4723-14-05 (A), OAC. 4. I have a CTP but I do not currently prescribe controlled substances and have no intention of prescribing schedule II controlled substances. Do I still have to take the sixhour CE course? All APNs with a CTP must complete the CE course no later than August 31, 2013 to renew their CTP. 5. Does the six-hour CE in schedule II prescribing required prior to the August 31,2013 renewal date need to be classroom time or can the course be on-line? Can CME (continuing medical education) qualify? The six-hour course that would qualify for CTP renewal, according to Rule 4723-9-13, must meet the requirements of Chapter 4723-14, OAC. Rule 4723-14-05 explains what kind of continuing education qualifies. Independent study, as defined in Rule 4723-14-01, would qualify. This generally includes approved on-line training, as long as the activity includes both a mechanism of evaluation of learning and feedback to the learner. Rule 4723-14-05 authorizes continuing education credit for activities approved by agencies that regulate a healthcare profession in Ohio or another state (such as the medical board), so CME may quality. For more information on what would qualify as CE, see Rule 4723-14-05. 6. Can the six hours of schedule II CE required by SB 83 and new Rule 4723-9-13, OAC, also be applied toward meeting the 12 contact hours of Advanced Pharmacology required for CTP renewal (i.e., I do not need to have 18 hours of advanced pharmacology CE)? Correct. Nothing in the law indicates that the six-hour required prior to August 31, 2013 cannot be otherwise applied toward the existing CTP renewal requirements. Amended Rule 4723-9-07, OAC, effective November 5, 2012, does not prohibit this either. 7. Can one hour of the six hours of schedule II CE required by SB 83 qualify for the one hour of Category A, Ohio law and rule, required by Rule 4723-14-03, OAC, for RN renewal? Possibly. If one hour of the six hours otherwise meets all the requirements for category A it may be applied toward the RN renewal requirement and the six-hour CTP renewal requirement. In order to qualify, the one-hour component needs to meet the definition of Category A set forth in Rule 4723-14-01, which requires that the education must be approved by an OBN approver, the Board, or offered by an OBN approved provider unit headquartered in Ohio. 8. For future renewal periods, will the six-hour course in schedule II controlled substances be required? No. However, you will need to obtain at least 12 hours in advanced pharmacology, of which includes at least some instruction in controlled substances. Rule 4723-9-07, OAC, as in effect November 5, 2012. There is no minimum hour component to the controlled substances instruction. 9. Do I need to mail in a copy of my certificate documenting completion of the six- hour course in schedule IIs with my CTP renewal application? No. You will be required to attest that you completed the six-hour course, and the Board will conduct a random audit to

verify completion, so retain your certificate of completion as evidence in the event you are audited. You are required to keep this proof for a period of six years. Rule 4723-14-06, OAC. Questions for current CTP-E holders 1. I am an APN and obtained a CTP-E prior to June 8, 2012. Must I take the six-hour course in schedule IIs prior to prescribing in accordance with SB 83? Effective June 8, 2012, in order to obtain a CTP-E, an applicant s course in Advanced Pharmacology must include the six-hour course in schedule II controlled substances. If you received a CTP-E prior to June 8, 2012, you need to obtain a six-hour course content in schedule II controlled substances as part of a course in Advanced Pharmacology prior to being eligible for a CTP. See Section 4723.482, ORC as amended by SB 83, and Rule 4723-9-02, effective November 5, 2012. In the interim, the law is silent on whether you may prescribe according to the expanded authority. The Board would recommend reviewing with your education program how to obtain the six-hours in schedule II controlled substances, and completing the requirement as soon as possible. 2. I have a CTP-E, but I do not currently prescribe controlled substances and have no intention of prescribing schedule II controlled substances. Do I still have to take the six- hour course? APNs with a CTP-E must complete a six-hour course in schedule II controlled substances, as part of a course in Advanced Pharmacology, prior to obtaining their CTP. See Section 4723.482, ORC, as amended by SB 83, and Rule 4723-9-02, OAC, effective November 5, 2012. 