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Ohio Nursing Law & Rules – Current Issues in Practice

DIRECTIONS & CRITERIA FOR SUCCESSFUL COMPLETION

1.   Please read carefully the below article “Ohio Nursing Law & Rules – Current Issues in Practice.”

2.   Complete and submit the post-test, evaluation form and the registration form.

The post-test will be reviewed. If a score of 70 percent or better is achieved, a certificate will be emailed to you and contact hours will be awarded. If a score of 70 percent is not achieved, a letter of notification of the final score and instructions on how to take second post-test will be sent to you. We recommend that this independent study be reviewed prior to taking the second post-test. If a score of 70 percent is achieved on the second post-test, a certificate will be issued.

If you have any questions, please contact the Ohio Nurses Association’s CE department at sswearingen@ce4nurses.org or 614-323-1164.

STUDY

The laws and rules surrounding nursing don’t have to be overwhelming. They exist to not only protect the patients nurses care for, but to protect the nurses themselves as well.

This independent study activity will cover the role of the Ohio Board of Nursing in supporting these rules, as well as some important and relevant information on current nursing practice issues including staffing, documentation, and patient rights. This study will also discuss how these current issues relate to Ohio nursing law and rules.

1.0 Contact Hour that will satisfy the Ohio Category A requirement will be awarded with successful completion of this activity.

 Who Makes the Rules?

All nurses in Ohio are familiar with the Ohio Board of Nursing, or “the board”. In addition to auditing things like continuing education hours, the board investigates complaints against nurses and administers discipline as appropriate (Ohio Board of Nursing [BON], 2017). The board works diligently to ensure the public is being cared for by safe, competent and qualified nurses.

Not Just for Nurses

While it is titled the Board of Nursing, the board oversees additional healthcare professions. Dialysis technicians, community health workers and certified medication aides all fall under the Board of Nursing (OAC, 2017).  Topics such as education requirements, intravenous therapy rules, and delegation practices are all set forth by the board.

The board consists of thirteen members, eight of which are nurses. Two of these nurses must be APRNs and four must be LPNs. Additionally, there is a “consumer” member, who represents the interest of the public (ORC, 2017).

The board contains 3 advisory groups: continuing education, dialysis, and nursing education. Additionally, there is a committee on prescriptive governance and an advisory committee on advanced practice registered nursing (OAC, 2017).

The basics

Nurses practicing in Ohio must be aware of both the Ohio Administrative Code, OAC, and the Ohio Revised Code, ORC. The ORC consists of the laws passed by the Ohio legislature, while the OAC has the specific ways those rules are to be carried out at the recommendation of entities such as the Board of Nursing (BON).

To make a continuing education activity qualify for Category A credit, it must include specific information related to ORC and OAC 4723. The law states,
“…portion of continuing education that meets the one hour requirement directly related to Chapter 4723. of the Revised Code and the rules of the board as described in rule 4723-14-03 of the Administrative Code” (OAC, 2018).

Additionally, the activity must be approved by the board or an approved provider of continuing education in Ohio, such as Ohio Nurses Association.

 So, what else can the OBN do? (4723)

In addition to audits and investigations, the board also manages the issuance and revocation of nursing licensure. They decide who gets a license and who doesn’t.

If a complaint is filed, the board does have a due process that it needs to follow. With a few serious exceptions, a full investigation must be done before disciplinary action is taken against the nurse, such as license suspension or revocation. This investigational process involves a hearing, where the nurse can share his/her side of the story.

It is also important to note that the board must follow the law. The board can make clarifying rules (OAC), but they must align with the laws passed by the Ohio legislature (ORC).

Disciplinary action taken by the board is not one size fits all. There are varying levels of discipline. One that not all nurses and students are aware of is the board’s ability to deny taking the NCLEX (4723-7-02 OAC).

Per ORC 4823.28 (2017), the board can: “…deny, revoke, suspend, or place restrictions on any nursing license or dialysis technician certificate issued by the board; reprimand or otherwise discipline a holder of a nursing license or dialysis technician certificate; or impose a fine of not more than five hundred dollars per violation”.

4723.33 in the ORC explains that there is protection for the nurse filing a complaint against retaliatory action. Anyone who has a concern is encouraged to report it to the board and should feel comfortable doing so. The concern for patient safety is always a priority, as well as the protection of their rights.

What is Nursing?

The ORC defines the practice of nursing as, “…providing to individuals and groups nursing care requiring specialized knowledge, judgment, and skill derived from the principles of biological, physical, behavioral, social, and nursing sciences” (ORC, 2017).

In other words, nurses take care of people, in more ways than one. Nurses have specialized knowledge of many fields that are combined to provide holistic and effective care to all patients. With that knowledge comes a great responsibility, one that all nurses must take seriously.

Suggested Resources:

http://codes.ohio.gov/orc/4723

http://codes.ohio.gov/oac/4723

 

OAC 4723-4-06 (2017) states that nurses must “provide privacy during examination or treatment and in the care of personal of bodily needs”. It goes on to say that nurses must “treat each client with courtesy, respect and full recognition of dignity…”.

What is important to take away from this is that nurses must be mindful of what this means for each patient. Not everyone’s idea of modesty or even privacy is the same. There are cultural considerations that nurses and healthcare professionals may not even be aware of. While it is not always possible to accommodate every cultural practice or preference, for example in the event of an emergency, nurses should strive to understand what the patient’s comfort level is and how they can meet it.

In addition to providing competent and respectful care to all patients, nurses have a responsibility to ensure they are practicing safely to the best of their abilities.

Practice Issues

 Nurse Fatigue: Why It Matters

While the board’s goal is to protect the public, it has no authority over healthcare facilities or staffing issues. If a nurse is fatigued and makes an error, the board’s responsibility is to investigate it.

When nurses are exhausted and overworked, patient care and public health suffers. There is overwhelming evidence that nurse fatigue puts patients, nurses and the public at risk (Emergency Nurses Association [ENA], 2013). Fatigue, whether physical, mental or both, can cause delayed response time, impaired decision making, and negative health outcomes (Drake, Luna, Georges, & Steege, 2012).

When you think of the job nurses are assigned to do, those three things do not fit in the equation. Patients need nurses with fast response times to emergent situations, top-notch decision making and critical thinking skills, and, obviously, positive health outcomes.

The ANA, American Nurses Association, issued several recommendations and a position statement on the issue. ANA recommends that the Registered Nurse have the right to decline or accept a work assignment or shift based on evaluation of their own fatigue (American Nurses Association [ANA], 2014). This should not be considered patient abandonment. Additionally, ANA advocates for a 40-hour work week, with no more than 12 hour shifts, and a ban on mandatory overtime (ANA, 2014).

Patient Safety and Patient Rights

Keeping patients safe and satisfied is not always an easy task.

Nurses must honor patient’s requests, even when they don’t agree. A common area of concern for nurses is when a patient refuses treatment or wishes to leave Against Medical Advice or “AMA”.  “Most of all, nurses can help by not perpetuating the concepts that AMA means you leave with nothing” (Barkley, 2014, para. 1).  The nurse’s role in AMA discharges is similar to their role in any other patient’s care.

The nurse is in a unique position to educate and advocate for their patient. It is the nurse’s role to support them even if we do not agree. All information should be provided unbiased, and all available options discussed. When a patient states they wish to sign out AMA, the nurse can use this opportunity to have an honest conversation. The nurse can ask why or what factors are driving the patient to this potentially dangerous decision. Sometimes, there are modifiable reasons or solutions that can be created in order to get the patient the safest care. Patients questioning or deciding to leave AMA still deserve the same education as any other patient.

As with all patient teaching, it should be documented in detail. Additionally, it is important to note how you as the nurse determined that the patient truly understands the information.

Interventions such as: any communication between the nurse and the physician, patient teaching, interventions made by the nurse, and resources contacted should all be documented. Documentation should be done real-time to avoid missing something. The use of quotes is especially useful in the case of refusal of care and/or AMA discharges.

Documenting something that happened earlier in the shift, or “back-charting”, is acceptable because it makes the documentation more thorough.

DOCUMENTATION DOs & DON’Ts

Do Example Don’t Example
Chart objective information Side rails up x2, fall risk sticker on the door, yellow non-skid footwear on. Patient education on preventing falls given. Patient verbalized understanding. Insert bias The patient is clearly making a bad choice by leaving AMA and does not seem to care about their health.
Utilize quotations when necessary “I will use the yellow socks you gave me before I get up to go to the bathroom”

“I want to leave the hospital. I understand the risks but I do not want a big bill.”

“… chart only what you – not what you infer or assume.” see, hear, feel, measure, and count”

Source: (American Society of Registered Nurses, 2008, para. 3)

 

Be judgmental The patient didn’t seem to understand what I said about preventing falls. I think she just doesn’t care about her safety.

 

 

Social Media

With social media rising in popularity, more people are using it now than ever before. Nurses must remain mindful of everything they post, share, and tweet.

According to the American Nurses Association’s position statements on social media: think before you post. Best practice is to treat everything you post as if your boss, employer, school, and/or patients will see it (American Nurses Association [ANA], 2011).

Even if the post or picture does not contain patient identifiable information, it may still be inappropriate for the professional nurse to post. While there is no current legislation in Ohio regarding the use of social media, the code of ethics for nurses still applies and the OAC standard for competent practice speaks to the need for nurses to uses social media wisely.

Ohio Administrative Code [OAC] 4723-4-03 Standards relating to competent practice as a registered nurse (2014).

“A registered nurse shall maintain the confidentiality of patient information. The registered nurse 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.

To the maximum extent feasible, identifiable patient health care information shall not be disclosed by a registered nurse unless the patient has consented to the disclosure of identifiable patient health care information. A registered nurse 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” (OAC, 2014).

“…a nurse shall not use social media, texting, emailing, or other forms of communication with, or about a patient, for non-health care purposes or for purposes other than fulfilling the nurse’s assigned job responsibilities” (OAC, 2014).

References

American Nurses Association. (2011). ANA’s principles for social networking and the nurse. Retrieved from https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/social-networking.pdf

American Nurses Association. (2014). Addressing nurse fatigue to promote safety and health: Joint responsibilities of registered nurses and employers to reduce risks. Retrieved from https://www.nursingworld.org/~49de63/globalassets/practiceandpolicy/health-and-safety/nurse-fatigue-position-statement-final.pdf

American Society of Registered Nurses. (2008). Charting and documentation. Retrieved from https://www.asrn.org/journal-chronicle-nursing/341-charting-and-documentation.html

Barkley, M. (2014). Against medical advice. Journal of Trauma Nursing, 21(6), 314-318. https://doi.org/10.1097/JTN.0000000000000091.

Caruso, C. (2012). Better sleep: Antidote to on-the-job fatigue. American Nurse Today, 7(5). Retrieved from https://www.americannursetoday.com/better-sleep-antidote-to-on-the-job-fatigue/

Drake, D., Luna, M., Georges, J., & Steege, L. (2012). Hospital nurse force theory: A perspective of nurse fatigue and patient harm. Advances in Nursing Science, 35(4), 305-314. https://doi.org/10.1097/ANS.0b013e318271d104.

