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).

Course preview

Ohio Nurse Practice Act: Initial Review

Disclosure Statement

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

describe the origin and purpose of regulatory bodies such as boards of nursing (BON)
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
explore the process and parameters for nurse delegation and supervision within the ORC Chapter 4723.67

Nursing education and practice standards result from nursing associations' efforts dating back over 100 years. Nursing regulatory bodies (NRBs), also referred to as state boards of nursing (BONs), were established to regulate nursing practice in all 50 states, the District of Columbia, and 4 US territories. The governments in these states and territories created NRBs to protect the public and ensure they receive quality and safe nursing care. This is achieved by establishing standards of safe nursing care, the scope of practice, and disciplinary guidelines known as the Nurse Practice Act (NPA). The NPA designates the BON, or the authoritative body within each state, to ensure the nursing workforce delivers safe, competent, skilled, and knowledgeable care. The NRBs also establish the requirements that must be met for an individual to obtain licensure to practice. Once a license is issued to an individual, it remains the duty of the NRB to monitor these individuals and ensure compliance with the established standards of care. When a nurse demonstrates unsafe nursing practice and deviates from the established standards of care, the NRB must take action and determine disciplinary action. All NRBs in the US are members of the National Council of State Boards of Nursing (NCSBN, n.d.).

This course explores the Ohio 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.

History of Boards of Nursing

In 1896 the American Nurses Association (ANA) was established to make nursing a recognized profession with established standards to regulate nursing practice. As the ANA made traction and nursing became recognized as a formal profession in the early 20th century, the need arose for the creation of regulatory bodies or nursing boards to enforce newly passed laws and maintain set professional standards. In 1903, North Carolina became the first state to establish a BON. Soon afterward, many states enacted similar legislation and established their own BON. As more BONs were established and professional standards were set, licensing became common and eventually mandatory in 1935. With this mandate, the title of registered nurse (RN) and licensed practical nurse (LPN) became legally protected as only referring to those that had gained state licensure (Graduatenursing.edu, n.d.).

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, and Table 2 lists the standards from the OAC for the LPN.

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 4723.0

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1 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 the 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)

Table 2

OAC 4723-4-04: Standards Relating to the Competent Practice as an LPN

A) An LPN shall function within the scope of practice of nursing for an LPN as outlined in division (F) of section 4723.01 of the Revised Code and the rules of the board.
B) An LPN shall maintain current knowledge of the duties, responsibilities, and accountabilities for safe nursing practice.
C) An LPN shall demonstrate competence and accountability in all areas of practice in which the nurse is engaged, which includes, but is not limited to, the following:
- 1) Consistent performance of all aspects of nursing care
- 2) Recognition, referral or consultation, and intervention when a complication arises
D) An LPN may provide nursing care in accordance with division (F) of section 4723.01 of the Revised Code that is beyond basic preparation for an LPN provided:
- a) The nurse obtains education that emanates from a recognized body of knowledge relative to the nursing care to be provided
- b) The nurse demonstrates the knowledge, skills, and abilities necessary to perform the nursing care
- c) The nurse maintains documentation satisfactory to the board of meeting the requirements outlined in paragraphs (D)(1) and (D)(2) of this rule
- d) When the nursing care is to be provided according to division (F)(3) of section 4723.01 of the Revised Code, the nurse has a specific current valid order or direction from an individual who is authorized to practice in this state and is acting within the course of the individual's professional practice
- e) The nursing care does not involve a function or procedure that is prohibited by any other law or rule
E) An LPN shall, in a timely manner:
- 1) Implement any order or direction for a patient unless the practical nurse believes or should have reason to believe the order or direction 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 or direction for a patient when the LPN believes or should have reason to believe the order or direction 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 or direction, the LPN shall, in a timely manner:
- 1) Consult with an appropriate licensed practitioner or directing RN
- 2) Notify the ordering practitioner or directing RN when the LPN makes the decision not to follow the order or direction or administer the medication or treatment as prescribed
- 3) Document that the practitioner or directing RN was notified of the decision not to follow the direction or 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 LPN shall, in a timely manner, report to and consult as necessary with other nurses or other healthcare team members and make referrals as necessary.
H) An LPN shall maintain the confidentiality of patient information obtained in the course of nursing practice. The LPN 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, or for otherwise fulfilling the nurse's assigned job responsibilities, 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 LPN unless the patient has consented to the disclosure of identifiable patient health care information. An LPN 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) When an LPN is directed to observe, advise, instruct, or evaluate the performance of a nursing task, the LPN shall use acceptable standards of safe nursing care as a basis for that observation, advice, instruction, teaching, or evaluation and shall communicate information that is consistent with acceptable standards of safe nursing care.

