About

Introduction   

As long as there have been human societies, and likely far earlier, there has been some care for the ill, injured, and infirmed (1). In the United States’ relatively brief history, nursing has been established as a profession since its earliest days, with evidence of formal education appearing in 1798 (2). Professional nursing in the U.S. likely began in earnest after the Civil War in the 1870s when multiple “Nightingale schools” emerged in New York, Connecticut, and Massachusetts (2). As nursing education was in its nascent stages, two professional organizations were formed to help regulate the profession: the American Society of Superintendents of Training for Nurses (later renamed the National League of Nursing Education) and the Associated Alumnae of the United States (which became the American Nurses Association) (2).  

Though the nursing scope of practice was largely undefined and unregulated for many decades, World War I demanded competent, diverse nursing care, prompting specialization and further regulation of the profession (2). Nurses served in civilian and military capacities at this time, which was again necessary during World War II. After these wars, debate broke out on whether nursing education should be carried out from within hospital training programs or in institutions of higher learning (2). Once the model shifted to the collegiate model, the following discussion was whether associate or bachelor’s degree programs were best suited for good patient outcomes; this topic continues into the modern day, where approximately 72% of American RNs have a baccalaureate or higher degree in nursing (2, 3).  

In the 21st century, people around the world are generally living longer than ever before, often with a myriad of comorbid conditions and the need for complex care. It requires a strong workforce of healthcare professionals to assist its aging or ailing population. In the U.S., the most significant workforce component is nurses, who provide the majority of hospital-based patient care and most of the nation’s long-term care (3). There are almost 5 million registered nurses, 89% of whom are employed in nursing (3). The U.S. federal government predicts that each year through 2031, over 200,000 new registered nurse positions will be created in the country (3). Thus, nurses must be well-trained, with their scopes and standards of practice clearly defined, to best serve patients.  

It is with these ideas in mind that the National Council of State Boards of Nursing (NCSBN) was formed in 1978, with its mission statement as follows: “NCSBN empowers and supports nursing regulators in their mandate to protect the public” (4). The NCSBN also created criterion-referenced scoring for the National Council Licensure Examination (NCLEX) in 1981. It adopted its first model, the Nurse Practice Act in 1982 with the Act and Administrative Rules formally published in 1983 (5). Other milestones discussed below are the Nurse Licensure Compact, which the NCSBN adopted in 1997, and measures for safety and standards, such as the Nursys database (national database providing direct data from various boards of nursing), which the NCSBN adopted in 1999 and launched in 2000 (5).  

Finally, the Nurse Practice Act (NPA) is a statutory law that helps define and regulate the profession of nursing; it pertains to nursing licensure, disciplinary actions, and license revocation (6, 7). Each state has an NPA, so it is important for every nurse, whether a licensed practical nurse (LPN), licensed vocational nurse (LVN), registered nurse (RN), or advanced practice registered nurse (APRN), to know what their state’s act entails. Most boards of nursing state that ignorance of the law is no excuse for non-compliance and substandard nursing practice (7).  

Nursing Regulatory Bodies  

Nursing Regulatory Bodies, or NRBs, are U.S. governmental agencies regulating nursing practice. There are 59 NRBs in the U.S. and its territories; all of these NRBs are members of the NCSBN (6). The NRB is the Ohio Board of Nursing in Ohio, also known as the OBN. Functions of NRBs include, but are not limited to (6):  

• Outlining standards for safe nursing care 

• Issuing licenses to engage in the practice of nursing 

• Monitoring the compliance of licensees with relevant laws 

The Nurse Practice Act 

As stated above, each state and U.S. territory has its own Nurse Practice Act (NPA). These laws govern all levels of nursing practice, including LPN/LVN, RN, and APRN (6, 7). The NPAs are used for guidance into action; each state interprets the laws defined in the NPA into regulations, with the power to regulate nursing practice and enforce the rules (7). Each state’s board of nursing (BON) regulates its individual NPA (7).  

The goal of NPAs is to protect the general public from health practitioners who may harm their patients or who might jeopardize the safety and well-being of the citizens within the jurisdiction of the state board of nursing (7). Only the BON has the authority to discipline a nurse who may be a danger to the public (7). 

