Ohio Nursing Law One contact hour

Transcription

1 Ohio Nursing Law 2011 One contact hour This continuing nursing education activity was approved by the Ohio Nurses Association (OBN ), an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. Approval valid through May 13, Assigned ONA #15,009-I. Underlined language in this course indicates rule changes that became effective since Spring Anderson Continuing Education 3246 Ramos Circle, Suite A P.O. Box Sacramento, CA Phone 1 (800) Fax 1 (916) hello@andersonce.com Web site:

2 Ohio Nursing Law 2011 by Robert D. Anderson, J.D.

3 Copyright 2011 Anderson Continuing Education. All rights reserved. Anderson Continuing Education P.O. Box Sacramento, California Phone 1 (800) Fax 1 (916) or hello@andersonce.com Website: andersonce.com ii

4 Table of Contents Introductory Note... iv 1. The Practice of Nursing Advanced Practice Nursing Standards of Safe Nursing Practice for Registered Nurses and Licensed Practical Nurses Dialysis Technicians Delegation by Licensed Nurses Prevention of Disease Transmission Endnotes iii

5 Introductory Note The State Legislature passed a law in 2001 changing the continuing education requirements by adding a law which states: Of the hours of continuing nursing education completed in any renewal period, at least one hour of the education must be directly related to the statutes and rules pertaining to the practice of nursing in this state. 1 The Board of Nursing regulation concerning this requirement states as follows: On or after September 1, 2001 for registered nurses, and on or after September 1, 2002 for licensed practical nurses, and for every renewal period thereafter,..., at least one of the required hours of continuing education shall be in category A continuing education. 2 According to the Board s regulations, Category A is continuing education that explains the laws and rules of the Ohio Board of Nursing (found in Chapter 4723, of the Revised Code and the rules of the Ohio Board of Nursing as set forth in Rule , OAC). Any Category A obtained after February 1, 2009 must be approved by an OBN approver, or offered by an OBN approved provider unit that is headquartered in the state of Ohio. 3 The purpose of this course is to meet this requirement. It should be noted that this course may require more than one contact hour to complete. Because of the many Ohio laws regulating nurses scope of practice and the extensive regulations of the BON, it is not possible to make it shorter and adequately cover the subject. This course uses basic legal terms, such as statute or rule. It is necessary to define them in order to understand the legal environment within which a nurse functions. A statute is a federal or state law dealing with a specific situation. The State Legislature, for example, has enacted statutes requiring the reporting of child abuse. A rule has been adopted by a state regulatory agency, such as the Ohio Board of Nursing (BON). The State Legislature gives state regulatory agencies the power to adopt rules because statutes are often very general in wording. The purpose of a rule is to make a statute more specific and workable. For example, a statute authorizes the BON to discipline any licensed nurse for Afailure to practice in accordance with acceptable and prevailing standards of safe nursing care.@ Because this statute is very broad, BON rules establish such standards in great detail, discussed below. 1 Some people assume that rules are less significant than statutes because statutes are enacted by the U.S. Congress or the State Legislature, whereas rules are adopted by state agencies. This is not so. Rules have the same force and effect as statutes; violating a rule is just as serious as violating a statute. For example, for a violation of its rules, the BON may take action against a nurse=s license or impose a fine of up to $ The laws and rules are available on the Board s website at iv

