About this course:

This learning activity aims to increase nurses' knowledge regarding the minimum acceptable standards of safe, effective nursing practice for a registered nurse (RN), licensed practical nurse (LPN), or advanced practice registered nurse (APRN) in any setting in Ohio as outlined in the Ohio Revised Code (ORC)-Chapter 4723 and chapters 4723-1 through 4723-27 of the Ohio Administrative Code (OAC).

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Ohio Nurse Practice Act: Subsequent Review

Disclosure Statement

Upon completion of this activity, learners should be able to:

summarize the Ohio Board of Nursing's (OBN's) standards of practice for RNs, LPNs, and APRNs
outline the OBN Scope of Practice Decision-Making Model
list the steps in the OBN's disciplinary process and discuss the OBN's most recent annual reports
define the steps for license renewal and continuing professional development requirements in the Ohio Nurse Practice Act

This course explores the Ohio Nurse Practice Act (NPA) standards outlined in Chapter 4723 of the Ohio Revised Code (ORC) to protect the public and ensure that minimum competencies and requirements are met and maintained by all nurses. The ORC comprises laws passed by the state of Ohio legislative bodies. The Ohio Administrative Code (OAC) is an adjunct document outlining the rules adopted by various agencies throughout Ohio to carry out the laws passed by the general assembly. OAC 4723 is relevant to the BON and divided into 27 chapters. These chapters outline the initial licensure and renewal regulations, standards of practice, disciplinary actions, and requirements for pre-licensure nursing education (Ohio Board of Nursing [OBN], n.d.-b; The Ohio Legislature 135th General Assembly, n.d.). This training will focus primarily on the OAC.

For the most recent copy of the Ohio NPA, please visit the OBN’s website.

Structure of the Ohio Board of Nursing

The structure of the OBN is specified in ORC 4723.02. The OBN comprises 13 members who must be US citizens and residents of Ohio. Eight members must be RNs (i.e., graduates of an accredited nursing school) with an active license in Ohio. These individuals must have been actively engaged in nursing practice as an RN for the 5 years immediately preceding their initial appointment to the board. Of the 8 RNs on the board, at least two must hold a current, valid license issued by the OBN to practice as an advanced practice registered nurse (APRN, including certified nurse-midwife [CNM], certified nurse practitioner [CNP], certified registered nurse anesthetist [CRNA], or clinical nurse specialist [CNS]). Four members must be LPNs who graduate from an accredited education program and hold an active license in Ohio. These individuals must have been actively engaged in nursing practice as an LPN for the 5 years immediately preceding their initial appointment to the OBN. One consumer member is appointed to represent the interest of individuals who receive care from nurses licensed by the state. This individual, or any of their immediate family members, must not have a financial stake in healthcare delivery or be associated with a particular healthcare profession (ORC, 2017a).

From the 12 nurse board members, a president and vice-president are elected for a 1-year term. Another nurse board member is designated as the overseer of matters involving discipline. Board members serve 4-year terms beginning on January 1 and ending on December 31. When an individual's term expires, a qualified candidate with the same nursing license is chosen as their successor. When selecting board members, the disbursement throughout Ohio is considered to ensure a fair representation of all geographical areas of the state. The Governor may remove any individual from the board who is unable or unwilling to meet the position's requirements during their term. This includes neglecting duties or engaging in unprofessional behavior. A new member will be selected to fill the vacancy in this circumstance. When an individual takes over the term before expiration, they hold that position until the term is complete. Nursing organizations within Ohio can submit nominations to fill the vacancies to the Governor; however, with input from the Senate, the Governor makes the member selection for appointment to the vacant position (ORC, 2017a).

Standards of Practice

The OBN can enforce and expand on state statutes through its written rules. Additionally, the OBN has the authority to conduct investigations and to impose discipline when a licensee violates a law or regulation. The minimally acceptable standards of safe and effective practice for the RN and LPN can be found in Chapters 4723-4-03 and 4723-4-04 of Ohio's Administrative Code (OAC, 2019a, 2019b). Table 1 lists the standards from the OAC for the RN.