Dyrbye, L., Shanafelt, T., Sinsky, C., Cipriano, P., Bhatt, J., Ommaya, A., … Meyers, D. (2017). Burnout among health care professionals:A call to explore and address thisunderrecognized threat to safe, high-qualitycare. Retrieved from https://nam.edu/wp-content/uploads/2017/07/Burnout-Among-Health-Care-Professionals-A-Call-to-Explore-and-Address-This-Underrecognized-Threat.pdf

Emergency Nurses Association. (2013). Nurse fatigue. Retrieved from https://www.ena.org/docs/default-source/resource-library/practice-resources/white-papers/nurse-fatigue.pdf?sfvrsn=f28a91eb_8

Ohio Administrative Code. (OAC). 4723 Ohio board of nursing. Retrieved August 24, 2018 from http://codes.ohio.gov/oac/4723

Ohio Board of Nursing. (2017). The Ohio board of nursing. Retrieved August 24, 2018, from http://www.nursing.ohio.gov/Law_and_Rule.htm

Ohio Revised Code. (ORC). Chapter 4723 Nurses. Retrieved August 24, 2018 from http://codes.ohio.gov/orc/4723

 

Ohio Nursing Law & Rules – Current Issues in Practice

  • Evaluation Were you able to achieve the following outcomes? Yes or No

Combating Lateral Violence

DESCRIPTION

This independent study has been developed for nurses to learn more about the problem of lateral violence and identify strategies to decrease it in the workplace.

OUTCOME
The learner will identify at least one strategy you will implement to help decrease the incidence of lateral violence in nursing.

1.3 contact hours will be awarded for successful completion of this independent study.

This independent study was developed by: Barbara Brunt, MA, MN, RN-BC, NE-BC, FABC. The author and members of the planning committee have no conflict of interest.

DISCLAIMER

Information in this study is intended for educational purposes only. It is not intended to provide legal and/or medical advice.

The Ohio Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation (OBN-001-91).

Expires 11/2020

Buy Now – $15

Combating Lateral Violence – Post-Test and Evaluation

DIRECTIONS

1.   Please read carefully the below article “Combating Lateral Violence.”

2.   Complete and submit the post-test, evaluation form and the registration form.

The post-test will be reviewed. If a score of 70 percent or better is achieved, a certificate will be emailed to you. If a score of 70 percent is not achieved, a letter of notification of the final score and instructions on how to take second post-test will be sent to you. We recommend that this independent study be reviewed prior to taking the second post-test. If a score of 70 percent is achieved on the second post-test, a certificate will be issued.

If you have any questions, please contact the Ohio Nurses Association’s CE department at info@ce4nurses.org.

Combatting Lateral Violence

  • Evaluation Were you able to achieve the following outcomes? Yes or No

Bipolar Disorder: Implications for Nursing Practice – Post Test and Evaluation

DIRECTIONS

1.   Please read carefully the below article “Bipolar Disorder: Implications for Nursing Practice.”

2.   Complete and submit the post-test, evaluation form and the registration form.

The post-test will be reviewed. If a score of 70 percent or better is achieved, a certificate will be emailed to you. If a score of 70 percent is not achieved, a letter of notification of the final score and instructions on how to take second post-test will be sent to you. We recommend that this independent study be reviewed prior to taking the second post-test. If a score of 70 percent is achieved on the second post-test, a certificate will be issued.

If you have any questions, please contact the Ohio Nurses Association’s CE department at info@ce4nurses.org or call 1-800-735-0056.

STUDY

Bipolar disorder (BO) is a complex and challenging brain disorder, in which moods range back and forth between sadness to euphoria. Widely recognized as a mental health entity, BO presents with a variety of symptoms: physical and emotional. The symptoms vary in duration and depth, and often resemble physiological possibilities. Bipolar disorder challenges patients, families and professional caregivers for many reasons, not the least of which is obtaining an accurate diagnosis.  Patience is essential as pharmacological treatment(s) are explored and refined. Psychosocial therapies offer support and strategies for coping with ongoing lifestyle interruptions and annoyances. Relapse and recurrence is common.

Bipolar disorder patients access the healthcare system in numerous ways. Consequently, nurses in any setting are likely to encounter a patient with a diagnosis of bipolar disorder, or a patient who has yet to receive the diagnosis of bipolar disorder.  As co­morbidities are often present in persons with bipolar disorder, it is even more likely that a nurse’s practice will encounter a bipolar disorder patient with heart disease, diabetes, substance use, suicidal thoughts, or acute psychosis.

This independent study describes bipolar disorder: scope, risk factors and symptoms, types of bipolar disorder, treatment options, and implications for nursing care along the lifespan.  Communication and coordination throughout the continuum of care among the disciplines, along with an understanding and trusting nurse-patient relationship contributes to care excellence.

Bipolar Disorder (BD)

Previously known as manic-depression, bipolar disorder is a chronic, persistent and complex illness which causes episodic changes in a person’s mood, energy levels, behaviors and thinking.  While the Greeks and Romans used the terms melancholia and mania, the first published description of “la folie circulaire” (circular insanity) was by Jean-Pierre Falret in 1851 with melancholia (depression) and mania as the key features (Krans, B. & Cherney, K., 2016). Known for years as a mental or mood disorder, BD is recognized as a brain disorder (American Psychiatric Association, 2015; NIMH, 2016). The recognition and acknowledgment of the brain-body-mind relationship underscores the interconnectedness of cause, treatment and response.

Scope

The age of diagnosis ranges from 18-60+ years. The average age of onset is 25 years. Unlike incidence which measures new case, lifetime prevalence describes the proportion or percentage of the population who has ever had a diagnosis of bipolar disorder. For the age demographic, the lifetime prevalence is as follows: 5.9% (18-29 years); 4.5% (30-44 years); 3.5% (45-59 years) and 1% (60+ years). The 12-month prevalence accounts for about 2.6% of the adult population; of these nearly 83% of cases in the adult US population are considered “severe” (nimh.nih.gov). Data by sex and race are not reported. Some data suggest that females are at greater risk for depression and rapid mood shift while males have a greater risk for mania. Debate continues about diagnostic criteria for children; prevalence data for children are not available. For statistical information about bipolar disorder in adults and children check out www.nimh.nih.gov/health/statistics/biopolar-disorder

Risk Factors

Multiple risk factors are believed to contribute to the development of bipolar disorder. No single etiology of BD has been identified. The National Institute of Mental Health describes bipolar disorder in adults possibly due to genetics, or brain variations in structure or function. A genetic etiology is being studied as there is evidence of familial tendencies.

Yet, in identical twins, bipolar disorder may be present in one twin and not the other twin. Stressful life events may also contribute to the development of BD. The impact of childhood adverse events and misdiagnoses across the lifespan – such as major depression postpartum depression attention deficit hyperactivity disorder (ADHD) and various anxieties – are also potentially undiagnosed cases of bipolar disorder.

Recognition and Diagnosis of Bipolar Disorder

As a chronic and complex disorder with relapses and recurrences, initial diagnoses may be inaccurate because patients tend to seek treatment when depressed not manic. Physical health problems – such as diabetes, heart or thyroid disease, alcohol and substance use – may also prompt the patient to seek health care. Nonadherence to medication therapy results in relapses. Office visits, community clinics, and emergency departments are among the many locations used to access the health care system. All nurses, especially in non-psychiatric practice settings, are important to the recognition and subsequent care of patients with bipolar disorder.

An accurate diagnosis of bipolar disorder is essential to development of an effective plan of treatment.

  • Complete physical exam to eliminate other diseases causing mood
  • A comprehensive medical history considering family and socially influenced behaviors that might be contributing to changes in
  • Screening for depression to differentiate unipolar (clinical depression or major depressive disorder) from bipolar depression (occurring with mania or hypomania).

Types and Symptoms of Bipolar Disorder

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), bipolar disorder is a brain disorder with mood changes (APA, 2013). This independent study focuses on Bipolar I Disorder (BID) and Bipolar II Disorder (BIID).

Bipolar I Disorder (BID)

Bipolar I Disorder is characterized by mood swings and patients experience one or more episodes of full mania. Mania is intense and may last for at least a week. Episodes of depression are also present and may last for up to two weeks. Most patients have both episodes of mania and depression.  It is rare that BID patients only experience mania.

Depression typically prompts people to seek treatment. With unipolar depression such as when a person feels ‘sad’ or ‘down’ because of a situation or series of stressors, depression in bipolar disorder significantly impacts a person’s ability to function. Emotionally, patients may be despondent and display a lack interest in family, friends, school, and/or work. Previous enjoyments hold no interest or enthusiasm.

Feelings of anxiety or an inability to concentrate, agitation, irritability and guilt are common. Further, they may express feelings of worthlessness and wonder if things will ever improve. Recurrent thoughts of death may prompt suicide contemplation or attempts. If clinical depression worsens and is untreated, patients may be unable to meet basic needs unassisted. Offers to help or provide assistance may prompt irritable responses to the concerns of loved ones and health care providers. Other causes of depression related to postpartum or a personal loss should also be considered.

Mania is the “high” side of bipolar 1 disorder. Patients experiencing full mania, or hypomania, rarely seek out treatment on their own. In a manic or hypomanic phase, people believe they are just fine and often consider those trying to assist them as hostile, or misguided.

During mania, the patient’s mood is elevated and expansive; irritability is common.  They feel great about themselves and hold grand ideas for accomplishments.  They may dart from idea to idea, be easily distracted and start multiple projects which are not completed.  As energy levels rise in the manic phase, sleeping, eating and drinking are also interrupted. Speech is rapid and pressured; attempts to interrupt or redirect are difficult. While in the manic phase, patients appear euphoric and happy. Judgment and insight are impaired. Risky behaviors associated with excessive drug use, speeding, gambling, spending sprees and acting out sexually may have long term negative consequences resulting in shame and guilt.

Psychosis in persons with bipolar I disorder may develop during episodes of severe depression or mania. Delusions (false beliefs) and hallucinations (auditory or visual) are reported and usually correspond to the patient’s mood. When depressed, delusions and hallucinations are consistent with despondency. The patient may not eat because they feel worthless, imagine that they’ve done something evil, or hear a voice that says the world has ended. If manic, themes tend to be more paranoid or grandiose. There may be a fear that someone will steal their belongings or money, or that God is speaking to them as them as a special messenger.  With psychosis, a diagnosis of schizophrenia is also possible.

Bipolar II Disorder (BIID)

Bipolar II Disorder is characterized by episodes of hypomania and depression. Hypomania is less intense than full mania. BIID patients experience at least one depression episode and episodes of hypomania, but never a full manic episode. Correct diagnosis of BIID is complex process, necessitates careful evaluation of mood states, and a patient-caregiver partnership.  To avoid misdiagnosis when a patient presents with depression symptoms, it is important to evaluate if there have been any past periods of hypomania or mania which can suggest this is bipolar disorder.