6 1. The Practice of Nursing In order to understand the laws regulating nursing practice, it is necessary first to understand that the legal definition of the practice of medicine is so broad that physicians have the only unlimited license in the health care field, allowing them to practice any health care profession, including dentistry, optometry or nursing. All other health care professionals have limited licenses that allow them to perform only those functions and procedures authorized by their particular licenses. This concept is reiterated by a statute in the laws regulating nursing, which states: Medical diagnosis, prescription of medical measures, and the practice of medicine or surgery or any of its branches by a nurse are prohibited. 5 Registered nurses (RNs) and licensed practical nurses (LPNs) who perform functions and procedures beyond those authorized by the statutes defining their scope of practice are subject to criminal prosecution for the unlicensed practice of medicine. An LPN who sutured a wound, for example, would be subject to potential criminal prosecution for the unlicensed practice of medicine. In addition, the LPN could be subject to disciplinary action against her license by the BON or a $500 fine for engaging in activities not authorized by his or her license. One of the grounds for discipline against an LPN license is engaging in activities that exceed the practice of nursing as a licensed practical nurse. 6 Furthermore, if the LPN s suturing caused the patient damages, such as permanent nerve damage, and he or she were sued, the LPN would also be presumed negligent under a legal concept called negligence per se, which means that anyone who violates the law is presumed negligent. Once an individual is presumed negligent because he or she is in violation of the law, the burden of proof shifts to that individual to prove he or she was not negligent, a very difficult task. Such a case would almost invariably be settled before trial in the patient s favor because the nurse would have a very weak defense. Obviously, it is important for a nurse to know what functions and procedures he or she may perform as well as the scope of practice of his or her subordinates. The Practice of Registered Nursing The practice of registered nursing is defined as providing nursing care requiring specialized knowledge, judgment, and skill derived from principles of biological, physical, behavioral, social, and nursing sciences. Such nursing care includes: $ Identifying patterns of human responses to actual or potential health problems amenable to a nursing regimen. A nursing regimen is defined as including preventative, restorative, and healthpromotion activities. $ Executing a nursing regimen through the selection, performance, management, and evaluation of nursing actions. $ Assessing health status for the purposes of providing nursing care. Assessing health status is defined as the collection of data through nursing assessment techniques, which may include interviews, observation, and physical evaluations, for the purpose of providing nursing care. $ Providing health counseling and health teaching. $ Administering medications, treatments, and executing regimens authorized by an individual authorized to practice in Ohio and acting within the course of the individual=s professional practice. $ Teaching, administering, supervising, delegating, and evaluating nursing practice. 7 1

7 The Board of Nursing has established standards for applying the nursing process as a registered nurse. The Board defines the process as cyclical in nature so that the nurse s actions are directed by the client s changing status throughout the process. The registered nurse collaborates, as appropriate with the client, family, significant others, and other members of the health care team in applying the steps of the nursing process. The following steps must be taken by the registered nurse (RN) in an accurate and timely manner in applying the nursing process for each client under the registered nurse s care: Assessment The RN must: - Collect data, which includes collection of subjective and objective data from the client, family, significant others, or other members of the health care team as appropriate. The RN may direct or delegate the performance of data collection. The RN must also document the collected data. Analysis and Reporting The RN must identify, organize, and interpret relevant data; and establish, accept, or modify a nursing diagnosis to be used as a basis for nursing interventions; and report collected data as necessary to other members of the healthcare team. Planning The RN must develop, maintain, or modify the nursing component of the plan of care, including establishing desired client outcomes and interventions; and communicate the nursing component of the plan of care and all modifications to appropriate members of the health care team. Implementation The RN must implement the current nursing plan of care which may include: - Executing the valid order or regimen by an individual authorized to practice in Ohio and is acting within the course of the individual s professional practice; - Providing direct nursing care commensurate with the education, knowledge, skills, of the RN; and - Assisting with the client s care. Delegating delegable nursing tasks, including medication administration, in accordance with the Board s rules. Evaluation The RN must evaluate, document, and report the client s response to nursing interventions and progress toward expected plan of care outcomes. In addition, the RN must reassess the client s health status, revise the nursing diagnoses or the nursing component of the client s care plan, and make changes in the nursing interventions as necessary. For purposes of this rule, standards for implementing the nursing process also apply to a certified nurse mid-wife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist. 8 Only a registered nurse may engage in the practice of registered nursing or use the title registered nurse or the initials RN. 9 Violations are punishable by up to a $2,500 fine. 10 Exempted from the laws prohibiting the unlicensed practice of registered nursing are: 2