Table 1

OAC 4723-4-03: Standards Relating to Competent Practice as an RN

A) An RN shall provide nursing care within the scope of practice of nursing for an RN as outlined in division (B) of section 4723.01 of the Revised Code and the rules of the board.
B) An RN shall maintain current knowledge of the duties, responsibilities, and accountabilities for safe nursing practice.
C) An RN shall demonstrate competence and accountability in all areas of practice in which the nurse is engaged, including:
- 1) Consistent performance of all aspects of nursing care
- 2) Recognition, referral or consultation, and intervention when a complication arises
D) An RN may provide nursing care that is beyond basic nursing preparation for an RN, provided:
- 1) The nurse obtains education that emanates from a recognized body of knowledge relative to the nursing care to be provided
- 2) The nurse demonstrates the knowledge, skills, and abilities necessary to provide nursing care
- 3) The nurse maintains documentation satisfactory to the board of meeting the requirements outlined in paragraphs (D)(1) and (D)(2) of this rule
- 4) The nursing care is to be provided according to division (B)(5) of section 4723.01 of the Revised Code; the nurse has a specific current order from an individual who is authorized to practice in this state and is acting within the course of the individual's professional practice
- 5) The nursing care does not involve a function or procedure prohibited by any other law or rule
E) An RN shall, in a timely manner:
- 1) Implement any order for a patient unless the RN believes or should have reason to believe the order is:
  - a) Inaccurate
  - b) Not properly authorized
  - c) Not current or valid
  - d) Harmful, or potentially harmful to a patient
  - e) Contraindicated by other documented information
- 2) Clarify any order for a patient when the RN believes or should have reason to believe the order is:
  - a) Inaccurate
  - b) Not properly authorized
  - c) Not current or valid
  - d) Harmful, or potentially harmful to a patient
  - e) Contraindicated by other documented information
F) When clarifying an order, the RN shall, in a timely manner:
- 1) Consult with an appropriate licensed practitioner
- 2) Notify the ordering practitioner when t
  
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  he RN makes the decision not to follow the order or administer the medication or treatment as prescribed
- 3) Document that the practitioner was notified of the decision not to follow the order or administer the medication or treatment, including the reason for not doing so
- 4) Take any other action needed to assure the safety of the patient
G) An RN shall, in a timely manner, report to and consult, as necessary, with other nurses or other health care team members and make referrals as necessary.
H) An RN shall maintain the confidentiality of patient information. The RN shall communicate patient information with other members of the health care team for health care purposes only, shall access patient information only for purposes of patient care or for otherwise fulfilling the nurse's assigned job responsibilities, and shall not disseminate patient information for purposes other than patient care through social media, texting, emailing, or any other form of communication.
I) To the maximum extent feasible, identifiable patient health care information shall not be disclosed by an RN unless the patient consented to the disclosing of identifiable patient health care information. An RN shall report individually identifiable patient information without written consent in limited circumstances only and in accordance with an authorized law, rule, or other recognized legal authority.
J) The RN shall use acceptable standards of safe nursing care as a basis for any observation, advice, instruction, teaching, or evaluation and shall communicate information that is consistent with acceptable standards of safe nursing care.
K) When an RN provides direction to an LPN, the RN shall first assess the following:
- 1) The condition of the patient who needs nursing care, including, but not limited to, the stability of the patient
- 2) The type of nursing care the patient requires
- 3) The complexity and frequency of the nursing care needed
- 4) The training, skill, and ability of the LPN who will be performing the specific function or procedure
- 5) The availability and accessibility of resources necessary to perform the specific function or procedure safely

Effective: 2/1/2019

5-Year Review Date: 10/16/2023

(OAC, 2019a)

Section 4723-4-04 contains similar standards for LPNs, with the addition that LPNs may consult with an RN when questioning the validity of an order or the decision not to carry out an order (OAC, 2019b).

