Ohio Nurse Practice Act (1 Hour)
Law and Rules - Category A

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this continuing education course, you will have increased your knowledge of the standards of safe nursing practice in accordance with the Ohio Nurse Practice Act and the state’s laws and rules. Specific learning objectives to address potential knowledge gaps include:

• Describe the Ohio Scope of Practice Decision-Making Model.
• Discuss the standards for competent nursing practice in Ohio.
• Explain standards for the delegation of nursing tasks to unlicensed personnel.
• Summarize the standards for applying the nursing process in Ohio.

Each state and territory in the United States has a Nurse Practice Act and a board of nursing with the authority to define and regulate the practice of nursing. The board also has the authority to discipline nurses who break nursing laws and regulations (Boehning, 2022). This course presents the standards of safe nursing practice as outlined in the Ohio Nurse Practice Act and the rules of Section 4723 of the Ohio Administrative Code as written by the Ohio Board of Nursing in accordance with Section 4723 of the Ohio Revised Code.

OHIO BOARD OF NURSING AND OHIO ADMINISTRATIVE CODE

All licensed medical professionals, including licensed nurses, work under accepted standards derived from local, state, and federal laws as well as professional guidelines. The Ohio Board of Nursing (OBN) is an agency of government that was created by Ohio law. The OBN regulates the practice of nursing in Ohio by implementing rules for nursing education and practice based on the Nurse Practice Act (NPA). The rules are outlined in Ohio Administrative Code (OAC) Section 4723. Chapters 1 through 27 of Section 4723 of the OAC establish regulations for licensure, standards of practice, discipline, and nursing education (OBN, n.d.-a).

Ohio Board of Nursing (OBN)

The Nurse Practice Act authorizes the OBN to make and enforce rules and regulations for registered nurses, licensed practical nurses, advanced practice nurses (certified nurse-midwives, certified nurse practitioners, certified nurse specialists, and certified registered nurse anesthetists), dialysis technicians, community health workers, and medication aides. The OBN regulates over 300,000 licenses and certificates. According to the OBN website, their top priorities are:

• To license the nursing workforce efficiently
• To protect Ohio patients by removing unsafe practitioners from practice in a timely manner
  (OBN, n.d.-b)

MEMBERSHIP

Board members are public officials, and OBN meetings are open to the public. The board is made up of thirteen members appointed by the governor. The members include:

• Eight registered nurses (including at least two licensed advanced practice registered nurses)
• Four licensed practical nurses
• One consumer who represents the interests of healthcare consumers

The board has the legal authority to administer and enforce all provisions of the Nurse Practice Act. It must review each rule within the Ohio Administrative Code at least once every five years. The board is funded and supported by mandatory licensure fees paid by nurses wishing to practice legally in the state of Ohio. The board does not have authority over employers (ORC 4723.02).

SCOPE OF PRACTICE

Because nursing is a dynamic practice, questions may arise about whether certain tasks are within the nurse’s scope of practice. All nursing care should be consistent with the nurse’s preparation, education, experience, knowledge, and demonstrated competency.

The Ohio Board of Nursing has developed a Scope of Practice Decision-Making Model to help nurses determine whether a task is within their scope of practice. The model uses a decision tree with references and is based on legality, competency, safety, and accountability.

Ohio Administrative Code

The rules of the Board of Nursing regulate nursing practice in Ohio and are contained in Section 4723 of the Ohio Administrative Code (OAC). This course reviews those chapters in Section 4723 that set forth the standards of competency, safe nursing practice, delegation, application of the nursing process, and discipline for registered nurses and licensed practical nurses in the state of Ohio.

STANDARDS OF NURSING PRACTICE

Standards of Competency for RNs

[This section covers subsections (A) through (K) of the OAC 4723-4-03, Standards relating to competent practice as a registered nurse.]

Registered nurses (A) provide nursing care within the scope of practice described in the Ohio Administrative Code and the rules of the Ohio Board of Nursing and (B) maintain current knowledge of the duties, responsibilities, and accountabilities of safe nursing practice.

RNs must (C) be competent and accountable in all areas of practice, including consistent performance of all aspects of nursing care and appropriate recognition, referral or consultation, and intervention when complications arise.