3. I am presently in a nurse practitioner program at a university and have already completed the Advanced Pharmacology course required for my CTP-E application, but I did not receive my CTP-E until after June 8, 2012, which was the effective date of the new law. Will I need to complete the six hours in schedule II controlled substances? In order to obtain a CTP-E, as of June 8, 2012, your Advanced Pharmacology course was required to include the six-hours in schedule II controlled substances. See Section 4723.482, ORC, as amended by the new law. You are required to complete six hours of course content in schedule II controlled substances as part of the Advanced Pharmacology course prior to being eligible for a CTP. Questions for APNs without a CTP or CTP-E 1. I am entering a nurse practitioner education program in the fall of 2012 at a local university. Will I need to take the six hours in schedule II prescribing before qualifying for a CTP-E? Yes. As part of the advanced practice nurse education program, you must complete a 45-hour Advanced Pharmacology course that is to be provided during your education program. The Advanced Pharmacology course content is established in Ohio law and rules, and it must be completed within three years of applying for a CTP-E. The law requires that the Advanced Pharmacology course now include six hours of content specific to schedule II controlled substances, and the Board amended its rule related to the Advanced Pharmacology course to reflect this (see Rule 4723-9-02, effective November 5, 2012). The rule amendment does not increase the minimum required 45 hours, but may require education programs to adjust their course content. Part II: Scope of Practice for Ohio licensed nurses Ohio Law The Nurse Practice Act Nurses in Ohio are accountable for the laws and rules regarding nursing practice in the state. The Nurse Practice Act (the law governing nursing practice) is codified in Chapter 4723 of the Ohio Revised Code (ORC), which defines the scopes of practice for registered and licensed practical nurses. The rules regarding nursing practice, the Ohio Administrative Code (OAC), fill in the law by specifying the rules and processes developed by the Board of Nursing (Board) to carry out the law. Rules are promulgated by the board and are reviewed at least every five years. Rules hearings are an open process, including an annual public hearing each November in which nurses are encouraged to participate. Standards of safe nursing practice, continuing education requirements and principles of delegation are some of the topics outlined in the rules. Page 6

Definitions The first section of the Ohio Nurse Practice Act is an explanation of definitions used in the text; it defines the general scopes of practice for nurses: Professional nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities and populations. Essential features of professional nursing are its provision of a caring relationship that facilitates health and healing and application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking. Registered nurse means an individual who holds a current, valid license issued under Chapter 4723 that authorizes the practice of nursing as a registered nurse. Practice of nursing as a registered nurse means providing to individuals and groups nursing care requiring specialized knowledge, judgment and skill derived from the principles of biological, physical, behavioral, social and nursing sciences. Such nursing care includes: Identifying patterns of human responses to actual or potential health problems amenable to a nursing regimen. Executing a nursing regimen through the selection, performance, management and evaluation of nursing actions. Assessing health status for the purpose of providing nursing care. Providing health counseling and health teaching. Administering medications, treatments and executing regimens authorized by an individual who is authorized to practice in this state and is acting within the course of the individual s professional practice. Teaching, administering, supervising, delegating and evaluating nursing practice. Nursing regimen may include preventative, restorative and health-promotion activities. Assessing health status means the collection of data through nursing assessment techniques, which may include interviews, observation and physical evaluations for the purpose of providing nursing care. Licensed practical nurse means an individual who holds a current, valid license issued under Chapter 4723 that authorizes the practice of nursing as a licensed practical nurse. Administration of medications and treatments authorized by an individual who is authorized to practice in this state and is acting within the course of the individual s professional practice, except that administration of intravenous therapy medications may be administered by a licensed practical nurse upon proof of completion of a course in medication administration approved by the board of nursing. Administration to an adult of intravenous therapy authorized by an individual who is authorized to practice in this state and is acting within the course of the individual s professional practice. Delegation of nursing tasks