8 $ The practice of nursing by a student enrolled in a Board-approved nursing program if the student is practicing under the auspices of the program and is being supervised by a registered nurse faculty member or teaching assistant. $ The rendering of medical assistance to a licensed physician, dentist, or podiatrist by a person under the direction, supervision, and control of such physician, dentist, or podiatrist. $ Persons employed as nursing aides, attendants, or orderlies in patient homes, nurseries, nursing homes, hospitals, or home health agencies. $ The provision of nursing services to family members or in emergency situations. $ The care of the sick when done in connection with the practice of religious tenets of any church. $ The practice of nursing by an individual licensed in another state and one of the following situations applies: B The individual is employed by or under contract with the U.S. government. B The individual is traveling with patients that includes transporting patients in Ohio less than 72 hours. B The individual is consulting with an individual licensed in Ohio to practice any healthrelated profession. B The individual is teaching in Ohio as a guest lecturer. B The individual is conducting evaluations of nursing care for a national accrediting organization. B The individual is providing nursing care to an individual who is in Ohio for less than six months if the nurse is directly employed by the patient or a guardian or other person acting on the patient s behalf. B The individual is providing nursing care during any natural disaster. 11 Following are RN/LPN Frequently Asked Questions (based on laws and rules in effect 06/01/2009) How do I know if a specific nursing task is within my scope of practice? The scope of practice for nurses can be found in Ohio Revised Code (ORC) Section (B) for RNs, and (F) for LPNs. In order to determine if an activity is within the scope of practice for a nurse, you should utilize the Decision Making Model which is available on the Board of Nursing Web site in the Nursing Practice section. The Board also has published Interpretative Guidelines concerning various nursing practices that may also be helpful. 2. Can a licensed practical nurse perform venipuncture in order to obtain blood samples for laboratory analysis? The Nurse Practice Act does not prohibit a licensed practical nurse with the necessary knowledge, skills and abilities, functioning at the direction of a physician or RN, from performing peripheral venous blood draws. Rule , Ohio Administrative Code (OAC), holds licensed practical nurses responsible for maintaining and demonstrating current knowledge, skills, abilities and competence in rendering nursing care within their scope of practice. 3. Can a licensed practical nurse/registered nurse work as a patient care assistant? The Nurse Practice Act does not prohibit a nurse from limiting his/her employment responsibilities to that of a patient care assistant or other unlicensed personnel. The licensed nurse that accepts employment in a position that does not require a nursing 3

9 license and who chooses not to engage in licensed nursing practice should not identify him/herself as a nurse. If he/she identifies himself as a nurse or engages in the practice of nursing, he/she will be accountable under the Nurse Practice Act and administrative rules. Can a nurse work as a state tested nursing assistant? The above response applies, but it should be noted that STNAs are regulated by the Ohio Department of Health (ODH). You should contact ODH regarding any requirements in order to work as an STNA. 4. Can a licensed practical nurse assess a patient? The scope of practice for RNs and LPNs can be found in Sections (B) and (F), ORC. As specifically noted in their scope, RNs may assess health status for the purpose of providing nursing care. RNs may fully utilize the steps in the nursing process including assessment, analysis, planning, implementation and evaluation, Rule , OAC. Licensed practical nurses provide nursing care requiring the application of basic knowledge of the biological, behavioral, social and nursing sciences at the direction of a licensed physician, dentist, podiatrist, optometrist, chiropractor or RN. Assessment of health status is not included in the LPN scope of practice. LPNs contribute to the assessment of the client by collecting and documenting objective and subjective data related to the client s health status and reporting that data as appropriate to other members of the healthcare team. Likewise, LPNs contribute to the development, maintenance, evaluation or modification of the nursing component of the care plan and communicate the care plan with any modifications to appropriate members of the healthcare team, Rule , OAC. 5. Can an RN or LPN accept a verbal order or an order that has been electronically transmitted (i.e. faxed, texted, ed)? The Nurse Practice Act does not address the manner in which an order is taken, relayed or transcribed. Rather, Chapter , OAC, places accountability on the nurse who is implementing the order to implement or clarify that the order is accurate, valid, properly authorized and is not harmful or potentially harmful to the client, or is not contraindicated by documented information. The nurse implementing the order is required to practice in accordance with the nurse s respective licensure scope. 6. What is the nurse to patient ratio in a hospital setting or long-term care setting? The Nurse Practice Act does not specify nurse to patient ratios in ANY patient care setting. Other regulatory or certifying bodies such as the Ohio Department of Health, JCAHO, etc. may address staff to patient ratios. In regard to hospitals, legislation enacted in 2008 requires hospitals to create and maintain committees to address nursing staffing levels. You may want to contact your facility leadership regarding the activities of these committees in your institution. 7. Can a nurse administer a medication such as Methotrexate, as ordered by a physician, to terminate an ectopic pregnancy? A nurse is prohibited from administering medication to terminate a live pregnancy, which includes all pregnancies unless it is known that the fetus or embryo has stopped developing and the tissue is dead. 4