RNs may (D) provide nursing care beyond basic nursing preparation for an RN provided they:

• Obtain additional education
• Demonstrate appropriate knowledge, skills, and abilities
• Maintain documentation of their additional education and training
• Have a specific current order from an authorized individual acting within their professional practice
• Do not carry out a function or procedure prohibited by any law or rule

RNs must (E) implement any order for a patient in a timely manner unless they believe or have reason to believe the order is:

• Inaccurate
• Not properly authorized
• Not current or valid
• Harmful or potentially harmful to a patient
• Contraindicated by other documented information

RNs must (E) clarify an order that meets any of the above criteria by consulting with an appropriate licensed practitioner.

When RNs (F) decide not to follow an order or prescribed medication or treatment after consulting with an appropriate licensed practitioner, the RN must:

• Notify the ordering practitioner of the decision not to follow the order
• Document that the practitioner was notified and state the reason for not following the direction
• Take any other action to ensure the safety of the patient

RNs (G) report to and consult with other nurses or members of the healthcare team and make referrals as necessary in a timely manner.

RNs must (H) maintain the confidentiality of patient information, communicating patient information with other members of the healthcare team for healthcare purposes only and accessing patient information only for patient care purposes or for fulfilling nursing responsibilities. This includes not disseminating patient information through social media, texting, emailing, or any other form of communication for purposes other than patient care.

To the maximum extent feasible, RNs must (I) not disclose identifiable patient healthcare information unless the patient has consented to such disclosure and must report individually identifiable patient information without written consent in limited circumstances only and in accordance with authorized laws and rules.

RNs must (J) use acceptable standards of safe nursing care as a basis for any observation, advice, instruction, teaching, or evaluation and communicate information that is consistent with acceptable standards of safe nursing care.

When RNs (K) give direction to LPNs, they must first assess:

• Condition and stability of the patient who needs nursing care
• The type of nursing care required
• The complexity and frequency of the care required
• The training, skill, and ability of the LPN who is to perform the specific function or procedure
• The availability and accessibility of resources needed to safely perform the function or procedure

The tasks assigned to LPNs must also be within the licensed practical nurse’s legal scope of practice.

Standards of Competency for LPNs

[This section covers subsections (A) through (J) of the OAC 4723-4-04, Standards relating to competent practice as a licensed practical nurse.]

A licensed practical nurse (LPN) must function (A) within the scope of practice of an LPN as set forth in division (F) of Section 4723.01 of the Ohio Revised Code and the rules of the Ohio Board of Nursing.

An LPN must (B) maintain current knowledge of the duties, responsibilities, and accountabilities for safe nursing practice.

An LPN must (C) demonstrate competency and accountability in all areas of practice, including consistent performance of all aspects of nursing care and appropriate recognition, referral or consultation, and intervention when complications arise.

An LPN may (D) provide nursing care beyond basic preparation for an LPN provided the LPN obtains appropriate education; demonstrates knowledge, skills, and abilities; and maintains satisfactory records of meeting these requirements. The LPN must have a valid order or direction from an authorized individual acting within their professional practice, and the nursing care cannot involve a function or procedure prohibited by any law or rule.

LPNs must (E) implement or clarify an order in a timely manner unless they believe or have reason to believe the order is:

• Inaccurate
• Not properly authorized
• Not current or valid
• Harmful or potentially harmful to a patient
• Contraindicated by other documented information

When (F) clarifying an order or direction, the LPN must consult with an authorized practitioner or directing RN. If the LPN decides not to follow the direction, the LPN, in a timely manner, must:

• Notify the ordering practitioner or directing RN of the decision not to follow the order
• Document that the ordering practitioner or directing RN was notified and state the reason for not following the direction
• Take any other action to ensure the safety of the patient

An LPN must (G) report to and consult with other nurses or other members of the healthcare team and make referrals as necessary.

An LPN must (H) maintain the confidentiality of patient information, communicating patient information with other members of the healthcare team for healthcare purposes only and accessing patient information only for patient care purposes or for fulfilling assigned job responsibilities. This includes not disseminating patient information through social media, texting, emailing, or any other form of communication for purposes other than patient care.

An LPN (I) must not disclose identifiable patient healthcare information unless the patient gives written consent by a properly executed release of information. Only in limited circumstances in accord with authorized legal authority should an LPN release individually identifiable patient healthcare information without written consent of the patient.

When directed to observe, advise, instruct, or evaluate the performance of a nursing task, the LPN must (J) use acceptable standards of safe nursing care as a basis for that observation, advice, instruction, teaching, or evaluation and should communicate information consistent with acceptable standards of safe nursing care with respect to the nursing task.