Nurses must provide care within their scope of practice, and the nursing care provided should be aligned with the individual nurse's education, knowledge, experience, and demonstrated competency. Since nursing is a dynamic practice, questions about the nurse's scope of practice may arise. To assist in delineating the scope of practice, the OBN developed a Scope of Practice Decision Making Model (see Figure 1 below). The model incorporates a decision tree that includes references and is based on safety, competency, legality, and accountability (OBN, 2019).

Figure 1

OBN RN and LPN Decision-Making Model

(OBN, 2019)

Specific areas addressed in the OAC include maintaining and demonstrating competency; assuring patient safety; maintaining confidentiality; delineating, establishing, and maintaining professional boundaries; and applying the nursing process (OAC, 2019a, 2019b).

The rules related to competency are found in 4723-4-03 (A)-(G) for RNs and 4723-4-04 (A)-(G) for LPNs. Both LPNs and RNs are accountable for maintaining current knowledge and demonstrating competency and consistent nursing care performance. When providing care beyond the basic nursing preparations, the nurse must maintain documentation to demonstrate that they obtained advanced knowledge from a credible source (OAC, 2019a, 2019b).
The rules related to safety are discussed in greater detail below. The OBN expects nurses to implement orders from licensed providers in a timely manner unless there is a reason to believe that the order is inappropriate for the patient. Additional details about this can be found in 4723-4-03 (E) and 4723-4-04 (E). The OBN expects the nurse to report to and consult with other nurses and healthcare team members and make necessary referrals. This information is detailed in 4723-4-03 (G) and 4723-4-04 (G). 4723-4-03 (J) and 4723-4-04 (J) outline the OBN's regulations regarding acceptable standards of safe nursing care as a basis for providing advice, instruction, teaching, and evaluation of nursing care (OAC, 2019a, 2019b).
The regulations related to confidentiality are found in 4723-4-03 (H) and 4723-4-04 (H). The OBN requires the nurse to carefully safeguard patient information and only access and disseminate information to provide patient care or fulfill job responsibilities (OAC, 2019a, 2019b).
The regulations related to professional boundaries and misappropriation of property are found in 4723-4-06 (H), (I), (J), (K), (L), (M). The OBN requires the nurse to provide privacy during examination, treatment, and when providing personal care. In addition, the OBN requires the nurse to demonstrate courtesy and respect each patient's individuality (OAC, 2021b).

Standards of Competency for Advanced Practice Registered Nurses

Section 4723-4-05 of the OAC outlines the standards related to competent practice for APRNs. These standards are generalized and apply to CNMs, CNPs, CRNAs, and CNS advanced practice providers (OAC, 2019c). To practice in Ohio, the APRN must enter into a standard care agreement with at least one physician or podiatrist. The exception is that any certified psychiatric-mental health CNS or psychiatric-mental health NP cannot enter into a collaborative agreement with a podiatrist (OAC, 2022). Standard care arrangements are addressed in rule 4723-8-04 of the OAC. The certification standards for APRNs are outlined in rule 4723-8-02 of the OAC (2021c).

The prescriptive authority of APRNs is addressed in Section 4723.481 of the ORC and Section 4723-9 of the OAC. A new version of this section of the ORC is set to be released on September 30, 2024. This section of the ORC sets the standards related to the prescriptive authority of APRNs. This section outlines that APRNs are only permitted to prescribe medications or medical devices not appearing on the exclusionary formulary listed under section 4723.5 of the ORC (i.e., any drug to induce abortion). The prescriptive capability of the APRN cannot exceed that of their collaborating physician or podiatrist. APRNs can only prescribe schedule II narcotics when specific criteria are met. There are exceptions for APRNs practicing in particular settings, such as long-term care facilities, birthing centers, hospitals, or ambulatory surgical centers (ORC, 2017b). The criteria that must be met include the following:

the patient must have a terminal condition
the quantity ordered is limited to a 3-day supply
the medication was initially prescribed by a physician (ORC, 2017b)