10 For further information regarding this question, see the article Administering Medications Relating to the Termination of a Pregnancy in the winter 2008 issue of Momentum, available on the Board of Nursing Web site under Publications. 8. What tasks can a nurse perform using a laser or a light-based medical device? According to Medical Board rules, a physician may delegate the use of light-based medical devices to RNs and LPNs only for the purpose of hair removal, and to appropriate persons for light phototherapy for the treatment of hyperbilirubinemia in neonates and for fluorescent lamp phototherapy for the treatment of psoriasis and similar skin conditions. For additional information, see the article The Use of Light Based- Medical Devices in the winter 2008 issue of Momentum, available on the Board of Nursing Web site under Publications. 9. What is the maximum number of hours a nurse may work in a specific timeframe? The Nurse Practice Act addresses the practice of nursing. It does not address employment activities or set a limit on the number of hours a licensee may practice within a given period of time. Licensees should be aware of Rule , OAC (related to RN practice), and Rule , OAC (related to LPN practice), which require the nurse to demonstrate competence and accountability in all areas of practice in which the nurse is engaged, which includes but is not limited to: 1) consistent performance of all aspects of nursing care, and 2) appropriate recognition, referral or consultation and intervention when a complication arises. A nurse who works an excessive number of hours within a specific period of time and as a result is not able to demonstrate competence or provide consistent performance within their nursing practice may place themselves at risk for not being able to comply with this standard. 10. Are nurses required to have malpractice or liability insurance? The Nurse Practice Act does not require nurses to have malpractice or liability insurance. 11. Who may supervise the practice of nursing? According to Section (B), ORC, the supervision and evaluation of nursing practice is established within the RN scope of practice. Rule (O), OAC, further states that only a registered nurse may supervise and evaluate the practice of nursing by other RNs or LPNs. Licensed practical nurses are not prohibited from participating in activities which contribute to the delivery of care, such as scheduling for coverage of nursing services and observation/documentation regarding care provided by assistive personnel. A non-nurse supervisor may evaluate a nurse employee in matters other than the practice of nursing. The Practice of Licensed Practical Nursing The practice of licensed practical nursing is defined as providing nursing care requiring the application of basic knowledge of the biological, physical, behavioral, social, and nursing sciences at the direction of a licensed physician, dentist, podiatrist, optometrist, chiropractor, or registered nurse. 13 Such nursing care includes: 5

11 $ Observation, patient teaching, and care in a diversity of health care settings. $ Contributions to the planning, implementation, and evaluation of nursing. $ Administration of medications and treatments authorized by an individual who is licensed to practice in Ohio and is acting within the course of the individual=s professional practice. Medications may be administered by an LPN upon proof of completion of a course in medication administration approved by the Board of Nursing. Intravenous therapy may only be administered by an LPN meeting the conditions discussed in the next section. $ Administration to an adult of intravenous therapy authorized by an individual who is licensed to practice in Ohio and is acting within the course of the individual s professional practice, on the condition that the LPN is authorized to perform intravenous therapy under the laws and regulations discussed in the next section. Delegation of nursing tasks as directed by a registered nurse. Teaching nursing tasks to licensed practical nurses and individuals to whom the licensed practical nurse is authorized to delegate nursing tasks to as directed by a registered nurse. 14 The Board of Nursing has established standards for applying the nursing process as a licensed practical nurse (LPN). The standards state that the LPN must contribute to the nursing process in the practice of nursing and that the steps of the nursing process are cyclical in nature so that the nurse s actions are directed by the client s changing status throughout the process. The LPN collaborates, as appropriate with the client, family, significant others, and other members of the health care team in applying the steps of the nursing process. The following steps must be taken by the LPN in an accurate and timely manner in utilization of the nursing process: Assessment The LPN must contribute to the nursing assessment of the client by collecting and documenting objective and subjective data related to the client s health status; and reporting objective and subjective data to other members of the health care team. Planning The LPN must contribute to the development, maintenance, or modification of the nursing component of the care plan; and communicate the nursing component of the care plan and all modifications to appropriate health care team members. Implementation The LPN must implement the nursing care plan, which may include: - Administering medications and treatments prescribed by an individual who is authorized to practice in Ohio and is acting within the course of the individual s professional practice; - Providing direct basic nursing care at the direction of a RN, licensed physician, dentist, optometrist, chiropractor, podiatrist; or a certified nurse mid-wife, certified registered nurse practitioner, certified registered nurse anesthetist, or a clinical nurse specialist; - Assisting with care at the direction of a RN, licensed physician, dentist, optometrist, chiropractor, or podiatrist; or a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or a clinical nurse specialist. - Collaborating with other nurses and other members of the health care team; and - Delegating delegable nursing tasks, including medication administration, in accordance with the Board s rules. Evaluation The LPN must contribute to the evaluation of the client s response to nursing interventions. The LPN must also document and communicate the client s responses to nursing interventions to appropriate health care team members. In addition, the LPN must contribute to 6