Effective: 2/1/2019

5-Year Review Date: 10/16/2023

(OAC, 2019b)

Section 4723-4-05 of the OAC outlines the standards of care for APRNs. These standards are generalized and apply to CNMs, CNPs, CRNAs, and CNS advanced practice providers (OAC, 2019c). Table 3 outlines Rule 4723-4-05.

Table 3

OAC 4723-4-05: Standards Relating to Competent Practice as an APRN

A) A CNM, CNP, CRNA, or CNS shall do all of the following:
- 1) Function within the scope of practice of nursing for an RN as set forth in division (B) of section 4723.01 of the Revised Code and the rules of the board.
- 2) Function within the nurse's applicable scope of practice as set forth in section 4723.43 of the Revised Code and the rules of the board.
- 3) If authorized by Ohio law to prescribe, practice according to section 4723.481 of the ORC and Chapter 4723-9 of the OAC.
B) When the practice of a CNM, CNP, or CNS is evaluated, the evaluation shall be provided by a collaborating licensed physician, podiatrist, or an APRN holding a current, valid license with the same designation as the individual being evaluated.
C) When the practice of a CRNA is evaluated, the evaluation shall be provided by a supervising licensed physician, podiatrist, dentist, or CRNA whose license is current and valid.
D) A CNM, CNP, CRNA, or CNS may provide care within their specialty 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 the 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

Effective: 2/1/2019

5-Year Review Date: 10/16/2023

(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 and outlined in Table 4.