Evaluations of an APRN must be completed by a collaborating physician, dentist, podiatrist, or registered anesthetist with a current and valid license with the same designation as the APRN being evaluated (OAC, 2021a). The APRN can provide care within their specialty provided they:

demonstrate the knowledge, skills, and abilities of the specialty
obtain appropriate education from a recognized body of knowledge
document evidence of skills and abilities and maintain records as required (OAC, 2021a)

Another aspect of the OAC for APRNs is title protection, which prohibits using an inappropriate or unearned credential when functioning as a licensed APRN. Only those with a valid license to practice as an APRN and have met all the criteria outlined in ORC 4723.41, 4723.42, and 4723.482 can utilize the specific APRN credentials associated with their role and specialty (i.e., CNP, CNM, CRNA, CNP). Additional information on title protection for the APRN can be found within OAC 4723-8-03 (OAC, 2021d).

Further information related to the APRN role can be found throughout OAC 4723-8.

Promoting Patient Safety

As discussed before, the BON's role is to protect the public from the unsafe delivery of nursing care. The standards of nursing practice that promote patient safety are outlined in rule 4723-4-06 of the OAC (OAC, 2021b). To protect the patient, the OAC prohibits engaging in the following:

behavior that may be viewed as abuse or results in physical, mental, or emotional harm to a patient
actions that might reasonably be interpreted as verbally, physically, mentally, or emotionally abusive
misappropriation of a patient's personal property
attempts to seek personal gain at the patient's expense
activities that can be reasonably interpreted as inappropriate in the patient's personal relationships or financial behaviors
sexual conduct with a patient
conduct or verbal exchanges while delivering care that might reasonably be construed as sexual, seductive, or demeaning to the patient (OAC, 2021b)

The OAC establishes standards for applying the nursing process as an RN. These regulations can be found in OAC-4723-4-07 and are outlined as follows (OAC, 2014a):

RNs must use the steps of the nursing process (assessment, analysis, planning, implementation, and evaluation) in nursing practice.
Effective use of the nursing process requires recognizing its dynamic nature and, thus, enables the nurse to respond to changes in the patient's health status.
The RN should begin with assessing the patient's status (collecting subjective and objective data from the patient, family, and other sources).
The RN then documents findings, analyzes and reports those findings, develops and modifies the plan of care as needed, and communicates the plan of care to other members of the healthcare team.
The RN implements the plan of care by executing the nursing regimen.
The RN provides care that is within their scope of practice.
The RN assists and collaborates with other healthcare team members.
Finally, the RN evaluates the patient's response to determine the effectiveness of the treatment and care plan. The nurse might need to revise the plan of care based on the evaluation. The nurse may also need to notify the provider if an adjustment in the patient's care plan is warranted based on the evaluation findings.

The standards for applying the nursing process are slightly different as an LPN. According to OAC 4723-4-08, LPNs must contribute to the nursing process by providing care based on the established nursing plan. LPNs also use assessment, planning, implementation, and evaluation described in the bullet points above in their nursing practice (OAC, 2014b).

Disciplinary Process

According to the NCSBN (2023), most licensed nurses in the US provide safe, competent, and compassionate nursing care. In addition, less than 1% of nurses are disciplined by their respective BON. Likewise, the OBN reports that most Ohio nurses practice with high standards; however, when a nurse allegedly violates OBN's laws or rules, they are subject to disciplinary action (NCSBN, 2023).

In carrying out its disciplinary responsibilities, the OBN has the authority to revoke or suspend any license or certificate endorsed by the board; impose probationary requirements, reprimands, fines, or practice restrictions; and deny initial or renewal licenses or certifications. The disciplinary process typically begins when a patient, family member, nurse manager, or employer files a complaint. See Table 2 for detailed information about the number of complaints and a partial list of the types of complaints the OBN received from the fiscal years 2016 to 2022. This information is publicly available and is posted on the OBN website within the Annual Report (OBN, 2022).