Hypomania also has negative impacts on the person’s life.  As the hypomanic patient experiences an intoxicating sense of well-being, they may decide to stop medications or not participate in psychosocial treatments. At this point, they believe that they do not have bipolar disorder and/or other physical conditions. Hypomania can also progress into either a full manic or depressive episode.  Repercussions of mania or hypomania can be as devastating as the episodes of depression for patients and their significant others.

Other Bipolar Disorders

Frequent and recurring periods of hypomania and depression lasting over a period of two years, one year in children, characterizes cyclothymic disorder or cyclothymia. Previously known as ‘rapid cycling bipolar disorder,’ the name change was made with the DSM-5 (APA, 2013).   In the other unspecified and specified disorders, patients do not have symptoms that would meet criteria for BID, BIID, or cyclothymic disorder. The diagnostic category of mixed episode was changed to mixed features in the DSM-5 (APA, 2013). With a mixed features category, moods shift rapidly between mania and depression with variations in intensity and duration. This diagnostic category was established to assist with the specificity of treatment and diagnosis. After an initial diagnosis, nurses and the treatment team are just beginning a plan of care to achieve mood stability and effective outcomes.

The variability of symptoms and manifestations of bipolar disorder challenges clinicians, the patient and family members.  Key points to remember include:

  • Changes in mood – often sadness or depression to some extent – accompany many chronic health problems, or the challenges of Some neurological disorders, living with COPD, CHF or limitations in mobility or cognitive function also can impact mood and result in depression.
  • Endocrine disorders such as hyperthyroidism may affect moods or result in hyperactivity, with an inability to concentrate, or stay Hypothyroidism results in loss of interest in personal care and relationships and a tendency to avoid usual enjoyments.
  • Mood swings may stabilize with medications, so patients ‘feel good,’ think they are well, and stop taking their Other patients may not like one or more of the side effects, and stop taking their meds. Adherence to prescribed medications is a major challenge to an effective treatment plan for patients with bipolar disorder.
  • Medication prescribed for mood stabilization, treatment of depression and others have side effects. Pharmacological advances have lessened the frequency of tardive dyskinesia and extrapyramidal symptoms present in typical The atypical antipsychotics present fewer problems, but may result in tremors, restlessness and muscle rigidity.

Treatment for Bipolar Disorder

Medications and psychosocial therapies are prescribed for bipolar disorders. As with many chronic health problems, bipolar disorder patients need to take medications and learn to make life style adjustments. Managing symptoms, finding and adhering to prescribed medications and participating in psychosocial therapies assist the patient to stabilize and enhance quality of life.  Psychosocial therapies include Psychoeducational Therapy (PE), Interpersonal Social Rhythm Therapy (ISRT), Cognitive Behavioral Therapy (CBT), and Family-Focused Therapy (FFT). Integrated care involving case managers in support of medication adherence and selected psychosocial therapies is providing additional support for the patient with bipolar disorder.

Medications

Medications are prescribed to prevent acute episodes of depression or mania and to stabilize mood variability.  With a diagnosis of bipolar disorder, medication becomes a critical part of his/her treatment regimen.  Medication management is complex and can be a frustrating process for the patient and his or her health care professionals.

Unfortunately, there is no single combination of medications which works well for everyone. The right combination to manage a specific patient’s mood instability takes time and can change over time.

Frustration and feelings of futility may ensue. Jann (2014) reported that more than 75% of the patients take the prescribed medications less than 75% of the time.

Polypharmacy, drug-drug interactions, lack of adherence and side effects necessitate that nurses appreciate some nuances of medications used to treat bipolar disorders. This article provides a limited overview of medication management options. Prescription guidelines vary depending on the source and date of publication. Research on the efficacy, quality of life and cost of medication therapy is of world-wide interest. Baseline lab work is needed prior to medication therapy for newly diagnosed patients. For long term use, on-going monitoring is also indicated.

Three categories of medications are used to treat bipolar disorder: mood stabil izers, antipsychotics including atypical antipsychotics, and antidepressants. The search for a combination of medications requires patience. For the patient, side effects or a feeling of being cured contributes to non­adherence. A variety of blood tests may be indicated to identify negative consequences (Cullison & Resch, 2014).  On-going monitoring to evaluate response to medication therapy is essential. Changes to the prescribed regimen are to be expected.

Mood Stabilizers

Lithium and anticonvulsants stabilize mood swings of mania/hypomania and depression. Lithium requires blood monitoring to assure a therapeutic range, and detect problems with deteriorating renal function or hypothyroidism. Patients taking sodium valproate need monitoring of liver function.  For Lithium and other mood stabilizers such as sodium valproate and lamotrigine, side effects may include gastrointestinal problems, hair loss, motor problems, fatigue, cognitive impairment, sexual issues, weight gain, skin eruptions and visual disturbances.

Antipsychotics and Atypical Antipsychotics

Antipsychotic medications may include both older conventional drugs such as the anticonvulsants and increasingly the newer atypical antipsychotics. Their primary treatment effect is for acute mania. Anticonvulsant side effects include extrapyramidal symptoms such as tremors or muscle spasms and tardive dyskinesia. Atypical antipsychotic medications can result in metabolic changes resulting in weight gain, high lipid levels, diabetes, dizziness, constipation, skin rashes, cataracts, hypotension, heart problems, seizures, cognitive problems and involuntary movements.

Antidepressants

Antidepressants are often prescribed in combination with a mood stabilizer or antipsychotic medication. The general recommendation is to taper and discontinue antidepressants after remission (Jan, 2014). When given alone (unopposed) to patients with a bipolar diagnosis, mania may result. Finally, antidepressant mediations can cause gastrointestinal problems, agitation, insomnia, tremors, dry mouth, headaches and sexual problems.

Medication Management Challenges

Medication management can be an ongoing struggle for patients with bipolar disorder, for family and friends of the patient and the professionals treating them.  Medication nonadherence or noncompliance is a common problem and occurs for many reasons.

Medication regimens are complex and often expensive. Unpleasant side effects may be annoying and perceived as not increasing quality of life. When seriously depressed, or hyperactive, energy levels and the inability to concentrate may result in nonadherence to the complex medication plan.

When manic, the patient with bipolar disorder may believe they are well, or feel robbed of the positive feelings associated with mania. Energy, competence and creativity may be missed. When the patient feels better, even in a manic state, the patient may believe they are cured and no longer need their medications. Medication physical and emotional side effects are of great concern and cause much noncompliance. It is helpful for the nurse to ask the patient about their physical and emotional struggles for mood stability with prescribed medications. As medications may need to change, the patient s perspective on lack of adherence may be insightful.

Psychosocial Treatment

Psychosocial therapies assist patients to understand, accept, monitor and manage their disorder. With a chronic disorder that affects physical health, emotional stability and social function, involvement of an entire team is needed to stabilize the patient. All healthcare providers, nurses, advanced practice nurses, physicians and mental health professionals must communicate and coordinate for optimum results. Newly diagnosed patients need referral to mental health professionals and existing bipolar patients with physical health concerns need understanding and support during management of physical health problems. Providers focused on physical problems need to work with the patient’s mental health team to understand and more fully manage the patient’s unique needs.

All nurses need to understand that while there are some commonalities among patients with bipolar disorder, every bipolar disorder patient is unique.  A relationship with the patient, his/her family, significant other, and the patient’s mental health professionals benefits all aspects of care for this complex, perplexing and recurring disorder. Medical and nursing care providers need to have the patient’s consent to communicate with their mental health providers for care coordination and continuity. Mental health providers will assist others to better understand effective approaches with the patient, especially in crisis situations.

Evidence Based Psychosocial Treatments for Bipolar Disorder

The psychosocial treatments for bipolar disorder include psychosocial education (PE), cognitive behavioral therapy (CBT), interpersonal social rhythm therapy (IPSRT), and family-focused therapy (FFT). Swartz and Swanson (2014) reviewed the literature from1995-2013 reported the advantages of psychosocial therapies in combination with medications.

 Psychoeducation (PE)

The effectiveness of psychoeducation for individuals and groups of patients consists of a number of sessions designed to provide information about the bipolar disorder, discussion to enhance understanding and support for the emotional response to the information. Psychoeducational approach would cover such topics as:

1)    Understanding the nature of bipolar disorder and necessary treatments for management to help with stability.

2)    Knowledge about signs and symptoms, recognition of risk factors and warning signs of relapse.

3)    Development of strategies to cope with stressful life events.

4)    Recognizing and developing protective factors in their lives which support treatment compliance.

5)    How to access and utilize the health care system to manage their illness and crisis situations if they occur.

Interpersonal Social Rhythm Therapy (IPSRT) IPSRT, a short term approach, helps bipolar disorder patients recognize and manage how changes in sleep and eating routines, social stimulation and other daily routines might impact symptoms associated with mood changes. The philosophy acknowledges the interrelationship between biological and social rhythms. As evidence increases that there is a biological and/or genetic basis for bipolar disorder, IPSRT promotes efforts for stability of routines and minimization of stress. With IPSRT, patients are helped to identify and track the connection between stress and their mood symptoms. By learning new interpersonal skills promoting relationships and minimizing conflicts, the patient can adjust daily routines to achieve a balance of social stimulation with adequate rest.

Cognitive Behavioral Thera py (CBT)

Cognitive behavioral therapy is based on the belief that problematic and chronic emotions can be impacted by distorted and irrational thoughts. How a patient with a bipolar disorder percei ves and thinks about a situation can affect feelings and behaviors.  CBT therapists help patients examine how their thinking patterns impact feelings and behaviors related to acknowledging the existence of their bipolar disorder, participation in the treatment plan to achieve adherence and decrease stress.

Family-Focused Therapy (FFT)

Family-focused therapy involves psychoeducation for the patient/family along with medications for the patient. Emphasis is upon communication and problem-solving skills (Miklowitz & Chung, 2016).

Encouraging patients with bipolar disorder and family member caregivers help them to manage their illness through medication compliance and a more complete understanding of the disorder.

Co-morbidities, Mortality and Bipolar Disorder Co-morbidities are common in persons with bipolar disorder. Alcohol and drug abuse, anxiety and panic attacks are not unusual. Suicide and accident rates remain high, but only partially account for the premature death rates in persons with BD.  Patients with severe mental illness often have worse physical health than the general population. The negative impact of severe mental illness on clinical outcomes of many other chronic health conditions such as cardiovascular disease, stroke, cancer, diabetes and respiratory illness is recognized (Collins, Tranter, & Irvine, 2012; Jann, 2014; Welsh & McEnany, 2015). In a blog about the physical health and mortality of patients with severe mental illness such as bipolar disorder, Insel (2011) commented about several reports that patients with chronic mental illnesses such as schizophrenia, bipolar disorder and depression lose 25 or more years of life expectancy when compared to persons without mental illness.