Table 4

OAC 4723-8-04: Standard Care Arrangement for an APRN

A) Prior to engaging in practice, a standard care arrangement shall be entered into with each physician or podiatrist with whom the CNM, CNP, or CNS collaborates.
- 1) The standard care arrangement shall be revised to reflect the addition or deletion of a physician or podiatrist with whom the nurse collaborates within that employment setting. Under these circumstances, a new standard care arrangement is not necessary.
- 2) A new standard care arrangement shall be executed when the nurse is employed in a different setting and engages in practice with a different collaborating physician or podiatrist.
B) A CNM, CNP, or CNS engaged in the practice of the nurse's specialty shall enter into a written standard care arrangement with one or more collaborating physicians or podiatrists whose practice is the same or similar to the nurse's practice.
C) In accordance with division (D) of section 4723.431 of the Revised Code, a CNS whose nursing specialty is mental health or psychiatric mental health, as determined by the board, must enter into a standard care arrangement with a collaborating physician who practices in one of the following specialties:
- 1) A specialty that is the same or similar to the nurse's specialty
- 2) Pediatrics
- 3) Primary care or family practice
D) The standard care arrangement shall include at least the following:
- 1) The signatures of each nurse, collaborating physician, the physician's designated representative, or podiatrist with whom the CNM, CNP, or CNS primarily collaborates, indicating review of and agreement to abide by the terms of the standard care arrangement. For purposes of this rule, a physician's designated representative means a physician who serves as the department or unit director or chair within the same institution, organization or facility department or unit, and within the same practice specialty that the nurse practices, and with respect to whom the physician has executed a legal authorization to enter collaborating agreements on the physician's behalf
- 2) The date when the arrangement is initially executed
- 3) The date of the most recent review of the arrangement
- 4) The complete name, specialty and practice area, business address, and business phone number or number at which the individual can be reached at any time for:
  - a) Each collaborating physician or podiatrist with whom the CNM, CNP, or CNS primarily collaborates and who is a party to the standard care arrangement
  - b) Each CNM, CNP, or CNS who is a party to the standard care arrangement
- 5) A statement of services offered by the CNM, CNP, or CNS consistent with section 4723.43 of the Revised Code and this chapter, including a description of the scope of prescriptive practice and the authorization to enter consult agreements for patients
- 6) A plan for incorporation of new technology or procedures consistent with the applicable scope of practice as set forth in section 4723.43 of the Revised Code and this chapter
- 7) Quality assurance provisions, including at least:
  - a) Every 2 years, review and reapproval of the standard care arrangement. The standard care arrangement shall be reviewed at least every 2 years. Each nurse who is a party to the arrangement and at least one collaborating physician or podiatrist shall sign and date the biennial review of the standard care arrangement
  - b) Criteria for referral of a patient by the CNM, CNP, or CNS to a collaborating physician or podiatrist, including, for the CNM, a plan for referral of breech or face presentation or any other abnormal condition identified as such in the standard care arrangement
  - c) A process for the CNM, CNP, or CNS to obtain consultation from a physician or podiatrist
  - d) A process for chart review in accordance with rule 4723-8-05 of the Administrative Code if the nurse's practice includes any direct patient care, education, or management
- 8)A plan for coverage of patients in instances of emergency or planned absences of either the CNM, CNP, or CNS, or the collaborating physician or podiatrist
- 9) A process for the resolution of disagreements regarding matters of patient management
- 10) Regarding the prescribing component of the clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner's practice, the following quality assurance provisions shall include at least the following:
  - a) Provisions to ensure timely direct, personal evaluation of the patient with a collaborating physician or the physician's design when indicated
  - b) Additional prescribing parameters for drugs or therapeutic devices, when indicated
  - c) Provisions for the use of schedule II substances
  - d) If the nurse is prescribing to minors, as defined in division (A) of section 3719.061 of the Revised Code, provisions for complying with section 3719.061 of the Revised Code when prescribing an opioid analgesic to a minor
  - e) Provisions for obtaining and reviewing the Ohio Automated Rx Reporting System (OARRS) reports and engaging in physician consultation and patient care consistent with section 4723.487 of the Revised Code rule 4723-9-12 of the Administrative Code
- 11) Quality assurance standards consistent with rule 4723-8-05 of the Administrative Code
E) The most current copy of the standard care arrangement and any legal authorization signed by a physician according to paragraph (C)(1) of this rule shall be retained on file by the nurse's employer. Upon request of the board, the CNM, CNP, or CNS shall immediately provide a copy of the standard care arrangement to the board.
F) Copies of previously effective standard care arrangements shall be retained by the nurse for 3 years and provided to the board upon request.
G) When a hospital negotiates a standard care arrangement in accordance with division (F) of section 4723.431 of the Revised Code and this chapter, the standard care arrangement shall be developed in accordance with paragraph (C) of this rule. Review and approval of the standard care arrangement shall be in accordance with the policies and procedures of the hospital governing body and the bylaws, policies, and procedures of the hospital medical staff.
H) A CNM, CNP, or CNS shall notify the board of the identity of a collaborating physician or podiatrist not later than 30 days after engaging in practice.
I) A CNM, CNP, or CNS shall notify the board of any change in the name and business address of a collaborating physician or podiatrist not later than 30 days after the change takes effect, except as provided in division (E) of section 4723.431 of the Revised Code.

Effective: 2/1/2022

5-year Review Date: 10/15/2025

(OAC, 2022)

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)

See Table 5 for the standards of care for the APRN outlined in rule 4723-8-02 of the OAC.

Table 5

OAC 4723-8-02: APRN Certification and Practice: Standards of practice

A) An APRN shall provide to patients nursing care that requires knowledge and skill obtained from advanced formal education, which includes a clinical practicum and clinical experience as specified in sections 4723.41, 4723.43, 4723.433, 4723.434, 4723.435, and 4723.482 of the Revised Code and this chapter.
B) Except as otherwise precluded by law or rule, each APRN shall practice in accordance with the following:
- 1) The APRN's education and clinical experience
- 2) The APRN's national certification, as provided in section 4723.41 of the Revised Code
- 3) Chapter 4723. of the Revised Code and rules adopted under that chapter
C) Only a CNM, CNP, or CNS holding a current valid license as an APRN may prescribe drugs.
D) Each CNM, CNP, or CNS shall utilize and incorporate into the nurse's practice knowledge of Chapter 4731 of the Revised Code and the rules adopted under that chapter that govern the practice of the nurse's collaborating physician or podiatrist. Each CRNA shall utilize and incorporate into the nurse's practice knowledge of Chapters 4715 and 4731 of the Revised Code and the rules adopted under these chapters that govern the practice of the nurse's supervising podiatrist, dentist, or physician.
E) Nothing in this rule precludes an APRN from practicing as an RN in accordance with section 4723.01 of the Revised Code and the rules of the board.