Practical functions of NPAs generally include (7):  

• Providing Nursing Practice Standards 

• Establishing a code of conduct for nurses 

• Defining the nursing scope of practice for each type of nurse  

• Establishing qualifications for initial nursing licensure and maintaining licensure throughout the nurse’s career 

• Ensuring the right to due process for any nurse who has a complaint brought against them 

• Establishing laws and rules regarding the Nurse Licensure Compact (NLC) 

Ohio Administrative Code (OAC) and the Ohio Board of Nursing (OBN)  

In the State of Ohio, the Ohio Board of Nursing (OBN) is the government agency that regulates the practice of nursing in the state with the ultimate goal of public safety (8). Based on the Ohio Nurse Practice Act, the OBN adopts rules that establish (8):  

• Pre-licensure nursing education 

• Regulations for licensure and certification 

• Standards of practice 

• Discipline against a license 

These rules are found in Chapters 4723-1 through 4723-27 of the Ohio Administrative Code (OAC) (8, 9).  

These 19 chapters encompass a plethora of topics, not all of which will be discussed here as they are beyond the scope of this Ohio Nurse Practice Act course. The content relevant to this course discuss some of the following (9): 

• Chapter 4723-4-03: Standards of Practice for RNs  

• Chapter 4723-4-06: Standards of Nursing Practice Promoting Patient Safety
  

Please refer to OAC Chapters 4723-3 and 4723-4-01 (9) for general information and definitions.  

Standards of Practice and Application of Nursing Process 

Despite the similar-sounding terms, there is a distinction to be made between scope of practice and standard of practice. In general, scope of practice can be defined as the skills a competent healthcare professional can perform according to the terms of their nursing license (11). The scope of nursing practice in Ohio is defined and set in the Ohio Revised Code (ORC) and is not discussed at length here (10). 

The scope of practice varies slightly from the standard of practice, which includes the legal aspect of providing nursing care; multiple organizations set these standards to assure safe, competent care to the general public (11). Expressly, standards of nursing care are set by the American Nursing Association (ANA), each state’s Nurse Practice Act, and several other federal regulators and nursing organizations (11). 

Arguably, one of the most essential functions of the Nurse Practice Act, in its application to Ohio nurses, is the definition of standards of practice for all three types of nursing licenses in the state: LPNs, RNs, and APRNs. These also include the minimal standards for safe, effective nursing practice in any setting. Below is more information about nurses’ training standards in the State of Ohio.   

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OAC 4723-4: Standards of Practice Relative to Registered Nurse  

As mentioned above, there are three types of nurses licensed and employed in Ohio: Licensed practical nurses (LPNs), registered nurses (RNs), and advanced practice registered nurses (APRNs). There are also unlicensed personnel, like state-tested nursing assistants (STNAs) and certified nursing assistants (CNAs). Part of the function of the Nurse Practice Act is to help differentiate what standards of practice fall under these distinctions and who may delegate what tasks to whom.  

The rules for nursing care are outlined in great detail in the Ohio Administrative Code (OAC) Rule 4723: Board of Nursing, and further exemplified in the Ohio Revised Code (ORC), Chapter 4723: Nurses (9, 10).  

General and specific standards of practice for RNs and LPNs are covered in OAC Chapter 4723-4: Standards of Practice Relative to Registered Nurses or Licensed Practical Nurses (12). Rule 4723-4-03 specifically refers to Standards relating to competent practice as an RN and includes the following (13, 14). 

Registered nurses (RNs) in Ohio shall: 

• Provide nursing care within the scope of practice outlined in ORC Section 4723.01, section (B) 

• Keep current on knowledge of duties, responsibilities, and accountabilities for safe nursing practice 

• Demonstrate accountability and competence in all areas in which the nurse practices 

RNs may also provide nursing care beyond basic RN preparation if the nurse: 

• Has received education from an accredited body of knowledge that is directly related to the care to be provided 

• Has the proper knowledge, skills, and abilities to provide the care  

• Maintains proper documentation 

• Has the necessary orders under division (B)(5) of section 4723.01 of the ORC 

• Ensures the care does not involve anything otherwise prohibited by another law or rule 

Other essential parts of the RN standards of care in Rule 4723-4-03 of the OAC include the following (13): 

• RNs should carry out orders for patients promptly unless the nurse believes the order to be unsafe, unauthorized, erroneous, not current, potentially harmful to the patient, or otherwise contraindicated.  

• In cases where the RN questions part of the order, the RN should clarify the order with the prescriber. The RN must also notify the provider that the order was not carried out as written and then document this notification in the electronic health record, explaining why the order still needs to be completed.  

• The RN should consult with other nurses and healthcare team members as quickly as possible to coordinate patient care whenever necessary.  

• At all times, the RN must protect patient information confidentiality.  

• The RN may disclose identifiable patient healthcare information only with written consent and in limited circumstances.  