Implications for Nursing Care of Patients with Bipolar Disorders and Their Significant Others Nursing care of a patient and family/significant others with bipolar disorder begins with understanding the complexity and recurrent nature of this brain disorder. In a qualitative study of persons with bipolar disorder, three areas were identified: individual, family and health system challenges (Blixen, C., Perzynski, A.T., Bukach, A., Howland, M., & Sajatovic, M., 2016). By understanding bipolar disorder and the potential physical and emotional impacts on patients and those who care about them, nurses in non-psychiatric settings can respond in helpful ways. Each encounter offers opportunities to optimize the patient’s future health status. These opportunities include consideration of safety, future health, emotional support and the environment.

Safety and emotional comfort can influence decisions to seek or participate in care.

Safety

If suicidal thoughts are expressed, or not, it is important to ask the question about whether there are thoughts or plans for self-harm. All health care professionals should screen for suicide, alcohol and/or drug use in a non-judgmental and empathetic manner. Suicide risk is increased when the bipolar patient is anxious or agitated, using drugs or alcohol. Previous suicide attempts and/or a family history of suicide also increase the risk.

  • Ask the patient about suicidal
  • Ask if the patient has a plan, or the means to carry out the
  • Take immediate steps for a suicidal patient’s safety by arranging transportation to a local emergency department, as emergency hospitalization may be
  • Arrange for prompt evaluation by a mental health

Physical Health

When there is problem with substance use, there is greater risk for physical health problems. Treatment non-compliance and suicide may result from a lack of impulse control.  Screening for substance use and encouraging the patient to accept and actively participate in treatment can also be a life-saving intervention. Do not be discouraged if the patient denies substance use, refuses help or relapses.  A non-judgmental and empathetic alliance with the patient may help future decisions. Encourage psychoeducational interventions and personal journals describing mood changes and behavior that may increase insights into the negative connection between substance use and quality life.  Managing bipolar disorder and other chronic illnesses can be a difficult journey and the nurse’s expertise and support are important to overall health.

  • Encourage screenings for prevention and/or management of common health problems (e.g. heart disease or pulmonary disease, diabetes, and stroke).
  • Promote education and insights about how substances such as alcohol, nicotine and drugs may interfere with bipolar disorder-management.
  • Encourage patients with bipolar disorder to get screenings and assist them in managing any health issues found.

Emotional Support

Listening with compassion builds a trusting relationship. This may prompt a patient with bipolar disorder and his/her family or significant others to share about living with bipolar disorder. Ask about how they think their physical and psychosocial treatments are working. Request consent to discuss their care with mental health providers.

Family and significant others are a critical support system and safety net for a person living with bipolar disorder.  These caregivers may also be exhausted, feel overwhelmed, and totally alone in their efforts to provide support.  Nurses will meet family and significant others in as many ways as they will meet the patient: in crisis situations, medical health problems, or social situations. The family may contact a patient’s medical caregiver when the patient is in crisis and does not have, or has refused, on­-going mental health assistance.

  • Listen and acknowledge expressed concerns, or any concerns that may be
  • Refer to local mental health associations or crisis centers, for information and additional
  • Encourage peer support groups and/or family-to­ family

Many national organizations such as the National Alliance on Mental Illness (NAM!) and the Depression and Bipolar Support Alliance (DBSA) have local chapters for patient and family participation.  Support from others who are trying to help a loved one cope with bipolar disorder may help with practical suggestions, or the knowledge that others understand the struggles they face.

Environment

Nurses working in any health care setting can work to make the environment friendly, less intimidating and more welcoming to patients and family members living with bipolar disorder.  All people with mental illness, including bipolar disorder, are exposed to stigma in everyday aspects of their life. Stigma about mental health can make relatively simple decisions more complicated.  Applying for a job, finding housing, or making friends are just a few of the day­ to-day challenges encountered.

  • Make certain informational pamphlets, magazine and visuals in your health settings’ waiting and public areas include mental health topics, in addition to the usual physical health materials.
  • Include concerns about stigma and mental health topics for staff educational development.

Conclusion

Working with a patient with bipolar disorder and their significant others can be difficult in non-psychiatric settings, but forming an alliance with them can be life-saving or life-enriching. The benefit of helping the patient feel comfortable in accessing health care for physical and mental health screening, prevention and care may never be known by the non-psychiatric nurse. Be assured that compassionate and empathetic communication and care does impact positive outcomes. Nurses assist patients living with bipolar disorder to manage life-threatening and life-sustaining health and emotional problems, as well providing support to their significant others.

Communication and coordination of care in partnership with mental health providers impacts the quality and length of their lives. Nurses in any setting – especially non-psychiatric nurses – are in a unique position to enhance care for the person with bipolar disorder.

Figure I

Risk Factors Contributing to Poor Physical Health in a Bipolar Disorder Patient

Health Habits

  • Poor diet
  • Inadequate exercise
  • Irregular sleep patterns
  • Smoking
  • Chronic stress responses
  • Substance use

Health Care Access and Utilization

  • Social factors -isolation, homelessness, lack of insurance
  • Lack of access to preventive healthcare or a “medical home”
  • Medication side effects used for treatment
  • Feeling stigmatized as a person with a mental disorder

Health Care System

  • Inadequate care coordination for psychiatric and physical health conditions
  • Inadequate education and staff development about bipolar disorder patient care among non-psychiatric caregivers

Figure 2

Resources for Support of the Bipolar Disorder Patient and Significant Others

Depression and Bipolar Support Alliance www.dbsalliance. org

Offers information about living with bipolar disorder

and finding support groups

Mental Health America www.nmha.org

Provides fact sheets and screening tools on bipolar disorder, including local resources

National Alliance on Mental Illness (NAMI) www.nami.org

Provides fact sheets, updates of recent research and personal accounts of living with bipolar disorder.

National Institute of Mental Health www.nimh.nih.org

Up-to-date resources and the latest research about all mental illnesses: statistics on prevalence, research about etiology, and current treatments.

References

 American Psychiatric Association. (2015). Help with bipolar disorders. Retrieved from httos://www.psychiatry.org/patients-families /bipolar-disorder

Blixen, C., Perzynski, A.T., Bokach , A., Howland, M., & Sajatovic, M. (2016). Patients’ perceptions of barriers to self-managing bipolar disorder: A qualitative study. International Journal Social Psychiat1 y, 62(7 ), 635- 644.

Collins, E.E., Tranter,  S.S., & Irvine, F.F. (2012). The physical  health of the seriously mentally  ill: An overview of the literature . Journal of Psychiatric and Mental Health Nursing,  19(7), 638-646.

Cullison, S.K. & Resch, W.J. (2014). How should you use the lab to monitor patients taking a mood stabilizer?

Current Psychiatry, 13(7), 51 -55.

Diagnostic and Statistical Manual of Mental Disorders: 5th Edition . (2013). Eds. American Psychiatric Association. American Psychiatric Association Publishing.

Insel, T. (2011). No health without mental health. Retrieved from

https : //www .nimh.nih.go     /about’di rectors/thomas- i nsel/blog/2011 /no-health-withouL-mental-heal t h .  html

Jann, J.W. (2014). Diagnosis and treatment of bipolar disorders in adults: A review of the evidence on pharmacologic treatments. American Health and Drug Benefits, 7(9), 489-499.

Krans, B. & Cherney, K. (2016). The history of bipolar disorder. Retrieved from ht1p://www.healthline.com /health/bipolar-disorder /history-bip

Miklowitz, D.J. & Chung, B. (2016). Family-focused therapy for bipolar disorder: Reflections on 30 years of research. Family Process. 55( 3 ), 483-99. doi: 10.1 1 1 1/famp.12237.

National  Institutes of Health.  (2016).  Retrieved  from  hrtps://v1ww.nimh .nih.gov/heaHh/topics/bi polar-di   order Swartz, H. A. & Swanson, J. (2014). Psychotherapy  for bipolar disorder in adults: A review of lhe evidence.

Focus (American Psychiatric Publication), 12(3): 251-266. doi: 10:1176/appi.focus. 12.3.251

Welsh, E.R. & McEnany, G.P. (2015). Approaches to reduce physical comorbidity in individuals diagnosed with mental illness. Journal of Psychosocial Nursing and Mental Health Services, 53(2), 32-37.

Bipolar Disorder: Implications for Nursing Practice

  • Evaluation Were the following outcomes met? Yes or No
  • This field is for validation purposes and should be left unchanged.

Ohio Nursing Law: The Basics That Every Nurse Needs to Know

DESCRIPTION

This independent study has been developed for nurses who are new to Ohio and who must complete two contact hours of continuing education on Ohio Law and rules in order to be eligible for licensure by endorsement.

OUTCOME

The nurse will have a better understanding of Ohio Nursing Law and Rules as it pertains to their practice.

2.0 contact hours of Nursing Law and Rules (Category A) will be awarded for successful completion of this independent study.

This independent study was developed by: Jan Lanier, JD,RN. The author and members of the planning committee have no conflict of interest.

DISCLAIMER

Information in this study is intended for educational purposes only. It is not intended to provide legal and/or medical advice.

The Ohio Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation (OBN-001-91).

Expires 5/2019

Buy Now – $20

Ohio Nursing Law: The Basics Every Nurse Needs to Know – Post-Test and Evaluation

DIRECTIONS

The post-test will be reviewed. If a score of 70 percent or better is achieved, a certificate will be sent to you. If a score of 70 percent is not achieved, a letter of notification of the final score and a second post-test will be sent to you. We recommend that this independent study be reviewed prior to taking the second post-test. If a score of 70 percent is achieved on the second post-test, a certificate will be issued.

If you have any questions, please contact the Ohio Nurses Association’s CE department at info@ce4nurses.org or call 1-800-735-0056.

STUDY

This independent study is intended for the nurse who is new to Ohio who must complete two hours of continuing education on Ohio laws and rules in order to be eligible for licensure by endorsement.  (Rule 4723-7-05 (B)(4) Oh Adm. Code).  It will also provide any nurse who is practicing in Ohio a refresher course on key laws and rules regulating nursing practice.  It begins with information about the Board of Nursing, its make-up and responsibilities; and then focuses on laws and administrative rules that are likely to affect a nurse’s daily practice.

Nurses are responsible for knowing the law and rules of the state in which they are practicing.  While there may be similarities from state-to-state there are also key differences.  In addition, laws and rules change frequently and some of those changes may be significant.  So while every effort is made to ensure this study includes the most current information, if you have questions be sure to check the laws and rules via the Board of Nursing web site (www.nursing.ohio.gov).