as directed by a registered nurse. Teaching nursing tasks to licensed practical nurses and individuals to whom the licensed practical nurse is authorized to delegate nursing tasks as directed by a registered nurse. Certified registered nurse anesthetist, clinical nurse specialist, certified nurse-midwife, and certified nurse practitioner mean a registered nurse who holds a valid certificate of authority issued under chapter 4723 that authorizes the practice of nursing as the named practitioner. Scope of practice Scope of practice refers to an area of competence, usually obtained through formal study, training, and/or professional experience, and one for which a certification or other proof of qualification is awarded. Professional accountability is the state of being accountable or responsible for professional obligations, including legal liability for failure to perform as expected. The licensed nurse is legally responsible and accountable for knowing the defined scope of nursing practice. Nursing practice is dynamic and responsive to societal health needs; therefore, it is generally impractical for the law and rules to list all the specific duties or tasks that licensed nurses may or may not perform. Attempts to delineate all the specific activities of licensed nurses would needlessly impede the growth of the discipline of nursing. It is critical to note that the law and rules require that the licensee provide nursing care only in circumstances that are consistent with his or her preparation, education, experience, knowledge and demonstrated competency. In many cases, nurses are required to make critical decisions about whether a specific activity or task falls within their scope of practice. The Ohio Board of Nursing has prepared a chart to help nurses make those decisions within the law. 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 licensed physician, dentist, podiatrist, optometrist, chiropractor or registered nurse. Such nursing care includes: Observation, patient teaching and care in diverse health care settings. Contributions to the planning, implementation and evaluation of nursing. Page 7

Decision Making Model Scope of Practice Decision Making Model Legality Define/ describe the activity or task Is the Activity or task within the scope of practice of the nurse and NOT prohibited or precluded by any other law or rule? The Nurse Practice Act (the law): 4723.01 (B) ORC practice as an RN 4723.01 (F) ORC practice as an LPN 4723.43 practice as a COA holder www.nursing.ohio.gov/law_and_rule.htm The Rules: Chapters 4723-1 to 4723-23 OAC www.nursing.ohio.gov/law_and_rule.htm Examples of Other Laws or Rules: Pharmacy Practice Act: Chapter 4729, ORC www.pharmacy.ohio.gov/lawrules.htm Medical Practice Act: Chapter 4731 ORC www3.med.ohio.gov/govstat.htm Activity/task NOT within scope and/or prohibited by law or rule. YES Competency Can the nurse perform the activity or task and meet the standards of safe nursing practice as defined in Chapter 4723-4 of the Administrative Code? www.nursing.ohio.gov/law_and_rule.htm NO Can the nurse demonstrate and document current knowledge, skills, and abilities? Safety YES Is this activity safe and appropriate to perform with this patient/client at this time? NO Accountability YES The nurse may perform the activity/task according to acceptable and prevailing standards of safe nursing care and prepare to accept accountability for the nursing actions. STOP DO NOT perform the activity or task Page 8

Scope of specialized nursing services A certified registered nurse anesthetist, clinical nurse specialist, certified nurse-midwife or certified nurse practitioner may provide to individuals and groups nursing care that requires knowledge and skill obtained from advanced formal education and clinical experience. A nurse authorized to practice as a certified nurse-midwife, in collaboration with one or more physicians, may provide the management of preventive services and those primary care services necessary to provide health care to women antepartally, intrapartally, postpartally and gynecologically, consistent with the nurse s education and certification, and in accordance with rules adopted by the board. No certified nurse-midwife may perform version, deliver breech or face presentation, use forceps, do any obstetric operation, or treat any other abnormal condition except in emergencies. A certified nurse-midwife who holds a certificate to prescribe may, in collaboration with one or more physicians, prescribe drugs and therapeutic devices in accordance with rules adopted by the board. A nurse authorized to practice as a certified registered nurse anesthetist, with the supervision and in the immediate presence of a physician, podiatrist or dentist, may administer anesthesia and perform anesthesia induction, maintenance, and emergence, and may perform with supervision preanesthetic preparation