• The RN will use acceptable standards of safe nursing care whenever they observe, advise, instruct, teach, or evaluate patients.  

• When the RN provides direction (delegates) to an LPN, the RN first needs to assess:  

• The patient’s condition and stability 

• The type of nursing care the patient needs 

• How complex the level of care is, and how frequently it is needed 

• The LPN’s level of training, skill, and ability to perform the procedure or function  

• The accessibility and availability of the resources required to perform the procedure of function in a safe manner 

Considerations for Registered Nurses Delegating to Licensed Practical Nurses 

In Ohio, one of the most significant differences between the standards and scopes of practice of LPNs and RNs is administering intravenous (IV) drugs, blood products, and central line care. According to Ohio Administrative Code (OAC) Rule 4723-4-02, LPNs may not perform any of the following tasks (15): 

• Initiating or maintaining these IV treatments:  

• Blood or blood products 

• Cancer medications, including chemotherapy, anti-neoplastic agents, and others 

• Solutions for total parenteral nutrition (TPN) 

• Experimental or investigational medications  

• Discontinuing an arterial or central venous line or changing the tubing on these lines  

• Changing an intermittent infusion device unless the tip of the connected IV catheter ends in a peripheral vein 

• Programming or setting any functions on a patient-controlled analgesia (PCA) pump 

With some exceptions, LPNs may also not do the following (15): 

• Initiate solutions through central venous lines or arterial lines  

• Exception: Rule 4723-4-02, (B)(1): An LPN may perform these procedures for adult patients (who are 18 or older), and only when they are directed to do so by an RN, physician, physician assistant (PA), podiatrist, optometrist, or dentist. The LPN may then administer the following solutions, or a combination thereof, through a venous line: D5W, D5LR, D5NS, 0.45% NaCl and water, 0.2% NaCl and water, and 0.3% NaCl and water. 

• Exception: Rule 4723-4-02, (B)(2): After an RN has initiated the first infusion of a solution above, which also contains vitamins or electrolytes, the LPN may continue subsequent administrations 

• Initiate or maintain an IV piggyback (secondary) infusion  

• Exception: Rule 4723-4-02, (B)(3): An LPN may initiate or maintain an intermittent or secondary (piggyback) IV infusion containing an antibiotic 

• Mix, reconstitute, or prepare any medication for IV therapy  

• Exception: Rule 473-4-02, (B)(4): An LPN may reconstitute or prepare an antibiotic additive to be given through an IV infusion 

• Inject medications by a direct IV route (IV push) 

• Exception: Rule 473-4-02, (B)(4): An LPN may flush an intermittent IV device or heparin lock with either heparin or normal saline 

General exceptions to the above limitations involve the direction of an RN, physician, PA, optometrist, or dentist, provided the patient is 18 or older (15). According to Rule 4723-4-02, paragraphs (B) and (C), the following criteria must also be met if the LPN is to perform the duties listed above (15):  

• The LPN is directed to perform IV therapy by a licensed physician, PA, dentist, optometrist, or podiatrist, who must be readily available where the IV procedure or treatment is to occur. 

• The RN must first perform an in-person, on-site assessment of the patient receiving the IV therapy.  

• The RN must also be physically present during the IV procedure or therapy.  

• If the IV therapy is to be performed in an alternative setting, such as a patient’s home or intermediate care facility, the RN who directs the LPN to perform the IV treatment must be available in person or by telecommunication.  

Additionally, if the above four criteria are met, LPNs may also do the following (15):  

• Place an IV catheter 3 inches long or less into the hand, forearm, or antecubital space, then place a saline or heparin lock. The purpose of this must include intermittent IV infusions or initiating infusions listed above.  

• Stop an infusion of blood, blood components, or PCA devices when a complication arises.  

Case Study 

You are an RN practicing on a busy inpatient med/surg floor at an Ohio hospital, and you are sharing part of a patient assignment with an LPN. You and the LPN each have three unique patients caring for two more together. You have worked with the LPN before and have found her to be conscientious, hard-working, and competent with the skills in her standard and scope of practice. She asks questions when unsure what to do and is keen to notice when a patient’s status declines. You have personally supervised her twice when she inserted peripheral IVs into patients and have noted her particular care and diligence with this task.  