12 revision of the nursing component of the client s care plan as a result of the evaluation. 15 Following are some frequently asked questions regarding LPNs scope of practice: 16 Q. Can an LPN do an initial assessment of a patient who has just been admitted to the unit? A. Whether it is an initial assessment or an on-going assessment of a patient, the LPN s role remains the same: the collection of objective and subjective data only. The analysis of the data and the formulation of the plan of nursing care is always the RN s responsibility. Q. Is the RN required to co-sign the documentation of the LPN? A. There is nothing in the law and rules regulating the practice of nursing that would require that the RN co-sign the LPN s documentation. It is within the LPN s scope of practice and a requirement of nursing standards that LPNs document their observations, their interventions and the patient s response in an accurate and timely manner. Q. What is meant by directing the nursing care provided by the LPN? A. Direction means communicating a plan of care to an LPN. The LPN has a legal scope of practice defined in law. The RN directs the LPN in the performance of nursing care for individuals or groups of individuals within the legal scope of practice of the LPN. It is the responsibility of the RN to know that the LPN has the appropriate education and training and has demonstrated competency in all aspects of nursing care that the LPN is directed to perform. It is the RN s responsibility to provide appropriate supervision of the LPN s provision of care. This supervision includes initial and ongoing direction, procedural guidance, observation and evaluation of the provision of care. IV Therapy by Licensed Practical Nurses The Board of Nursing may authorize an LPN to administer intravenous (IV) therapy to an adult if the nurse has a current license that includes authorization to administer medications and one of the following conditions is met: $ The LPN has completed, within a practical nurse prelicensure education program approved by the Board or by another jurisdiction=s agency that regulates the practice of nursing, a course of study that prepares the nurse to safely perform the IV procedures authorized by this section. Such an LPN must be issued an intravenous therapy card by the Board. $ Or, the LPN has successfully completed an intravenous therapy administration course approved by the Board. An LPN authorized by the Board to perform IV therapy may perform the following procedures only for individuals aged eighteen or older and only when directed to do so by a licensed physician, dentist, optometrist, podiatrist, or a registered nurse: Administer the following solutions through a venous line: - 5% dextrose and water; - 5% dextrose and lactated ringers; - 5% dextrose and normal saline; - Normal saline; 7