Board of Nursing in Ohio

The Board of Nursing (Board) is a public body whose sole purpose is to protect the public, in part by ensuring its licensees and certificate holders are at least minimally competent to practice and by taking action when a licensee poses a threat to public safety.  Part of the executive branch of government, the Board’s 13 members are appointed by the governor to serve a four-year term, and they may be re-appointed for one additional term.  The eight registered nurses (RNs), two of whom must be advanced practice registered nurses (APRNs)[1]; four licensed practical nurses (LPNs); and one consumer member are charged with issuing licenses to qualified individuals, approving pre-licensure nursing education and other training programs, and taking disciplinary action when a licensee violates Section 4723.28 Ohio Revised Code (ORC). The Board meetings (held at the Board office in Columbus in January, March, May, July, September and November) are open to the public.  Meeting materials are posted on the Board’s web site immediately prior to each meeting along with specific meeting dates and times.  The 13-member Board appoints the executive director, and the executive director then names additional staff members who carry out the directives of the appointed Board members. (Section 4723.05 ORC).

The Board has authority over only the individuals it regulates.  As the largest regulatory board in the state, the Board has jurisdiction over 280,000 individuals.  That includes RNs, LPNs, APRNs, dialysis technicians, community health workers, and medication aides.  Not on that list are medical assistants, state-tested nurse aides, patient care technicians or associates, physician assistants, hospitals, nursing homes, clinics etc.

In addition to having specific responsibilities defined by the Nurse Practice Act (also known as Chapter 4723 of the Revised Code or the law regulating nursing practice) the Board also has rule making authority relative to its statutory responsibilities.  Rules of the Board can be found in Chapters 4723-1 through 4723-27 of the Ohio Administrative Code (OAC). The Board is charged with enforcing the laws enacted by the Ohio General Assembly that affect nurses and nursing practice.  Typically, the law (found in the Revised Code) sets out what is required, while the rules (found in the Administrative Code) are more detailed and describe how the requirements are met.  The rules must be consistent with the law, and once adopted the rules have the force and effect of law.  Therefore, nurses must be aware of both the law and the rules in order to make sure their practice is in keeping with all legal requirements.

TAKE AWAYS

√    The Board of Nursing was established to protect the public.

√    Laws regulating nursing practice differ from state to state.

√    The law enacted by the General Assembly is often less detailed than rules adopted by the Board of Nursing. The law tells nurses what they must do. The rules explain how the legal requirements are to be met.

√    The Ohio Board of Nursing regulates RNs, LPNs, APRNs, dialysis technicians, community health workers, and medication aides.

√      Information about the Board and Ohio nursing laws and rules can be found at the Board’s website: www.nursing.ohio.gov.

Licensing competent individuals

Requirements for licensure

In order to engage in the activities that comprise the practice of nursing in Ohio one must hold a current valid Ohio license.  (Section 4723.03 ORC).  (More about those activities later in this study).  The law in Ohio does not differentiate as to whether the individual is engaged in nursing practice for compensation or without compensation.  In other words, an individual who volunteers to provide care that would constitute the practice of nursing in Ohio may do so ONLY if holding a current valid Ohio license (unless the individual meets one of the exceptions set out in Section 4723.32 (ORC) described more fully below).

An initial license to practice nursing in Ohio may be obtained by examination or endorsement.  A license by examination is awarded to an individual who has never been licensed to practice as a nurse in any state and who has completed an approved pre-licensure nursing education program and received a passing score on the NCLEX-RN or NCLEX-PN ® examination.  The applicant must also complete a criminal records check.  (Rule 4723-7-02 OAC).  An individual who holds a current valid license to practice nursing in another state or jurisdiction may apply for licensure by endorsement.  That applicant must also complete a criminal records check.  (Rule 4723-7-05 OAC).  A nurse may be licensed simultaneously in multiple states but must meet each state’s renewal requirements to ensure that the license is considered current and valid in that location.  Only in certain circumstances (described more fully below) may a nurse who is licensed in another state engage in nursing practice in Ohio based on valid licensure held elsewhere.

An APRN license is awarded to an RN who has earned a graduate degree in a nursing specialty or related field that qualifies the individual to sit for the certification examination of a national certifying organization accepted by the Board, and who has successfully passed that certification examination.

A license is valid for a defined period of time—generally two years depending upon when the initial license is issued.  For LPNs the license must be renewed in the even-numbered years and for RNs (including APRNs) renewal is in the odd-numbered years.  Effective in 2016, licenses expire as of November 1st of the renewal year.  Renewal applications must be submitted to the Board by September 15th.  Failure to do so will subject the licensee to a late fee of $50 in addition to the renewal fee of $65 for an RN or LPN license.  APRNs must hold both an RN and APRN license. The fee for renewing the APRN license that includes prescriptive authority is $135.  The fee for initial licensure by examination or endorsement is $75 for RNs and LPNs and $150 for APRNs.   Licensure fees are set in statute (Section 4723.08 (ORC) and therefore can be changed only through legislative action.  Regulatory boards in Ohio must generate sufficient revenue to be financially self-sustaining.  That means fees collected by the Board are the sole source of revenue used to support its activities.  No taxpayer dollars are allocated.

The Board will send out a license renewal notice via the U.S. mail to remind nurses that renewal begins July 1st and to provide them the information needed to access the online renewal process.  These notices will be sent to the licensee’s last known address; and for security reasons, the notice will not be forwarded should the licensee no longer live at that address.  It is important, therefore, for nurses to keep the Board apprised of address changes.  In fact every licensee is required to give the Board written notice of a change of name or address within 30 days of the change. (Section 4723.24(B) ORC). Failure to do so could result in licensees not receiving critical information from the Board.

Licensure exceptions—Section 4723.32 ORC

Not surprisingly, with every law there are also exceptions or exemptions.  Ohio allows individuals to engage in nursing practice without an Ohio license in the following circumstances:

  • Students enrolled in and actively pursuing completion of a nursing education program, including graduate degree programs if:
    • The program is located in Ohio and approved by the Board or by another board in a jurisdiction that is a member of the National Council of State Boards of Nursing;
    • The student is acting under the auspices of the program; and
    • The student is under the supervision of an RN faculty member.
  • Individuals rendering medical assistance to licensed physicians, dentists, or podiatrists if the individual is under the direction, supervision, and control of the licensed physician, dentist, or podiatrist.
  • Individuals employed as nursing aides, attendants, orderlies, or other auxiliary workers in patient homes, hospitals, home health agencies, or similar institutions.
  • Individuals providing care to family members or in emergency situations.
  • Individuals caring for the sick when doing so in connection with the practice of religious tenets of any church by or for its members.

Section 4723.32 ORC.

These exemptions may seem broad, but all associated restrictions or limitations must be met before the exemption applies.  For example, a nursing student is allowed to engage in activities reserved to licensed nurses, such as medication administration, ONLY if the student is doing so as part of an educational program’s clinical experience.  Students who work in a health care setting outside of that nursing education program framework are considered unlicensed persons and may engage only in activities that any other unlicensed persons may perform.

Ohio also recognizes that individuals holding current valid licenses to practice nursing in a state other than Ohio may engage in certain activities in Ohio without an Ohio license.  Those activities include:

  • Discharging official duties while employed by or under contract with the United States government.
  • Transporting a patient into or out of Ohio as long as each trip does not exceed 72 hours.
  • Consulting with an individual in Ohio who is licensed to practice a health-related profession.
  • Teaching as a guest lecturer at a nursing education program, nursing continuing education, or in-services.
  • Evaluating nursing care on behalf of an accrediting organization.
  • Providing nursing care to someone who is in Ohio on a temporary basis not to exceed six months in a calendar year if the nurse is directly employed by or under contract with a person acting on the patient’s behalf.
  • Providing nursing care during an officially declared disaster.

Section 4723.32 ORC

The exemptions are intended to strike a balance so that licensure requirements do not hamper legitimate activities while still ensuring the public is protected from unsafe nursing practices.  It is important for nurses going to another state to engage in nursing practice to check that state’s licensure requirements to avoid unexpected challenges, pitfalls, and possible criminal prosecution.

Ohio law does not provide an exemption or exception from licensure for nurses practicing electronically across state lines.  Should a licensed nurse located in a state other than Ohio engage in activities that would be considered the practice of nursing in Ohio for a patient located in Ohio, the nurse would need to hold an Ohio license.  While some states have enacted the multi-state licensure compact that allows nurses in those states to practice in other compact states on a single license, Ohio is not part of the compact.

The Board has no jurisdiction or authority over unlicensed individuals who engage in nursing practice or who hold themselves out as nurses.   The only recourse the Board has is to submit its findings to a county prosecutor for possible criminal prosecution for engaging in the unauthorized practice of nursing, which is a felony.

TAKE AWAYS:

√    If practicing nursing in Ohio, an individual must be licensed by the Board to do so even if the nurse is activing in a volunteer capacity.

√    Licenses must be renewed every two years – LPNs in even-numbered years; RNs, including APRNs, in odd-numbered years.

√    Exemptions to the licensure requirement exist, but they have specific criteria, all of which must be met for the exemption to apply.

√    A state’s licensure exemptions will vary so a nurse should check a state’s practice act before engaging in practice there, even on a temporary basis. To find a link to boards of nursing in other jurisdictions, go to: www.ncsbn.org.

Protected titles

In addition to authorizing the holder to engage in the practice of nursing, the license also entitles the holder to use the titles protected under Ohio law.  Those titles include licensed practical nurse (LPN), registered nurse (RN) advanced practice registered nurse (APRN), APRN-CRNA (for a certified registered nurse anesthetist) APRN-CNS ( for a clinical nurse specialist)  APRN-CNP (for a certified nurse practitioner) and APRN-CNM (for a certified nurse midwife).  In addition, individuals may not use any other title that implies the person is authorized to practice nursing.  Examples include but are not limited to graduate nurse (GN) or trained nurse (TN). (Sections 4723.03 & 4723.44 ORC).  Using a protected title without a nursing license is a felony of the 5th degree for the first offense and a felony of the 4th degree for each subsequent offense. An RN, LPN, or APRN who uses the protected title when holding a lapsed or inactive license is guilty of a minor misdemeanor, which is a criminal offense and could lead to other disciplinary action by the Board.  (Section 4723.99 ORC).  A nurse whose license is on inactive status or has lapsed may not use the protected titles.

License preclusion

Not everyone who applies for a license to practice nursing in Ohio is eligible to receive one.   An individual who has been convicted of, pleaded guilty to, or had a judicial finding of guilt to specific criminal offenses are totally precluded from licensure in the state.   Those offenses include: aggravated murder, murder, voluntary manslaughter, felonious assault, kidnapping, rape, sexual battery, gross sexual imposition, aggravated arson, aggravated robbery, and aggravated burglary.  (Section 4723.092 ORC).  Individuals seeking an Ohio license who have been convicted or had a judicial finding of guilt relative to criminal offenses other than the ones noted above may or may not be granted a license.  In these cases, the Board will consider the circumstances surrounding the offense and will decide whether the potential licensee poses any danger to the public.  If the Board members decide to issue a license it may include restrictions that limit the job locations or positions the nurse may hold.

TAKE AWAYS

√    ONLY an individual hold a current, valid Ohio license may use the titles protected under Ohio law. Those titles include LPN, RN, and APRN. A nurse whose license has lapsed or is on inactive status may not use the licensure title.