Standards of Competency for Advanced Practice Registered Nurses

[This section covers subsections (A) through (D) of the OAC 4723-4-05, Standards relating to competent practice as a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist.]

A certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, and clinical nurse specialist must (A):

• Function within the scope of practice of nursing for a registered nurse as set forth in division (B) of Section 4723.01 of the Ohio Revised Code and the rules of the Ohio Board of Nursing.
• Function within the nurse’s applicable scope of practice as set forth in section 4723.43 of the Ohio Revised Code and the rules of the Ohio Board of Nursing.
• If authorized by Ohio law to prescribe, practice according to Section 4723.481 of the Ohio Revised Code and Section 4723-9 of the Ohio Administrative Code.

When the practice of a certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist is evaluated, the (B) evaluation must be done by a collaborating licensed physician or podiatrist, or an advanced practice registered nurse holding a current, valid license with the same designation as the individual being evaluated.

When the practice of a certified registered nurse anesthetist is evaluated, the (C) evaluation must be done by a supervising licensed physician, podiatrist, dentist, or certified registered anesthetist whose license is current and valid.

A certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist may provide care within their specialty, provided the nurse (D):

• Obtains appropriate education from a recognized body of knowledge similar to the nursing care that will be provided
• Demonstrates knowledge, skills, and abilities
• Maintains documented evidence of the education received and their skills and abilities

Standards That Promote Patient Safety

[This section covers subsections (A) through (Q) of the OAC 4723-4-06, Standards of nursing practice promoting patient safety.]

(A–C) When providing direct nursing care to patients or engaging in nursing practice in person or by telecommunication, licensed nurses, certified nurse-midwives, certified nurse practitioners, certified registered nurse anesthetists, or clinical nurse specialists must display and identify their applicable title or initials (degree) or identify to each patient or healthcare provider the nurse’s title or initials (degree) as a registered nurse or licensed practical nurse.

Licensed nurses must (D) delegate nursing tasks, including medication administration, only in accordance with chapters 4723-13, 4723-23, 4723-26, or 4723-27 of the OAC. (See also “Delegation Guidelines” below.)

Licensed nurses must (E) report and document their nursing assessments and observations, care provided, and the patient’s response to that care in a complete, timely, and accurate manner. Licensed nurses must report any (F) errors in or deviations from a current valid order to the appropriate practitioner in a timely and accurate manner.

Licensed nurses must (G) not falsify, or conceal by any method, patient records or any other document prepared or used in the course of nursing practice. This includes case management documents or reports, time records, reports, and other documents related to billing for nursing services.

Licensed nurses must (H) implement measures to promote a safe environment for patients and (I) delineate, establish, and maintain a professional boundary between themselves and patients. They must (J) provide privacy during examination and care and treat each patient with courtesy, respect, and full recognition of dignity and individuality.

Licensed nurses must (K) not engage in behavior that causes or may cause physical, verbal, mental, or emotional abuse to a patient or engage in behavior that a reasonable person would interpret as physical, verbal, mental, or emotional abuse.

A licensed nurse must not (L) misappropriate the property of patients or:

• Engage in behavior to seek or obtain personal gain at the patient’s expense, or what may reasonably be interpreted as such
• Engage in behavior that constitutes inappropriate involvement in the patient’s personal relationships or financial matters, or what may reasonably be interpreted as such

A licensed nurse must not (M):

• Engage in sexual conduct with a patient, or conduct that may be reasonably interpreted as sexual
• Engage in verbal behavior that is seductive or sexually demeaning to a patient, or that may be reasonably interpreted as such

The patient is always presumed incapable of giving free, full, or informed consent to the behaviors by the nurse set forth in (L) and (M) above.

When licensed nurses (N) function in administrative roles, they must make sure that there are procedures in place and implemented to verify that every nurse, dialysis technician, or medication aide working under their administration has a current valid license in Ohio or valid certificate in Ohio to practice in the role to which they are assigned.

Only RNs may (O) supervise or evaluate the nursing practice of RNs and LPNs; however, non-nursing supervisors may evaluate nurse employees in matters other than the practice of nursing. RNs who supervise other nurses are not required to be regularly on-site but must be continuously available via telecommunication with the nurse being supervised and be able to take any action necessary, including visits on-site, to make sure that the nurse being supervised is practicing according to standards of safe nursing care outlined in Chapter 4723 of the Ohio Revised Code and the rules of the Ohio Board of Nursing. RNs who evaluate other nurses must conduct on-site visits.