One of the LPN’s patients had a peripheral IV in their left antecubital fossa, but the access was lost when the patient pulled the line out by accident. The patient now requires both a peripheral and central line for blood sampling, IV fluid boluses, blood products, and IV antibiotics due to a deteriorating condition. During the shift, the patient has current and appropriate orders for the following:  

• Insert two peripheral IVs, at least 20-gauge  

• Two units of packed red blood cells (PRBCs) due to a hemoglobin level of 5.4 g/dL 

• Stat complete blood count (CBC), type and crossmatch, comprehensive metabolic panel (CMP), and lactate 

• Repeat CBC 1 hour after the second unit of PRBCs is infused  

• 1 liter bolus of normal saline over 1 hour 

• Maintenance fluids (normal saline) at 125 mL/hour 

• 1 gram ceftriaxone, IVPB (IV piggyback), over 30 minutes, every 12 hours 

With the information given above: 

• How would you prioritize the orders, ensuring good nursing practice and patient safety?  

• Which of the above tasks can you, the RN, legally delegate to the LPN?  

• What conditions need to be met for the LPN to complete the tasks you assigned to her?  

• What are your responsibilities for your delegation?  

• What else can the LPN do to assist you with the eight patients for which the two of you are responsible?  

In addition to all the rules above, OAC 4723-4 also has standards of competent practice as they relate to LPNs and APRNs, including, but not limited to, certified nurse-midwives, certified nurse practitioners, certified registered nurse anesthetists, and clinical nurse specialists (12).  

OAC 4723-4-06: Standards of Nursing Practice Promoting Patient Safety 

Another component of the Ohio Administrative Code (OAC) is the standards of nursing practice as they pertain to patient safety. Some of these rules also include codes of conduct to which all nurses in the State of Ohio are expected to adhere. The specifics are outlined in OAC Rule 4723-4-06 (16).  

Some pertinent pieces of these standards include the following (16):  

• When providing direct patient care, the nurse must display their relevant credentials. This pertains to LPNs, RNs, and APRNs. This includes both in-person and telehealth visits.  

• Nursing task delegation, including medication administration, must be done only in accordance with the relevant sections of Chapter 4723 of the OAC.  

• Nursing documentation should be performed in an accurate, timely manner and include the following:  

• Nursing assessments or observations 

• Care provided for the patient by the nurse 

• Patient’s response to care 

• Any errors or deviations in performing current, valid orders from practitioner orders 

• The nurse must be honest and never falsify or conceal documentation related to nursing and billing services that they complete. 

• All licensed nurses will actively facilitate and promote safe environments for each patient while maintaining professional boundaries.  

• Each patient shall be provided privacy during examination and personal care and treated with respect, courtesy, and dignity.  

• A licensed nurse must not:  

• Participate in any physical, verbal, mental, or emotional abuse of a patient 

• Misappropriate a patient’s property 

• Engage in any sexual conduct with a patient, even if the patient gives consent  

• Make any false, misleading, or deceptive statements to the OBN, current or prospective employers, other members of the patient’s healthcare team, or law enforcement personnel.  

The National Licensure Compact 

In 1997, the National Council of State Boards of Nursing (NCSBN) adopted the National Licensure Compact (NLC) to increase “access to care while maintaining public protection at the state level” (5, 17). The NLC allows nurses to practice in member states without needing additional licenses. Currently, the NLC only pertains to RN and LPN licenses, but a separate APRN compact is gaining momentum in the U.S. (18). At the time of writing, 42 jurisdictions are part of the NLC; 7 will be involved in the APRN compact once the legislation is enacted (17, 18).  

Utah was the first state to adopt the NLC in 2000, and Ohio joined in 2021, which went into full effect on January 1, 2023 (5, 19). This means Ohio RNs and LPNs can now apply for a multistate, or compact, nursing license. Though brief, the OAC’s Chapter 4723-11 addresses fees and employer obligations related to the NLC (20).  

Converting an Ohio license to a multistate license (MSL) is simple and includes a one-time fee of $100; the steps are laid out on the Ohio Board of Nursing website (20, 21).   

Another part of the NLC is its adoption of nurses to coordinate nursing licenses and verify licensure and discipline taken against them (5). Nursys aims to promote safe nursing care by allowing public access to its database since 2003 (5).  

Conclusion  

With its intricate history, nursing has evolved to a very high level of specification and regulation. In the United States, many governing bodies are concerned with the rules and laws about nursing; these include the National Council of State Boards of Nursing and each state member, along with a host of other organizations.  

While it might seem confusing at first to sort through all the legalese regarding one’s nursing license, it is essential for each nurse to know their expectations and standards of practice. This knowledge protects not only the nurse’s license but also each patient’s safety and well-being. With a standardized set of rules and definitions, nurses and the general public can better understand what is and is not involved with good nursing care.  

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