√    An individual without a valid Ohio License to practice nursing may not use any title that leads the public to believe the individual is a nurse.

√    Engaging in the unauthorized practice of nursing is a criminal offense.

√    Licensees must notify the Board of Nursing in writing within 30 days of a change of name or address. Failure to do so could mean the nurse will not receive renewal notices or other important information from the Board.

Defining nursing practice—Scope of Practice

Because the unauthorized practice of nursing is a criminal offense, it is important for the law to define that practice so the public has notice of what is prohibited and nurses know what their license authorizes them to do.  The definition section (4723.01 ORC) of the law regulating nursing practice contains what is commonly referred to as the nurse’s “scope of practice”.  Each state defines nursing practice, but the definitions may vary from state to state.  There is no national scope of practice.  For that reason, it is important to be familiar with each state’s requirements.  Generally, the RN’s scope is more consistent between states than are the scopes of practice for LPNs and APRNs.

Because RNs, LPNs, and APRNs frequently work together, it is important to be aware of the scopes of practice for each.  It is also important to know that employers may restrict what nurses may do in their particular workplace but may not expand the legal scope of practice.  That means, for example, Ohio restricts the activities LPNs may engage in with respect to intravenous (IV) therapy.  An employer may adopt a policy that prohibits LPNs from administering any IV medications, but it may not adopt a policy that expands the LPNs’ authority in that regard beyond what is allowed by law.

Many nurses would like to have their practice more clearly defined, perhaps identifying in law specific tasks or activities that they may perform.  While that may appear to be a way to eliminate or minimize scope of practice questions, it would not allow nurses to adapt to the ever-changing technology and other advances that characterize health care today. Revisions to scope of practice language must be enacted by the legislature, which can be a long process fraught with many pitfalls and often, significant opposition.  For that reason, the definitions of practice for licensed nurses are purposefully non task-specific.

The current scope of practice for both RNs and LPNs in Ohio was defined in large part in 1988.  Before that revision, nursing practice was defined as anything nurses learned in a nursing education program.  The 1953 definition was severely limiting nursing practice so the changes made in 1988 were intended to allow more flexibility.  At that time, however, some influential interest groups believed nurses were trying to infringe on the practice of medicine so much of the definitional language adopted by the legislature reflects compromises that allowed certain emerging concepts to become part of the law.  For example, nursing diagnosis, health assessment, and nursing regimen were controversial concepts so they were defined using terminology that distinguishes the nurse’s role from that of the physician relative to these activities.

It is important that RNs understand the scope of practice for LPNs and the legal relationship between RNs and LPNs created by the scope language set out in the law.  An RN may be directing the LPN’s practice; however, directing is NOT the same as delegating.  The differences are subtle and will be discussed later in this study.

Scope of practice:  RNs

In Ohio, the practice of nursing by RNs includes five independent functions that a nurse may engage in without specific orders or directions to do so.  These activities are inherent expectations of all RNs regardless of practice location or specialty.  The independent functions include:

  • Identifying patterns of human responses to actual or potential health problems amenable to a nursing regimen;
  • Executing a nursing regimen through the selection, performance, management, and evaluation of nursing actions;
  • Assessing health status for the purpose of providing nursing care;
  • Providing health counseling and health teaching; and
  • Teaching, administering, supervising, delegating, and evaluating nursing practice

(Section 4723.01 (B) ORC)

The law goes on to define “nursing regimen” as preventative, restorative, and health promotion activities. (Section 4723.01(C) ORC).  “Assessing health status” means the collection of data through nursing assessment techniques which may include interviews, observation, and physical evaluation for purposes of providing nursing care (Section 4723.01 (D) ORC). Note the repeated use of the word “nursing” throughout the scope of practice language to make clear the individual is not engaging in the practice of medicine.  In fact, RNs and LPNs are explicitly prohibited from engaging in medical diagnosing, the prescription of medical measures and the practice of medicine or surgery or any of its branches.  (Section 4723.151 ORC).   The prohibition found in Section 4723.151 ORC does not apply to APRNs who are acting within their scope of practice.

The only dependent component of RN practice is administering medications, treatments, and executing certain medical regimens.  These activities must be authorized (ordered) by individuals authorized to practice in Ohio who are acting within their professional practice. (Section 4723.01 (B)(5) ORC).  In other words, a registered nurse may not administer medication without a valid order from an authorized individual to do so.  RNs may not prescribe, which means a medication order must be specific with respect to dosage, indications for administering the drug, time, and route of administration.  Failure to heed this limitation could result in a charge of practicing medicine without a license.

Scope of practice: LPNs

The scope of practice for LPNs includes no independent functions or activities.  An LPN must practice under the direction of a registered nurse, physician, physician assistant, dentist, podiatrist, optometrist, or chiropractor.  (Section 4723.01 (F) ORC).  “Direction” does not mean over-the-shoulder supervision. Rather, there must be someone who is communicating or has communicated a plan of care to the LPN. (Rule 4723-4-02 (B)(6) OAC). The LPN contributes to the development of the plan of care but cannot independently develop or revise it.

Nursing care provided by LPNs includes:

  • Observation, patient teaching, and care in a diversity of health care settings;
  • Contributions to the planning, implementation, and evaluation of nursing;
  • Administering medications and treatments authorized (ordered) by an individual who is authorized to practice in Ohio who is acting within their professional practice provided the LPN has successfully completed a course in basic pharmacology either in a pre-licensure education program approved by the Board or a post licensure basic pharmacology course approved by the Board (Section 4723.17 ORC);
  • Administering to an adult appropriately authorized IV therapy within the requirements set forth in Section 4723.18 ORC (described more fully below);
  • Delegating nursing tasks as directed by a registered nurse. Note: if the LPN is being directed by a non-nurse, the LPN may not delegate nursing tasks; and
  • Teaching nursing tasks to LPNs and individuals to whom the LPN is authorized to delegate nursing tasks.

(Section 4723.01 (F) ORC)The Board through its rules specifies that RNs and LPNs apply the nursing process when engaging in practice.  The process is cyclical and the nurse’s action should respond to the patient’s changing care needs.  An RN is expected to use clinical judgment in establishing and revising the patient’s nursing plan of care (Rule 4723-4-07 OAC) while LPNs contribute to the care plan, they may not act independently to develop or change it.

LPNs and IV therapy

LPNs in Ohio have very specific requirements and limitations they must adhere to with respect to IV therapy.  In order to be authorized to engage in any of the allowable activities the LPN must have completed a course in IV therapy that includes 40 hours of training approved by the Board.  The curriculum must include the anatomy and physiology of the cardiovascular system, signs and symptoms of local and systemic complications in administering IV fluids and antibiotic additives and guidelines for management of these complications.  The course must also include a testing component.

When the LPN is providing IV therapy at the direction of an RN the RN must be readily available at the site where the IV therapy will be done, and the RN must personally perform an on-site assessment of the patient who will receive the IV therapy.  LPNs my provide IV therapy only to an adult.

(Section 4723.18 ORC).

LPNs may NOT do the following with respect to IV therapy:

  • Initiate or maintain blood or blood products;
  • Initiate or maintain solutions for total parenteral nutrition;
  • Initiate or maintain cancer therapeutic medications including but not limited to chemotherapy and anti-neoplastic agents;
  • Initiate or maintain solutions administered through any central venous line or arterial line or any other line that does not terminate in a peripheral vein,
    • except that a licensed practical nurse may maintain the following solutions—dextrose 5%, normal saline, lactated ringers, sodium chloride .45%, sodium chloride 0.2 %, sterile water;
  • Administer any new investigational or experimental drug;
  • Initiate intravenous therapy in any vein, except in a vein of the hand, forearm, or antecubital fossa;
  • Discontinue a central venous, arterial, or any other line that does not terminate in a peripheral vein;
  • Initiate or discontinue a peripherally inserted central catheter;
  • Mix, prepare, or reconstitute any medication for intravenous therapy,
    • except an antibiotic additive;
  • Administer medication via the intravenous route, including all of the following activities:
    • Adding medication to an intravenous solution or to an existing infusion,
      • except the following:
        • Initiate an intravenous infusion containing one or more of the following elements: dextrose 5%, normal saline, lactated ringers, sodium chloride .45%, sodium chloride 0.2 %, sterile water;
        • Hang subsequent containers of the intravenous solutions specified above that contain vitamins or electrolytes, if a registered nurse initiated the infusion of that same intravenous solution;
        • Initiate or maintain an intravenous infusion containing an antibiotic additive;
      • Injecting medication via a direct intravenous route,
        • except heparin or normal saline to flush an intermittent infusion device or heparin lock including, but not limited to, bolus or push;
      • Change tubing on any line including, but not limited to, an arterial line or a central venous line,
        • except tubing on an intravenous line that terminates in a peripheral vein; and
      • Program or set any function of a patient controlled infusion pump.

(Section 4723.18 ORC).

To summarize that can be very confusing language, LPNs who have completed the required IV therapy course may do the following for an adult patient:

  • Change tubing on an IV line that terminates in a peripheral vein;
  • Inject IV heparin or normal saline to flush an intermittent infusion device or heparin lock including bolus or push;
  • Initiate an IV infusion containing one or more of the following dextrose 5%, normal saline, lactated ringers, sodium chloride .45%, sodium chloride 0.2%, and sterile water;
  • Hang subsequent containers of the above IV solutions that contain vitamins or electrolytes if an RN initiated the infusion of that same IV solution;
  • Initiate or maintain an IV infusion containing an antibiotic additive;
  • Use only the veins of the hand, forearm, or antecubital fossa when performing IV therapy;
  • Maintain an IV administered through any central venous or arterial line of the following solutions dextrose 5%, normal saline, lactated ringers, sodium chloride .45%, sodium chloride 0.2%, and sterile water.

“Maintain” is defined as administering or regulating an IV according to the prescribed flow rate (Rule 4723-17-01 (E) OAC).  An “adult” is defined as anyone who is 18 years of age or older.  (Rule 4723-17-01 (A) OAC).

LPNs who have NOT successfully completed the required IV therapy course may do the following regardless of the patient’s age:

  • Verify the type of peripheral intravenous solution being administered;
  • Examine a peripheral infusion site and the extremity for possible infiltration;
  • Regulate a peripheral intravenous infusion according to the prescribed flow rate;
  • Discontinue a peripheral intravenous device at the appropriate time; and
  • Perform routine dressing changes at the insertion site of a peripheral venous or arterial infusion, peripherally inserted central catheter infusion, or central venous pressure subclavian infusion. (Section 4723.181 ORC).