13 - Lactated ringers; 8

14 - 0.45% sodium chloride and water; or - 0.2% sodium chloride and water. Administer any of the solutions set forth above that contains vitamins or electrolytes after an RN initiates the first infusion of the solution containing vitamins or electrolytes. Initiate or maintain a peripheral intermittent or secondary intravenous infusion containing an antibiotic. Prepare or reconstitute only an antibiotic additive to be administered through a peripheral infusion. Inject heparin or normal saline to flush an intermittent infusion device or heparin lock, including, but not limited to, bolus or push. Change tubing on an intravenous line only if the line terminates in a peripheral vein. Place a venous access catheter, no longer than three inches in length, in the hand, forearm or antecubital space, followed by the placement of a saline or heparin lock, either for purposes of intermittent infusions, or to initiate infusions of any of the solutions set forth above administered through a venous line; or Stop an infusion of blood or blood component when a complication arises. 17 An LPN authorized by the Board to perform IV therapy may perform an IV therapy procedure only when directed to do so by one of the following: $ A licensed physician, dentist, optometrist, or podiatrist who is present and readily available at the facility where the procedure is performed. $ A registered nurse under the following conditions: B Either the RN or another RN is readily available at the site where the IV therapy is performed, and before the LPN initiates the IV therapy, the RN must personally perform an on-site assessment of the patient who is to receive the IV therapy. B When an LPN performs an IV therapy procedure in a nursing home as defined in Section of the Revised Code, or in an intermediate care facility for the mentally retarded, at the direction of a registered nurse, or a licensed physician, dentist, optometrist, or podiatrist, an RN shall be on the premises of the nursing home or facility or accessible by some form of telecommunication. No LPN may perform any of the following IV therapy procedures: $ Initiating or maintaining any of the following: B Blood or blood components B Solutions for total parenteral nutrition B Any cancer therapeutic medication including, but not limited to, cancer chemotherapy or an anti-neoplastic agent B Solutions administered through any central venous line or arterial line or any other line that does not terminate in a peripheral vein, except that an LPN authorized to perform IV therapy may maintain some solutions specified below that are being administered through a central venous line or peripherally inserted central catheter B Any investigational or experimental medication. $ Initiating intravenous therapy in any vein, except in a vein of the hand, forearm, or antecubital fossa $ Discontinuing a central venous, arterial, or any other line that does not terminate in a peripheral vein $ Initiating or discontinuing a peripherally inserted central catheter that is longer than 3 inches. 9

15 $ Mixing, preparing, or reconstituting any medication for IV therapy, except preparation or reconstitution of an antibiotic additive $ Administering medication via the intravenous route including all of the following: B Adding medication to an intravenous solution or to an existing infusion, except that the LPN may do either of the following: $ Initiate an intravenous infusion containing one or more of the following elements: dextrose 5%, normal saline, lactated ringers, sodium chloride 0.45%, sodium chloride 0.2%, sterile water; or $ Hang subsequent containers of such solutions that contain vitamins or electrolytes, if an RN initiated the infusion of that same intravenous solution. B Initiating or maintaining an IV piggyback infusion, except an IV piggyback infusion containing an antibiotic additive B Injecting medication via a direct IV route, except heparin or normal saline to flush an intermittent infusion device or heparin lock including, but not limited to, bolus or push $ Aspirating any IV line to maintain patency Injecting medications by a direct intravenous route, except injecting heparin or normal saline to flush an intermittent infusion device or heparin lock, including but not limited to bolus or push. $ Changing tubing on any line, including an arterial line or a central venous line, except changing tubing on an IV line that terminates in a peripheral vein $ Programming or setting any functions of a patient-controlled infusion pump. However, at the direction of a licensed physician or an RN, an LPN authorized to perform IV therapy may perform the following activities for the purpose of performing dialysis: $ The routine administration and regulation of saline solution for the purpose of maintaining an established fluid plan $ The administration of a heparin dose intravenously $ The administration of a heparin dose peripherally via a fistula needle $ The loading and activation of a constant infusion pump or the intermittent injection of a dose of medication prescribed by a licensed physician for dialysis. No person may employ or direct an LPN to perform an IV procedure without first verifying that the LPN is authorized by the Board to perform IV therapy. 18 The Board must maintain a registry of the names of LPNs authorized to perform IV therapy. 19 Intravenous Procedures that may be Performed by LPNs Who are Not Authorized to Perform IV Therapy An LPN not authorized by the Board to perform IV therapy may perform the IV therapy procedures listed below if both the following conditions are met: $ The LPN acts at the direction of an RN, or a licensed physician, dentist, optometrist, or podiatrist and the RN, physician, dentist, optometrist, or podiatrist is on the premises where the procedure is to be performed or accessible by some form of telecommunication. $ The LPN can demonstrate the knowledge, skills and ability to perform the procedure safely. 10