Table 2

OBN Disciplinary Data

	2016	2018	2020	2022
Number of complaints	8,845	7,317	8,350	6,053
Boundaries	25	60	40	50
Confidentiality	24	36	61	57
Criminal	391	371	360	366
Drugs/alcohol	783	787	695	543
Fraud/theft	74	159	173	43
Multiple allegations	448	508	441	82
Noncompliance with board action	500	430	414	236
Patient abuse	90	69	61	50
Practice Issues	1,123	708	851	739

(OBN, 2022)

The OBN is the governing body within the state that upholds the NPA and the rules found in the OAC. The NPA lays out the process by which the OBN investigates evidence having the appearance that a nurse has failed to practice in accordance with acceptable standards of safe practice. After the evidence has been gathered, a thorough review by the OBN is performed to determine the presence of wrongdoing or a deficiency in practice without harm or risk of serious imminent harm (indicating that the NPA may offer a less stringent alternative; ORC, 2021).

Additional information on disciplinary actions for nurses can be found within the Ohio Revised Code-ORC 4723.28.

License Renewal and Education Requirements

Most states require evidence of continued professional development as part of the license renewal process for nurses to continue to practice. For nurses in Ohio, the renewal cycle is every 2 years from November 1 to October 31 (even years for LPNs and odd years for RNs). During each licensure cycle, the nurse must complete and maintain records for 24 contact hours of continuing education (CE) approved by the OBN. One hour of these 24 hours must be regarding category A training, and up to 8 hours can be satisfied by providing volunteer healthcare services. Those who have held a nursing license by endorsement in Ohio for 1 year or less at the time of renewal are only required to obtain 12 CE hours. A nurse that gains licensure through examination is exempt from the CE requirements for the first renewal cycle following examination (OAC, 2023).

Each nurse applying for renewal must attest to having completed the required CE hours at an appropriate level within the 2-year timeframe. Documentation must be provided upon request by the OBN during routine audits. If evidence is not provided or the individual does not meet the requirements upon request, their license will be inactivated. To reactivate or reinstate a lapsed license, the nurse applicant must complete 24 hours of continuing education. At least one of these hours must pertain to category A, and the applicant must maintain documentation that the hours were completed during the 24 months before their reapplication date. The OBN allows for one waiver period per license. A waiver request must be submitted to the OBN and, once requested, cannot be withdrawn. The waiver eliminates the CE requirements for one renewal cycle (OAC, 2023).

Specific initial licensure and renewal requirements for LPNs, RNs, and APRNs can be found on the OBN website.

*Category A is CE directly related to the Ohio NPA and the administrative rules of the OBN. To qualify as Category A, the CE must be approved by an OBN approver or offered by an OBN-approved provider unit headquartered in the state of Ohio. 4723-14-01(E), OAC.

Education activities for CE should be approved by an OBN approver or administered by an approved provider unit as listed by the OBN, which includes those accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Continuing Medical Education (ACCME), or the International Association for Continuing Education and Training (IACET). Academic credit taken through an accredited educational institution can also be utilized towards a nurse's CE requirements, along with an independent study or volunteer hours spent caring for indigent or uninsured populations. As with RNs, APRNs in Ohio are not required to submit proof of CE hours obtained during their first licensure renewal after initial licensure by examination. CE hours for all other renewing APRNs in Ohio must be obtained between November 1 and October 31 of odd-numbered years. APRNs are required to complete 24 contact hours of CE in the 24-month renewal cycle, including 12 hours of advanced pharmacology training if they are active prescribers, in addition to the 24 hours of CE they are required to obtain for the RN licensure renewal. This requires a total of 48 contact hours for the 2-year renewal period. These hours may also be used towards their national specialty certification (OBN, n.d.-a).

Important Note and Disclaimer

The information in this module is general in nature and is not, nor intended to be, legal advice. The laws are complex, and circumstances vary. Therefore, you should consult an attorney for advice regarding your individual situation.