 TAKE AWAYS – LPNs & IV Therapy

LPNs who complete the required IV therapy course may for adults only: LPNs who have not completed the IV therapy course may regardless of the patient’s age:
Change tubing on an IV line that terminates in a peripheral vein Verify the type of peripheral IV solution being administered
Inject IV heparin or normal saline to flush an intermittent infusion device or heparin lock including bolus or push Examine a peripheral IV site and the extremity for possible infiltration
Initiate an IV infusion containing one or more of the following: dextrose 5%, normal saline, lactated ringers, sodium chloride .45%, sodium chloride 0.2%, and sterile water Regulate a peripheral IV infusion according to the prescribed flow rate
Hang subsequent containers of the above IV solutions that contain vitamins or electrolytes if an RN initiated an IV of the same solution Discontinue a peripheral IV device at the appropriate time
Initiate or maintain an IV infusion containing an antibiotic additive Perform routine dressing changes at the insertion site of a peripheral venous or arterial infusion, peripherally inserted central catheter infusion, or central venous pressure subclavian infusion
Use only the veins of the hand, forearm, or antecubital fossa when performing IV therapy
Maintain an IV administered through any central venous or arterial line of the following solutions: dextrose 5%, normal saline, lactated ringers, sodium chloride .45%, sodium chloride 0.2%, and sterile water.


Scope of practice: APRN’s

With the passage of HB 216 by the legislature in late 2016, several significant changes were enacted that affect the APRN scope of practice.  While the law continues to define APRNs as including CRNAs, CNPs, CNMs and CNSs, nurse anesthetists have significant differences from other APRNs with respect to their authorized activities.  Most notably, CRNAs do NOT have prescriptive authority and practice with physician supervision.  All other APRNs have prescriptive authority and practice in collaboration with a physician pursuant to a standard care arrangement.

The legislation also eliminated the requirement that newly licensed APRN prescribers complete an externship before obtaining a certificate to prescribe (CTP).  As April 4, 2017 the Board will issue an APRN license (rather than a certificate of authority or COA) that includes prescriptive authority.[2]

The scope of practice for all APRN specialty designations recognizes that advance practice requires knowledge and skill gained from advanced formal education, training, and clinical experience. (Section 4723.01(P) ORC). Specific scope of practice language for each APRN designation can be found in Section 4723.43 ORC.

  • Practice as a CNM includes:
    • Management of preventive services and primary care services to women antepartally, intrapartally, postpartally, and gynecologically;
    • Performing episiotomies and repairing vaginal tears.
    • A CNM may not perform version, deliver breach or facial presentations, use forceps, do any obstetrical operation or treat an abnormal condition except in an emergency. (Section 4723.43 (A) ORC).
  • Practice as a CRNA includes:
    • Administering anesthesia induction, maintenance, and emersion in the immediate presence of a physician, dentist, or podiatrist;
    • Pre-anesthesia preparation and evaluation, post anesthesia care and clinical support functions under the supervision of a physician, dentist or podiatrist.
    • The CRNA who is supervised by a dentist or podiatrist may perform only the anesthesia procedures the dentist is authorized to perform and may not administer general anesthesia in a podiatrist’s office. (Section 4723.43(B) ORC).
  • Practice as a CNP includes:
    • Prevention and primary care services;
    • Services for acute illnesses; and
    • Evaluation and promotion of patient wellness.
    • If collaborating with a podiatrist, the CNP is limited to procedures the podiatrist is authorized to perform. (Section 4723.43 (C) ORC).
  • Practice as a CNS includes:
    • Providing and managing care of individuals and groups with complex health care problems;
    • Providing health care services that promote and manage health care.
    • If collaborating with a podiatrist, the CNS is limited to procedures the podiatrist is authorized to perform. (Section 4723.43 (D) ORC).

Protecting the public in an evolving health care system

Nursing care is not static.  As technology evolves, care that may have once been considered the practice of medicine may be seen as appropriately within a nurse’s scope.  The Board recognizes the inevitability of change, and through its rules establishes factors that must be considered before a nurse provides care that is beyond basic preparation.   The nurse must:

  • Obtain education from a recognized body of knowledge;
  • Demonstrate the knowledge, skills, and ability to provide the care; and
  • Document completion of both the required education and demonstration of skills needed to safely provide the care.

The care in question must not be prohibited by any other law or rule and there must be an appropriate order to perform the tasks associated with the care.  (Rules 4723-4-03 and 4723-4-04 OAC).  An order does not, however, authorize a nurse to act outside his/her legal scope of practice.  That means an RN or LPN may not perform a surgical procedure or diagnose a medical condition even if a physician orders him/her to do so.

Because the Board’s focus is solely on public safety, it is concerned about the competency of the individuals it licenses both initially and on an ongoing basis.  In addition to knowing their scope of practice, nurses are expected to be competent practitioners of nursing.  Competent practice includes maintaining current knowledge of duties, responsibilities and accountability as well as consistent performance of all aspects of care.  This expectation is particularly important when a nurse is considering whether to engage in or perform a specific task, procedure, or activity.   The nurse must have both the knowledge needed to consistently perform the task, procedure, or activity safely and be able to recognize complications should they arise.   The nurse must also have the ability to refer or consult and provide appropriate intervention to address the complications.   (Rules 4723-4-03 (C) & 4723-4-04 (C) OAC.  Often it is the latter factor, dealing appropriately with complications, that is the most crucial issue to be considered when determining whether to engage in a particular activity.

TAKE AWAYS

√    There is no national scope of practice for nurses. Each state defines nursing practice and those definitions are the scope of a nurse’s practice when he/she is practicing in that state.

√    RNS have 5 independent activities they are allowed to engage in without need for a specific order to do so. Administering medications and performing medical treatments, however, are dependent functions and require a valid order for both RNs and LPNs.

√    LPN always must work at the direction of a physician, dentist, optometrist, podiatrist, chiropractor, registered nurse, or a physician assistant.

√    APRNs (other than CRNAs) working pursuant to the scope of practice for their particular specialty designation may diagnose and prescribe. CRNAs do not have prescriptive authority in Ohio.

√    Simply because a task or activity is within a nurse’s legal scope of practice is not enough. The nurse must also have the knowledge, skills and ability to safely perform the task in the clinical setting in which it will be performed. Safe practice means knowing how to do the task correctly and having the means to recognize complications when they arise and appropriately respond to those complications.

Delegation and Direction

Delegation

The scope of practice for nurses recognizes that delegation of certain aspects of nursing care is an independent function for RNs, and LPNs may delegate nursing tasks but only at the direction of an RN.  The Board adopted a series of rules setting out standards nurses must use when delegating these activities.  (Chapter 4723-13 OAC).  Delegation is defined as the “transfer of responsibility for performance of a selected nursing task from a licensed nurse authorized to perform the task to an individual who is not so authorized.” (Rule 4723-13-01(B) OAC). A nursing task is defined as those activities that constitute the practice of nursing including assistance with activities of daily living that are performed to maintain or improve the patient’s well-being when the patient is unable to perform that activity for him or herself.  (Rule 4723-13-01(I) OAC).  While nurses may delegate a task, that action does not absolve them of responsibility with respect to the patient’s overall care needs.  The nurse must make sure the task is performed as delegated and take action if it is not in order to make certain the patient’s safety is maintained and care needs are met.

The rules addressing delegation do not include a list of activities or tasks that can always be delegated because no task is always delegable.  Whether to delegate a task is left to the nurse’s clinical judgment based on the complexity of the task, the patient’s health status, the skill of the unlicensed person who will perform the task, and the availability of necessary resources and supervision.  (Rule 4723-13-05 OAC).  For a task to be delegable certain criteria must be met.  Those criteria include:

  • The task requires no judgment based on nursing knowledge and expertise;
  • The results of the task are reasonably predictable;
  • The task can be performed safely according to exact unchanging directions with no need to alter the standard procedures for performing the task;
  • Performance does not require repeated nursing assessments; and
  • The consequences of incorrectly performing the task are minimal and not life threatening.

Rule 4723-13-05 (D)(6) OAC.

Given the stringent criteria for defining a delegable task, the administration of medication is not generally considered delegable.  There are exceptions, however, that allow delegation to occur.  Nurses may delegate:

  • Over-the-counter topical medications applied to intact skin to improve a skin condition or provide a barrier; and
  • Over-the-counter eye drops, ear drops, suppositories, foot soak treatments and enemas.

Rule 4723-13-05 (C) OAC

An APRN may delegate medication administration to an unlicensed person if:

  • The drug is one the APRN may prescribe; and
  • The drug is not to be administered in a hospital inpatient care unit, a hospital emergency department, a free-standing emergency department, or an ambulatory surgical facility.

Section 4723.489 ORC

Ohio law explicitly authorizes unlicensed assistive personnel to administer medications in certain specific settings, for example public schools.  If a school district has established a policy that authorizes unlicensed individuals to administer medications, no nurse delegation is needed.  (Section 3313. 713 ORC).  Within specific developmental disability care sites the law allows certain medications to be administered without delegation while others require nurse delegation.  (Sections 5123.4 et. seq. ORC and Rules 5123:2-6-01 to 5123: -6-07 OAC).  If delegation is required, the nurse must act in accordance with the requirements and limitations set out in Chapter 4723-13 OAC. (Rule 4723-13-02 OAC).

Additionally, Ohio law recognizes “assistance with self administration of medications” when the activity occurs in a facility where the substantial purpose of the setting is not the provision of health care.  An unlicensed person acting without delegation may:

  • Remind the individual when to take the medication & observe to ensure the medication is taken according to directions on the container;
  • Bring the medication in its container to the individual, and if the individual is physically unable to do so, open the container; and
  • Remove the oral or topical medication from the container and if the individual is physically impaired place a dose of medication in another container and place that container to the mouth of the individual. (Rule 4723-13-02 OAC)

When a licensed nurse delegates a task, the nurse must supervise the performance of the task.  Supervision does not mean over-the-shoulder observation.  Rather it means initial and ongoing procedural guidance and evaluation.  Adequate communication regarding the nurse’s expectations is critical to successful, safe delegation.

If the substantial purpose of the setting in which the delegation is occurring is the provision of health care services, the supervision must be on-site.  However, if the purpose of the setting is other than the provision of health care, the supervision may be indirect, but the nurse must always be accessible electronically.  When not required to be on site, several factors must be considered by the nurse when making a decision regarding delegation.  Those factors include:

  • The number of individuals needing nursing care and their health status;
  • The types and number of nursing tasks being delegated; and
  • The continuity, dependability, and reliability of the unlicensed individual.

If the license nurse is responsible for more than one site, the distance and accessibility of each setting and any unusual problems that may be encountered must also be considered, as must the availability of emergency aid if needed.

Rule 4723-13-07 OAC.

Direction

LPNs work at the direction of RNs, which means the RN communicates a plan of care to the LPN.  (Rule 4723-4-01 (B) (6) OAC).   When directing an LPN the RN must assess:

  • The condition of the patient, including the patient’s stability;
  • The type of care the patient requires;
  • The complexity and frequency of the nursing care needed; and
  • The training, skill, and ability of the LPN being directed.

Rule 4723-4-03 (K) OAC

TAKE AWAYS

√    The scope of practice recognizes that delegation is an independent function for RNs.

√    LPNs may delegate to an unlicensed person and must delegate according to standards established by the Board. A physician, dentist, podiatrist, chiropractor, optometrist, and physician assistant may not direct the LPN to delegate nursing care. Only the RN may do so.