A licensed nurse must not (P) make, submit, or cause to be submitted any false, misleading, or deceptive statements to the Ohio Board of Nursing, current or prospective employers, facilities or organizations for whom the nurse is working in a temporary assignment, members of the healthcare team, or law enforcement personnel.

A nurse must not (Q) use social media, texting, emailing, or other forms of communication with or about a patient for non-healthcare purposes or for purposes other than fulfilling the nurse’s assigned job responsibilities.

CRITERIA AND STANDARDS FOR DELEGATION

Delegating Nursing Tasks

[This section covers subsections (A) through (H) of the OAC 4723-13-05, Criteria and standards for a licensed nurse delegating to an unlicensed person.]

When all conditions for delegation set forth in Chapter 4723-13-05 of the OAC are met, a registered nurse may delegate a nursing task to an unlicensed person (A) and a licensed practical nurse may delegate a nursing task to an unlicensed person at the direction of the registered nurse (B). These conditions are summarized below.

Except as otherwise authorized by law or this chapter, a licensed nurse may delegate to an unlicensed person the administration of only the following medications (D):

• Over-the-counter topical medications to be applied to intact skin for the purpose of improving a skin condition or providing a barrier
• Over-the-counter eye drop, ear drop, and suppository medications, foot soak treatments, and enemas

Prior to delegating a nursing task to an unlicensed person, the delegating nurse must make certain determinations regarding the nature of the task and the qualifications of the unlicensed person who will carry it out (E):

• The nursing task is within the scope of practice of the delegating nurse
• The nursing task is within the knowledge, skill, and ability of the nurse delegating the nursing task
• The nursing task is within the training, ability, and skill of the unlicensed person who will be performing the delegated nursing task
• Appropriate resources and support are available for the performance of the task and management of the outcome
• Adequate and appropriate supervision by a licensed nurse of the performance of the nursing task is available
• That:
  • The nursing task requires no judgment based on nursing knowledge and expertise on the part of the unlicensed person performing the task
  • The results of the nursing task are reasonably predictable
  • The nursing task can be safely performed according to exact, unchanging directions, with no need to alter the standard procedures for performing the task
  • The performance of the nursing task does not require that complex observations or critical decisions be made with respect to the nursing task
  • The nursing task does not require repeated performance of nursing assessments
  • The consequences of performing the nursing task improperly are minimal and not life-threatening
  • The nursing task does not require licensed nursing care instead of care provided by an unlicensed person

Prior to delegating a nursing task, the delegating nurse must also make certain determinations regarding the patient and the conditions (F):

• Identify the individual on whom the nursing task may be performed and a specific time frame during which it may be performed.
• Complete an evaluation of the conditions that relate to task to be performed, including:
  • An evaluation of the individual who needs nursing care
  • The types of nursing care the individual requires
  • The complexity and frequency of the nursing care needed
  • The stability of the individual who needs nursing care
  • A review of the evaluations performed by other licensed healthcare professionals

The delegating nurse must be accountable for the decision to delegate nursing tasks to an unlicensed person (G).

If a licensed nurse determines that an unlicensed person is not correctly performing a delegated nursing task, the licensed nurse must immediately intervene (H).

Delegating Medication Administration

[This section covers subsection (C) of the OAC 4723-13-05, Criteria and standards for a licensed nurse delegating to an unlicensed person; subsections (A) through (B) of the ORC 4723.48, Delegation of authority to administer certain drugs; and subsections (A) through (F) of the ORC 4723.489, Delegated authority to administer drugs.]

An advanced practice registered nurse (APRN) such as a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner may delegate medication administration to unlicensed personnel when both of the following requirements have been met:

• The APRN must assess the patient and decide that the drug is appropriate for the patient.
• The APRN must ascertain that the unlicensed personnel to whom the authority will be delegated has successfully completed appropriate education regarding drug administration and is able to demonstrate the knowledge, skills, and ability to administer the drug safely.

STANDARDS FOR APPLYING THE NURSING PROCESS FOR RNs

[This section covers subsections (A) and (B) of the OAC 4723-4-07, Standards for applying the nursing process as a registered nurse.]

A registered nurse (A) must apply the nursing process in the practice of nursing as set forth in division (B) of section 4723.01 of the Ohio Revised Code and in the rules of the OBN. Nurses provide care to patients using a cyclic series of steps called the nursing process. With clinical judgment, RNs assess, analyze/report, plan, implement, and evaluate the changing status of patients. RNs apply the nursing process in various practice settings and collaborate with patients, family, significant others, and members of the healthcare team according to the following standards.