Effective: 2/1/2021

5-year Review Date: 10/15/2025

(OAC, 2021c)

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.

Scope of Practice

All 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).

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 6 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 6

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. The current CE requirements for license renewal for LPNs/RNs are listed in Table 7.

Table 7

OAC 4723-14-03: Continuing Education Requirements for RN and LPN License Renewal

A) A nurse applying to renew an active license to practice nursing as an LPN or RN in Ohio must complete 24 contact hours of continuing education during the renewal period unless an exception applies, and at least 1 of the required hours needs to be in category A* continuing education.
- 1) For the period immediately following licensure by examination, a nurse who holds an active license to practice nursing in Ohio is not required to complete any contact hours of continuing education for the first license renewal
- 2) A nurse who has been licensed by endorsement in Ohio for 1 year or less must complete 12 contact hours of continuing education
- 3) A nurse who has been licensed by endorsement in Ohio for more than 1 year must complete 24 contact hours of continuing education
B) An LPN who has an active license as an RN in Ohio is not required to meet the continuing education requirement for renewal of the license to practice as a practical nurse.
C) A nurse from another jurisdiction who applies for licensure by endorsement to practice as an LPN or RN in Ohio is required to complete 2 contact hours of category A* continuing education in order to be eligible for licensure.
D) To renew, applicants must attest to completing the continuing education required by this rule on the application for renewal. The board may require a renewal applicant to show proof of completion of continuing education. If the board requests proof of continuing education and the applicant fails to provide proof to the board before the end of the renewal period, the license shall lapse.

*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.

(OAC, 2023)

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).

Delegation of Tasks and Supervision

The nursing world functions as a multidisciplinary and cohesive team, with care provided by various professionals at different licensure levels and corresponding scopes of practice. The APRN can delegate tasks to RNs, LPNs, and unlicensed assistive personnel (UAP) within this structure. For more information on APRN delegation, the learner can reference the ORC 4723.48 (ORC, 2023). RNs can delegate tasks to LPNs and UAPs. LPNs can delegate tasks to UAP. In Ohio, an LPN may only delegate to a UAP under the RN's direction (OAC, 2021e). The delegation of medication administration to medication aides in Ohio is covered in the ORC 4723.67 (ORC, 2016). This delegation must be done within the scope of practice. Assigning, delegating, and supervising are skills that nurses may need to manage the needs of their assigned patients. To utilize these skills, the nurse must understand the difference between these terms (Assessment Technologies Institute [ATI], 2016; Craven et al., 2021).

Assigning refers to transferring authority, accountability, and responsibility of patient care to another healthcare team member.
Delegating refers to transferring the authority and responsibility of a task to another healthcare team member while retaining accountability.
Supervising refers to directing, monitoring, and evaluating the performance of tasks completed by another healthcare team member. RNs are responsible for supervising tasks delegated to an LPN or UAP.

Nurses must assign, delegate, and supervise appropriately, following the American Nurses Association (ANA) professional standards, healthcare facility policies, and state nurse practice acts. Assigning occurs in a downward or lateral manner to another healthcare team member (ATI, 2016; Craven et al., 2021). The OAC defines direction as “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.” (OAC, When assigning, the nurse should consider various factors, including

condition of the patient and level of care
need for specific precautions (i.e., seizure, fall, isolation)
particular care needs (i.e., cardiac monitoring, wound care)
knowledge and skill of the team member
staffing mix (i.e., RN, LPN, UAP)
nurse-to-patient ratio
experience of staff with similar patients
amount of supervision required (ATI, 2016; Craven et al., 2021)