√    The delegating nurse remains responsible for the overall outcome when a task is performed by an unlicensed person.

√    Medication administration is not, typically, a delegable task for RNs and LPNs; however, APRNs may delegate the administration of mediations in certain non-hospital settings.

Maintaining a license

Consistent with its obligation to protect the public from unsafe nursing practice, the law authorizes the Board to establish criteria, including continuing education requirements, licensees must meet to renew a license.  The Board also is authorized to revoke, suspend, or restrict a license should it find a licensee has engaged in activities that constitute a violation of certain provisions of law set out in Section 4723.28 ORC.  These activities are intended to help the Board ensure the ongoing competency and safe practice of its licensees. 

Continuing education

In order to be eligible to renew a nursing license in Ohio (EXCEPT the first renewal following initial licensure by examination) the licensee must complete 24 hours of continuing nursing education (CE), one hour of which must be directly related to the laws and rules pertaining to the practice of nursing in Ohio, so-called Category A continuing education.  (Section 4723.24 ORC).  Effective April 4, 2017 APRNs must obtain an additional 24 hours of continuing education to renew an APRN license and 12 of those hours must include advanced pharmacology. (Section 4723.24 ORC).   If a nurse completes more than the required 24 (or 48) hours during a renewal cycle those additional hours may NOT be applied to future renewal periods.  Continuing education requirements are described in more detail in Board rules found in Chapter 4723-14 (OAC).  A licensee may also use a one-time only waiver to renew a license without obtaining the requisite continuing education.  The waiver request must be submitted in writing and once requested it may not be withdrawn.  Once that waiver option is used it may never be used again. (Rule 4723-14-03 (G) OAC).

Ohio accepts, for continuing education purposes, both independent studies as well as faculty-directed activities.  In fact, nurses may rely on independent studies to satisfy all hours of the CE requirement if they choose to do so.  Regardless of the format of the study or activity, the nurse must maintain documentation or verification of completion of the CE that is issued by the CE provider.  The nurse must retain this documentation for six years or three renewal cycles.

As part of the renewal process, the nurse will be asked to attest to having met the CE requirement, and the Board may ask the nurse to verify that the attestation is accurate.  When this CE audit is conducted, the nurse must provide the requested documentation—the relevant CE certificates.  Failure to do so before November 1st will result in a lapsed license.  (Rule 4723-14-03 OAC).  If a license is lapsed or on inactive status for more than two years, the nurse must complete 24 hours of prescribed CE that includes the following content:

  • Two contact hours on scope of practice, standards of safe practice, and delegation;
  • Six contact hours addressing the nursing process and critical thinking, clinical reasoning, or nursing judgment related to patient care;
  • Six contact hours in pharmacology, drug classification, medication errors, and patient safety;
  • Two contact hours related to clinical or organizational ethics; and
  • Eight contact hours related to the nurse’s particular practice.

Rule 4723-14-03 OAC.

Individuals taking college courses may apply the credit hours earned in those courses to satisfy the CE requirement.  One credit hour earned in an academic semester is equivalent to 15 contact hours of CE; one credit hour earned in a quarter system is equivalent to 10 contact hours; and one credit hour earned in a trimester system is equivalent to 12 contact hours.  (Rule 4723-14-04 OAC).  However, if the college course work does not include the content required to meet the Category A law and rules requirement, the nurse would need to obtain that hour through an approved continuing education program designated as a Category A presentation.

Although Ohio is fairly generous in its determination of what constitutes acceptable continuing nursing education, there are specific exceptions to that flexibility.  The following activities cannot be used to satisfy the 24 hours of CE required for license renewal:

  • Repetition of an activity with identical content and outcomes within a single reporting period;
  • Self-directed learning such as reading texts or journal articles not approved as an independent study;
  • Participation in clinical practice or research;
  • Personal development activities;
  • Professional meetings or conventions except for portions designated as CE
  • Community service or volunteer practice;
  • Membership in professional organizations; and
  • CE ordered by the Board as a result of disciplinary action.

Rule 4723-14-05 (OAC).

Taking disciplinary action to protect the public

The Board may take disciplinary action when a nurse (or other individual under the Board’s jurisdiction) violates specific provisions found in Section 4723.28 ORC. If an action or inaction is not included in that section of law, the Board cannot act.   That same section of law also defines the processes the Board must use when it proposes to take the allowed action.   The Board must provide the accused individual due process, which includes notice of the allegations and an opportunity for the accused individual to tell his/her side of the story.  Just like other judicial or quasi-judicial proceedings, the Board must prove the charges, in other words, the nurse is “innocent until proven otherwise”, but the Board’s burden of proof is comparatively light; a preponderance of the evidence standard, rather than the beyond a reasonable doubt standard that is typically seen in criminal cases.

The Board relies generally on its complaint process as the basis for its disciplinary activities.  In other words, the Board does not typically initiate an investigation unless it has received information in the form of a complaint that describes what the regulated individual did or did not do that would be considered a violation of Section 4723.28 ORC.  All complaints are confidential and must be investigated by Board staff, who are trained investigators.   Nurses have the right to have an attorney represent them in these proceedings with the processes for doing so set out in Chapter 4723-16 of the Ohio Administrative Code.  Once an investigation has been completed by Board staff, a decision is made as to whether the charges constitute a violation of Section 4723.28 ORC and whether there is sufficient evidence to support the allegation.   Board members then decide whether to proceed to adjudicate the case.  At this point the case becomes public information, and the nurse is notified regarding his/her right to request a formal hearing.

Because felonies and certain misdemeanor criminal convictions, a plea of no contest to, or treatment in lieu of conviction are the grounds for Board action under Section 4723.28, county prosecutors are required by law to report these judicial outcomes to the Board.  In addition, employers are required to report to the Board any current or former employees whose conduct would be grounds for disciplinary action under the law.   (Section 4723.34 ORC) Individual nurses, however, are not mandated by law to report to the Board.  Any person who reports to the Board in good faith is immune from liability and other adverse actions. (Section 4723. 341 ORC).

In addition to convictions or adjudicatory action related to felonies, misdemeanors in the course of practice and crimes involving moral turpitude, Section 4723.28 ORC includes in part the following as grounds for the Board to take disciplinary action:

  • Impairment in the ability to practice according to acceptable prevailing standards of safe care due to:
    • Use of drugs, alcohol, or other chemical substances;
    • Habitual or excessive use of controlled substances or other habit forming drugs, alcohol, or other chemical substances;
    • Physical or mental disability;
  • Failure to practice in accordance with acceptable and prevailing standards of safe nursing care. (Those standards are found in Chapter 4723-4 OAC and address both competency and patient safety considerations);
  • Engaging in activities that exceed one’s scope of practice;
  • Aiding and abetting in the unlicensed practice of nursing;
  • Taking into the body any dangerous drug not in accordance with a legal valid prescription;
  • Selling, giving away, or administering drugs for other than legitimate therapeutic purposes;
  • Failure to use universal and standard precautions;
  • Assaulting or causing harm to a patient or depriving a patient of the means to summon assistance;
  • Failure to establish and maintain professional boundaries;
  • Engaging in sexual contact or verbal behavior that is sexually demeaning with a patient;
  • Misappropriation of anything of value in the course of practice; and
  • Action taken by another regulatory board.

(It is important to note that this is only a partial list of grounds for Board disciplinary action). 

TAKE AWAYS

√    The Board can take action that could revoke, suspend, restrict or otherwise limit a nurse’s license to practice nursing.

√    A nurse has a right to be notified of the charges against him/her and to have an opportunity to offer a defense-due process rights. The nurse may also be represented by legal counsel.

√    The Board, typically, learns of alleged violations of Section 4723.28 ORC from complains filed with the Board. All complaints are confidential until the Board completes its investigation and believes it has reason to believe it can prove the charge. At that point, the case becomes public information.

Acceptable Standards of Safe & Effective Nursing Practice

Acceptable standards include (in part):

·         Timely implementation of an authorized practitioner’s order unless the nurse believes the order is inaccurate, not properly authorized, not current or valid, harmful or potentially harmful, or contradicted.

o   If a nurse believes an order is not appropriate, he/she must clarify the order.

o   If after clarification the nurse determines not to implement the order, that determination must be documented accurately and in a timely manner and the nurse must act to assure the patient’s safety.

·         Maintaining patient confidentiality.

·         Displaying title or licensure initials when providing direct patient care, including when practicing via telecommunication.

·         Documenting accurately, timely, and completely nursing assessments or observations, the care provided by the nurse, and the patient’s response to that care.

·         Accurately and in a timely manner, reporting errors or deviations from a current valid order.

·         Providing a safe environment.

·         Providing privacy during examination and treatment.

·         Treating each patient with courtesy, respect, and with full recognition of the patient’s dignity and individuality.

·         Establishing & maintaining professional boundaries with a patient.

·         Not falsifying any patient records or other documents prepared or utilized in the course of or in conjunction with nursing practice.

·         Not engaging in physical, verbal, mental, or emotional abuse.

·         Not misappropriating a patient’s property or seeking or obtaining personal gain at the patient’s expense.

·         Not becoming in appropriately involved in a patient’s personal relationships or financial matters.

·         Not engaging in sexual conduct with a patient or verbal behavior that is seductive or sexually demeaning to a patient.

Rule 4723-4-06 OAC.

Nurses are responsible for knowing when changes occur to the laws and rules governing their practice.  One way to stay informed is by going to the Board’s web page (www.nursing.ohio.gov) and subscribing to e-news.

Conclusion

Licensed nurses by virtue of holding a current valid license are allowed to touch people physically and emotionally in ways others may not.  That authority is a privilege and carries with it an obligation to engage in nursing practice safely and in accordance with all relevant laws and rules.  The Board of Nursing is charged with protecting the public from the unsafe practice of nursing.  That responsibility includes the adoption of rules that enable the Board to enforce the law effectively.  Nurses must know both the law and the rules governing their practice and keep up with changes as they occur.  The Board’s web site (www.nursing.ohio.gov) has many resources licensees may find useful in helping them decipher some of the more complex aspects of nursing practice including the regulations they must follow.   In addition, professional associations such as the Ohio Nurses Association and the Ohio Association of Advanced Practice Nurses are excellent resources for nurses who may have questions or concerns.  Safe practice is a goal for everyone, regulators and nurses alike.  Knowing the rules and practicing in accordance with them is an important component of safe practice, especially in today’s complex health care environment.

[1] HB 216 effective April 4, 2017 increased the number of APRNs on the Board from one to two.

[2] APRNs holding a COA and CTP will receive the APRN license during the regular RN/APRN renewal process in late 2017.  APRNs who did not previously hold a CTP must now satisfy specific educational requirements with respect to an advanced pharmacology course in order to receive an APRN license (and use the protected titles).

Ohio Nursing Law: The basics that every nurse needs to know

  • Evaluation Were you able to achieve the following outcomes? Yes or No