References

National Council on State Boards of Nursing. (2023). Discipline. https://www.ncsbn.org/discipline.htm

Ohio Administrative Code. (2014a). Rule 4723-4-07: Standards for applying the nursing process as a registered nurse. https://codes.ohio.gov/ohio-administrative-code/rule-4723-4-07

Ohio Administrative Code. (2014b). Rule 4723-4-08: Standards for applying the nursing process as a licensed practical nurse. https://codes.ohio.gov/ohio-administrative-code/rule-4723-4-08

Ohio Administrative Code. (2019a). Rule 4723-4-03: Standards relating to competent practice as a registered nurse. https://codes.ohio.gov/ohio-administrative-code/rule-4723-4-03

Ohio Administrative Code. (2019b). Rule 4723-4-04: Standards relating to competent practice as a licensed practical nurse. https://codes.ohio.gov/ohio-administrative-code/rule-4723-4-04

Ohio Administrative Code. (2019c). Rule 4723-4-05: Standards relating to competent practice as a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist. https://codes.ohio.gov/ohio-administrative-code/rule-4723-4-05

Ohio Administrative Code. (2021a). Prescriptive authority. http://codes.ohio.gov/oac/4723-9

Ohio Administrative Code. (2021b). Rule 4723-4-06: Standards of nursing practice promoting patient safety. https://codes.ohio.gov/ohio-administrative-code/rule-4723-4-06

Ohio Administrative Code. (2021c). Rule 4723-8-02: Standards of practice. https://codes.ohio.gov/ohio-administrative-code/rule-4723-8-02

Ohio Administrative Code. (2021d). Rule 4723-8-03: Title protection. https://codes.ohio.gov/ohio-administrative-code/rule-4723-8-03

Ohio Administrative Code. (2022). Rule 4723-8-04: Standard care arrangement for a certified nurse-midwife, certified nurse practitioner, and clinical nurse specialist. https://codes.ohio.gov/ohio-administrative-code/rule-4723-8-04

Ohio Administrative Code. (2023). Rule 4723-14-03: Continuing education requirement for licensed practical and registered nurses. https://codes.ohio.gov/ohio-administrative-code/rule-4723-14-03

The Ohio Board of Nursing. (n.d.-a). CE requirements for license renewal. Retrieved February 8, 2023, from https://nursing.ohio.gov/continuing-education-and-pre-licensure/continuing-education/ce-requirements-for-renewal

The Ohio Board of Nursing. (n.d.-b). Ohio Board of Nursing. Retrieved February 8, 2023, from https://nursing.ohio.gov/about-us/ohio-board-of-nursing

The Ohio Board of Nursing. (2019). RN and LPN decision-making model. https://nursing.ohio.gov/wps/wcm/connect/gov/3642faaa-ea51-4562-bd9b-68f73c7ec1cc/decision-making-model20191007_14055357.pdf?MOD=AJPERES&CONVERT_TO=url&CACHEID=ROOTWORKSPACE.Z18_K9I401S01H7F40QBNJU3SO1F56-3642faaa-ea51-4562-bd9b-68f73c7ec1cc-onAELGP

The Ohio Board of Nursing. (2022). Fiscal and annual reports. https://nursing.ohio.gov/static/uploads/OBN%20Reports/AnnualReport-FY22.pdf

The Ohio Legislature 135th General Assembly. (n.d.). Laws. Retrieved February 9, 2023, from https://www.legislature.ohio.gov/laws

Ohio Revised Code. (2017a). Section 4723.02: Board of Nursing. https://codes.ohio.gov/ohio-revised-code/section-4723.02

Ohio Revised Code. (2017b). Section 4723.481: Authority of APRN designated as clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner to prescribe drugs and therapeutic devices. https://codes.ohio.gov/ohio-revised-code/section-4723.481

Ohio Revised Code. (2021). Disciplinary actions. http://codes.ohio.gov/orc/4723.28

Ohio Category A Nursing CE Course: Subsequent Review of the Nurse Practice Act

About this course:

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Single Course Cost: $10.00

Ohio Category A Nursing CE Course: Subsequent Review of the Nurse Practice Act

About this course:

Course preview

Single Course Cost: $10.00

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