and evaluation, postanesthesia care, and clinical support functions consistent with the nurse s education and certification and in accordance with rules adopted by the board. A certified registered nurse anesthetist is not required to obtain a certificate to prescribe in order to provide the anesthesia care described in this division. The physician, podiatrist or dentist supervising a certified registered nurse anesthetist must be actively engaged in practice in this state. When a certified registered nurse anesthetist is supervised by a podiatrist, the nurse s scope of practice is limited to the anesthesia procedures that the podiatrist has the authority to perform. A nurse authorized to practice as a certified nurse practitioner, in collaboration with one or more physicians or podiatrists, may provide preventive and primary-care services and evaluate and promote patient wellness within the nurse s nursing specialty, consistent with the nurse s education and certification, and in accordance with rules adopted by the board. A certified nurse practitioner who holds a certificate to prescribe may, in collaboration with one or more physicians or podiatrists, prescribe drugs and therapeutic devices. A nurse authorized to practice as a clinical nurse specialist, in collaboration with one or more physicians or podiatrists, may provide and manage the care of individuals and groups with complex health problems and provide health care services that promote, improve and manage health care within the nurse s nursing specialty, consistent with the nurse s education and in accordance with rules adopted by the board. RN and LPN: Clarifying scopes of practice The purpose of this section is to help clarify and differentiate the scope of practice of the registered nurse (RN) and the licensed practical nurse (LPN), and the role of each as a member of the health care team. Page 9 Educational preparation The Ohio Board of Nursing establishes the minimum standards for curriculum, faculty qualifications and student progression for both the registered nurse (RN) and practical nursing (PN) pre-licensure nursing education program. Only those students who have graduated from an approved prelicensure nursing education program are eligible to sit for the licensure exam (NCLEX ). There are some basic differences between the RN and the PN pre-licensure education program. The PN program must be a minimum of one academic or calendar year; the RN program must be a minimum of two academic years. The RN curricula focus is on the principles of biological, physical, behavioral, social and nursing sciences across the life span. The PN programs focus on basic biological, physiological, social and behavioral sciences as well as nursing art and science across the life span. The RN applies these principles to provide complex care to individual and groups in a variety of settings using specialized knowledge, judgment and skill. The LPN applies this knowledge to provide basic care to individuals and groups in structured settings. Scope of practice Both the RN and the LPN are valuable members of the health care team. Both are expected to know and practice within their respective scopes of practice as stated in the Nurse Practice Act [Chapter 4723 Ohio Revised Code (ORC)] and the standards of safe nursing care as stated in Chapter 4723-4, Ohio Administrative Code (OAC). The legal scope of practice for both the RN and the LPN can be found in Section 4723.01 Ohio Revised Code. Revised Code, the Nurse Practice Act. The RN and LPN are required to maintain current knowledge of the duties, responsibilities and accountabilities for practicing within their respective scopes of practice and for safe nursing practice. The scopes of practice for the RN and the LPN are based on their respective educational programs. RNs have the authority to identify patterns of human responses to actual or potential health problems by independently: Providing preventative, restorative and health promotion activities. Assessing health status for the purpose of providing nursing care. Providing health counseling and health teaching. Teaching, delegating, administering, supervising and evaluating nursing practice. The LPN has a dependent role and provides patient care only at the direction of the registered nurse, licensed physician, dentist, podiatrist, optometrist or chiropractor. Direction means communicating a plan of care to a licensed practice nurse. Supervision would include the initial and ongoing directions, procedural guidance and observation and evaluation by the RN of the nursing care provided by the LPN. The amount of supervision that would be required for the LPN would be decided by the RN on an individual basis. The nursing care provided by the LPN includes patient observation, direct patient care, patient teaching and contributing to the planning and evaluation of patient care.