The standards for implementing the nursing process (B) also apply to a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist.

Assessment

Assessment involves the accurate and timely collection of both subjective and objective data about a patient’s condition from the patient, family members, significant others, and members of the healthcare team. The RN may direct or delegate the gathering of data but must document and report it, as appropriate, to other members of the healthcare team.

Analysis and Reporting

In an accurate and timely manner, RNs identify, organize, assimilate, and interpret relevant data. RNs establish, accept, or modify a nursing diagnosis, which will be carried out through nursing interventions, and report the patient’s health status and nursing diagnosis as needed to other members of the healthcare team.

Planning

In an accurate and timely way, RNs develop, establish, maintain, or modify the nursing care plan with current nursing science, including the nursing diagnosis, desired patient outcomes or goals, and nursing interventions. RNs communicate the plan of care and all care plan modifications to members of the healthcare team.

Implementation

In an accurate and timely way, RNs implement the nursing care plan. RNs execute the nursing regimen; implement current valid orders or directions from authorized practitioners; and provide nursing care commensurate with their education, knowledge, skills, and abilities. RNs assist and collaborate with other healthcare providers in the care of the patient and delegate nursing tasks, including medication administration, only in accordance with applicable rules and laws (see also “Delegation Guidelines” earlier in this course).

Evaluation

In an accurate and timely way, RNs evaluate, document, and report patient responses to nursing interventions and progress toward expected outcomes to appropriate members of the healthcare team. RNs then reassess the patient’s health status, establishing or modifying any aspect of the nursing plan.

STANDARDS FOR APPLYING THE NURSING PROCESS FOR LPNs

[This section covers the OAC 4723-4-08, Standards for applying the nursing process as a licensed practical nurse.]

Licensed practical nurses must contribute to the nursing process as set forth in division (F) of section 4723.01 of the Ohio Revised Code and rules of the OBN. The steps of the nursing process are cyclical in nature, so that the patient’s changing status affects the action of LPNs as they assess, plan, implement, and evaluate the patient’s status. The LPN collaborates, as appropriate, with the patient, family, significant others, and members of the healthcare team. The LPN must use the following standards for applying the nursing process.

Assessment

The LPN contributes to the nursing assessment of a patient. In an accurate and timely manner, LPNs collect and document objective and subjective data related to the patient’s health status and report the data to the directing registered nurse or healthcare provider and other members of the healthcare team. The subsequent analysis of this data, however, is not part of the LPN’s role.

Planning

In an accurate and timely manner, LPNs contribute to the development, maintenance, or modification of the nursing component of the care plan and communicate the nursing care plan and all modifications of the plan to appropriate members of the healthcare team.

Implementation

Licensed practical nurses implement the nursing care plan in an accurate and timely manner as follows:

• Provide nursing interventions
• Collect and report patient data as directed
• Administer medications and treatments prescribed by an authorized individual
• Provide basic nursing care at the direction of an RN, advanced practice registered nurse, or licensed physician, dentist, optometrist, chiropractor, or podiatrist
• Collaborate with other nurses and members of the healthcare team
• Delegate tasks as directed, including medication administration, only in accordance with the OAC (see also “Delegation Guidelines” earlier in this course)

Evaluation

In an accurate and timely manner, LPNs contribute to the evaluation of patient responses to nursing interventions, document and communicate patient responses to nursing interventions to appropriate members of the healthcare team, and contribute to the reassessment of the patient’s health status and to modifications of any aspect of the nursing plan of care.

CONCLUSION

The Ohio Nurse Practice Act defined the scope of practice for nurses in Chapter 4723 of the Ohio Revised Code and established the Ohio Board of Nursing. The Board of Nursing is responsible for the administration and enforcement of the Nurse Practice Act. This responsibility is accomplished through Section 4723 of the Ohio Administrative Code (OAC). The OAC are the rules written by the Ohio Board of Nursing in accordance with the Ohio Nurse Practice Act.

Chapters 1 through 27 of the OAC contain the rules and regulations for all aspects of nursing practice in the state of Ohio. The OAC sets forth the standards of competent nursing practice and standards for promoting patient safety. By so doing, OAC 4723 fulfills the mission of the Board of Nursing to actively safeguard the health of the public through the effective regulation of nursing care. It is the responsibility of all nurses in the state of Ohio to be familiar with and to abide by these laws and rules.