The delegating nurse must consider the following:

task factors
- potential for harm (i.e., bleeding, aspiration, fall)
- predictability of outcome (i.e., is it a routine treatment with a predictable outcome)
- need for problem-solving and innovation (i.e., clinical judgment or assessment)
- complexity of care (i.e., is the delegatee qualified to perform the skill)
- level of interaction with the patient (i.e., is education required)
delegatee factors
- knowledge, training, and experience
- demonstrated competence
- institutional policies and licensing legislation
- ability to communicate with others
five rights of delegation
- right task (i.e., the task should be appropriate and require minimal supervision and risk of harm)
- right circumstance (i.e., assess the complexity of care and match this to the skill level of the delegatee)
- right person (i.e., assess and verify the delegatee's scope of practice, training, and competence)
- right direction/communication
  - data to be collected
  - specific task to be performed
  - method and timeline for reporting concerns or findings
  - expected results
- right supervision/evaluation
  - provide supervision directly or indirectly (i.e., assign to another licensed nurse)
  - monitor performance
  - provide feedback
  - evaluate the patient and determine if outcomes were met
  - intervene if necessary (i.e., unsafe practices; ATI, 2016; Craven et al., 2021)

Table 8

Tasks Appropriate for Delegation from an RN to an LPN or UAP

LPN	UAP
Reinforcing patient teaching from a care plan	Activities of daily living (ADLs; bathing, grooming, dressing, toileting)
Tracheostomy care or suctioning	Ambulating
Monitoring findings (input for the RN's assessment)	Feeding (excluding aspiration precautions)
Inserting a urinary catheter	Positioning
Checking nasogastric (NG) tube patency	Intake and output
Administering enteral feedings	Vital signs (for stable patients)
Administering medication (excluding first-dose intravenous [IV] medications in some states)	Specimen collection

(ATI, 2016; Craven et al., 2021)

The OAC defines safe delegation within nursing in rule 4723-13 (2021e) and specifies that only a licensed nurse may delegate a task to an unlicensed person. Once a nursing task has been delegated, it can not be delegated (passed along) to another individual. In Ohio, a licensed nurse may delegate the administration of an over-the-counter topical medication to improve skin condition or provide a barrier or an over-the-counter eye/ear drop or suppository. They may also delegate foot soak treatments and enemas to UAPs if appropriate. Delegated tasks must be within the licensed nurse’s scope of practice, knowledge, skill, and ability. The task must be within the delegate's training, ability, and skill. The required resources/support to complete the task are evident, including the supervision by the licensed nurse. Tasks that require judgment based on nursing knowledge, complex observations, critical decision-making, and nursing assessment or may have unpredictable outcomes are not appropriate to delegate to a UAP. Delegated tasks should be able to be completed using specific, consistent directions without alteration. Tasks should have minimal repercussions if performed incorrectly. Ultimately, the delegating licensed nurse is held accountable for their decision to delegate, with the ability (and intention) to intervene if the task is being performed incorrectly. When teaching a UAP to perform a task, the nurse should provide background information, including the concepts underlying the task, infection control/universal precautions, and step-by-step instructions. The licensed nurse should demonstrate the task and then observe and document a return demonstration by the UAP. Supervision should be onsite when providing healthcare services and may include “initial and ongoing direction, procedural guidance, and evaluation, and may include direct observation of the performance of the nursing task” (OAC, 2021e, 4723-13-07[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

Assessment Technologies Institute. (2016). Content mastery series: Review module. Nursing leadership and management (7th ed.). Assessment Technologies Institute.

Craven, R. F., Hirnle, C. J., & Henshaw, C. M. (2021). Fundamentals of nursing: Concepts and competencies for practice (14th ed.). Wolters Kluwer.

Graduatenursing.edu. (n.d.). What is a state board of nursing? Retrieved February 9, 2023, from https://www.graduatenursingedu.org/state-board-of-nursing

National Council on State Boards of Nursing. (n.d.). About US nursing regulatory bodies. Retrieved February 8, 2023, from https://www.ncsbn.org/nursing-regulation/about-nursing-regulatory-bodies.page

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). Rule 4723-4-09: 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. (2021e). Rule 4723-13: Delegation of Nursing Tasks. https://codes.ohio.gov/ohio-administrative-code/chapter-4723-13

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. (2016). Section 4723.67: Administration of medication by aides- delegation by nurse required. https://codes.ohio.gov/ohio-revised-code/section-4723.67

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). Section 4723.28: Disciplinary actions. http://codes.ohio.gov/orc/4723.28

Ohio Revised Code. (2023). Section 4723.48: Delegation of authority to administer certain drugs. https://codes.ohio.gov/ohio-revised-code/section-4723.48

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

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

About this course:

Course preview

Single Course Cost: $20.00

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