Both the RN and the LPN administer medications and treatments and execute regimens authorized by an appropriately authorized individual, such as physicians or an advanced practice nurse. Both the RN and LPN are responsible for implementing the nursing process in the delivery of nursing care (Rules 4723-4-7 and 4723-4-08 Ohio Administrative Code). The Nursing Board receives many questions about the LPN s role in the assessment component of the nursing process. While the law does not specifically address the issue of the LPN s role in the assessment process, the rule as found in 4723-4-08 Ohio Administrative Code clearly places the responsibility for the analysis of the data on the RN. It is the responsibility of the LPN to contribute to that data analysis by collecting objective and subjective data at the direction of the RN and by reporting and documenting the information collected. The LPN contributes to all steps of the nursing process. It is the responsibility of the RN to direct the LPN in the roles of collection of data, the implementation of the plan of nursing care and the evaluation of the nursing care. RN role/nursing process Collect and document objective and subjective data. Analyze assessment data. Establish, accept or modify a nursing diagnosis. Implement the current plan of nursing care. Evaluate and document the patient s response to the nursing care. Reassess and revise the nursing plan of care as appropriate. LPN role/nursing process Collect and document objective and subjective assessment data and observations about the patient s condition. Contribute observations to the nursing assessment and report data to the appropriate practitioner. Implement the current plan of nursing care at the direction of the RN, licensed physician, dentist, podiatrist, optometrist or chiropractor. Contribute to and document the evaluation of the patient s response to the nursing plan of care. Contribute to the revision of the nursing plan of care. Contribute to the evaluation of the patient s response to the plan of care through documentation and verbal communication with other members of the health care team. Part III: Standards of safe practice for Ohio licensed nurses Ensuring client safety Identification All licensed nurses providing direct nursing care to a client, including certified nurse-midwives, certified nurse practitioners, certified registered nurse anesthetists and clinical nurse specialists must display the applicable title or initials set forth in division C of section 2723.03 of the Revised Code to identify their relevant licensure. They must identify their titles whenever interacting with a client or other health care providers on behalf of the client in person or on the telephone. The approved initials are: 1. A person licensed to practice nursing as a registered nurse may use that title and the initials R.N. ; 2. A person licensed to practice nursing as a licensed practical nurse may use that title and the initials L.P.N. ; 3. A person authorized to practice nursing as a certified registered nurse anesthetist may use that title, the initials C.R.N.A. or N.A., and any other title or initials approved by the board of nursing; 4. A person authorized to practice nursing as a clinical nurse specialist may use that title, the initials C.N.S., and any other title or initials approved by the board; 5. A person authorized to practice nursing as a certified nursemidwife may use that title, the initials C.N.M., and any other title or initials approved by the board; 6. A person authorized to practice nursing as a certified nurse practitioner may use that title, the initials C.N.P., and any other title or initials approved by the board; 7. A person authorized to practice as a certified registered nurse anesthetist, clinical nurse specialist, certified nursemidwife, or certified nurse practitioner may use the title advanced practice nurse or the initials A.P.N.. Professional care: Nurses may delegate tasks, including medication administration, only in accordance with Chapters 4723-13, 4723-23, 4723-26 or 4723-27 of the Administrative Code. These include regulations that express specific rules on delegating tasks (See Part IV of this course), and the standards for delegating tasks to community health workers and medication aides. Nurses must report and document assessments, observations and care provided to a client and the client s response to that care. Nurses shall not falsify any client records including case management documents or reports, or time records and other documents related to billing for nursing services. They must report accurately and in a timely manner any errors or deviations from the current valid order that occur with a client. A safe environment: Nurses shall implement measures to promote a safe environment for each client and delineate, establish and maintain professional boundaries with each client. This means that at all times when providing direct nursing care to a client, they shall provide privacy during examination or treatment and in the care of personal or bodily needs and treat each client with courtesy, respect and with full recognition of dignity and individuality. A licensed nurse shall not: Engage in behavior that causes or may cause (or may be reasonably interpreted as) physical, verbal, mental or emotional abuse to a client. Page 10

Misappropriate a client s property or engage in behavior (or what appears to be such behavior) to seek or obtain personal gain at the client s expense or that constitutes inappropriate involvement in the client s personal relationships or financial matters. Engage in sexual conduct with a client or conduct in the course of practice that is sexual, seductive or sexually demeaning or conduct that may be reasonably interpreted as such. (For the purpose of these rules, the client is always presumed incapable of giving free, full, or informed consent to sexual activity with the nurse.) Supervision concerns: A licensed nurse, when functioning in an administrative role, shall verify that each nurse, dialysis technician, or medication aide under the nurse administrator has a current valid license to practice nursing in Ohio or valid certificate to practice as a dialysis technician or medication aide in Ohio; and other valid documents of approval or certification as required by the board. When nursing practice, as set forth in section 4723.01 of the Revised Code, is supervised or evaluated, only a registered nurse may supervise and evaluate the practice of other registered nurses and licensed practical nurses. In matters other than the practice of nursing, a non-nursing supervisor may evaluate a nurse employee. Honesty A licensed nurse shall not make any false, misleading or deceptive statements, or submit or cause to be submitted any false, misleading or deceptive information or documentation to: The Nursing Board or any representative of the board. Current employers. Prospective employers when applying for positions requiring a nursing license. Facilities in which or organizations for whom the nurse is working a temporary or agency assignment. Other members of the client s health care team. Law enforcement personnel. Definitions Part IV: Laws and rules on delegation of nursing tasks Chapter 4723-13 of the Administrative Code outlines definitions, rules and standards for the delegation of nursing tasks, including administering medications, for nurses. The chapter begins with definitions of terms for the chapter. Among them are: Client means the recipient of nursing care, which may include an individual, a group or a community. Delegation means the transfer of responsibility for the performance of a selected nursing task from a licensed nurse authorized to perform the task to an individual who does not otherwise have the authority to perform the task. Delegating nurse means the nurse who delegates a nursing task or assumes responsibility for individuals who are receiving delegated nursing care. Direction means communicating a plan of care to a licensed practical nurse. Direction by a registered nurse is not meant to imply the registered nurse is supervising the licensed practical nurse in the employment context. Licensed nurse means a registered nurse or a licensed practical nurse licensed to practice nursing in Ohio. Medication aide means an individual who holds a current valid certificate issued under Chapter 4723 of the Revised Code that authorizes the individual to administer medications in nursing homes or residential care facilities. Nursing tasks means those activities that constitute the practice of nursing as a licensed nurse and may include, but are not limited to, assistance with activities of daily living that are performed to maintain or improve the client s wellbeing when the client is unable to perform that activity for him or herself. Unlicensed person means an individual, not currently licensed by the board as a registered nurse or licensed practical nurse, or an individual who does not hold a current valid certificate to practice as a dialysis technician or administer medications as a medication aide. General information Only a licensed nurse may delegate a nursing task to an unlicensed person. However, individuals who are registered, certified, licensed or otherwise legally authorized in Ohio under any law, including some nursing specialists, may engage in the practice for which they are registered, certified, licensed or authorized. Unlicensed individuals covered by any other law or rule that authorizes them to administer medications also may do so. An unlicensed person also may assist with self-directed care, including self-administration of medications in a facility where the substantial purpose of the setting is other than the provision of health care. Page 11 Medication aides On March 26, 2009, the Medication Aide Pilot Program at various non-hospital settings ended. Since then, the state allows any nursing home or resident care facility to utilize one or more medication aides to administer prescription medications to its residents. The medication aide must hold a current, valid medication aide certificate issued by the board and have received appropriate, prescribed training. A licensed nurse must delegate the task of medication administration to the medication aide. Chapter 4723-67 of the Revised Codes limits the prescription medications the aide may administer to: Oral medications. Topical medications. Medications administered as drops to the eye, ear or nose.