16 The IV procedures that can be performed by an LPN meeting both these conditions are: $ Verification of the type of peripheral intravenous solution being administered; $ Examination of a peripheral infusion site and the extremity for possible infiltration; $ Regulation of a peripheral intravenous infusion according to the prescribed flow rate; $ Discontinuation of a peripheral intravenous device at the appropriate time; $ Performance of 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 Advanced Practice Nursing The Board issues certificates of authority to several categories of advanced practice nurses who have additional education and training, including certified registered nurse anesthetists, clinical nurse specialists, certified nurse-midwives, and certified nurse practitioners. These nurses have an expanded scope of practice that, under specific conditions, allows them to perform functions and procedures that otherwise would be considered the practice of medicine. Thus, the law prohibiting medical diagnosis, prescriptions of medical measures, and the practice of medicine by a nurse states that it does not prohibit a certified registered nurse anesthetist, clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner from practicing within the nurse s scope of practice. 21 The scope of practice of each category of advanced practice nursing is discussed below. Certified Nurse-Midwives A certified nurse-midwife, in collaboration with one or more physicians, may provide the management of preventative services and those primary care services necessary to provide health care to women antepartally, intrapartally, postpartally, and gynecologically. Collaboration with one or more physicians requires what is called a standard care arrangement discussed below and the physician or physicians are continuously available to communicate with the certified nurse-midwife either in person or by radio, telephone, or other form of telecommunication. 22 No certified nurse-midwife may perform version, deliver breech or face presentation, use forceps, do any obstetric operation, or treat any other abnormal condition, except in emergencies. A certified nursemidwife may perform episiotomies, normal vaginal deliveries and repair vaginal tears. A certified nursemidwife issued a certificate to prescribe, under conditions discussed later, may prescribe drugs and therapeutic devices. The Board has addressed the issue of certified nurse-midwives performing circumcisions as follows: Circumcisions and Certified Nurse-Midwives Q. Is it within the scope of practice of a Certified Nurse-Midwife (CNM) to perform newborn circumcision? A. No 11

17 During the spring 2006 meetings of the Ohio Board of Nursing APN Task Force, the Certified Nurse-Midwife (CNM) participants queried the Board regarding newborn circumcision as it relates to the current scope of practice of CNMs in Ohio. At that meeting, the CNMs referenced that it was the practice of CNMs to perform circumcisions when CNMs were previously registered with the State Medical Board prior to 1988, after which CNM circumcision was moved to the Board of Nursing. The Board clarified CNM practice prior to 1988, and discussed the past practice of CNMs with Medical Board staff who stated that circumcision was not an authorized practice for CNMs prior to We have been unable to identify a Medical Board statute, rule or policy indicating that CNMs were authorized to perform newborn circumcisions while registered by the State Medical Board. Further, minutes from an October 14, 1994 CNM Focus Group meeting of Board of Nursing staff and CNM representatives discussed the CNM scope of practice in relation to various types of instruments used and procedures performed, and included a specific recommendation that three procedures were prohibited in the scope of practice of the CNM: C-sections, forceps deliveries, and circumcisions. Currently, the Nurse Practice Act defines the CNM scope of practice in Section of the Revised Code: A certified registered nurse anesthetist, clinical nurse specialist, certified nursemidwife, or certified nurse practitioner may provide to individuals and groups nursing care that requires knowledge and skill obtained from advanced formal education and clinical experience. (A) A nurse authorized to practice as a certified nurse-midwife, in collaboration with one or more physicians, may provide the management of preventive services and those primary care services necessary to provide health care to women antepartally, postpartally, and gynecologically, consistent with the nurse=s education and certification, and in accordance with rules adopted by the Board. (Emphasis added) No certified nurse-midwife may perform version, deliver breech or face presentation, use forceps, do any obstetric operation, or treat any other abnormal condition, except in emergencies. Division (A) of this section does not prohibit a certified nurse-midwife from performing episiotomies or normal vaginal deliveries, or repairing vaginal tears. A certified nurse-midwife who holds a certificate to prescribe issued under Section of the Revised Code may, in collaboration with one or more physicians, prescribe drugs and therapeutic devices in accordance with Section of the Revised Code. The plain language of the statute provides that a CNM may provide care to women before, during, and after their pregnancy. There are certain newborn activities performed by CNMs that are directly related to intrapartal and postpartum care of women that include but are not limited to the care of the newborn at the time of delivery, maternal-child bonding, and lactation counseling. However, the performance of newborn circumcision is not a procedure that is necessary to provide intrapartal, postpartum, and/or gynecological health care to women and therefore is not included in the CNM scope of practice

18 Certified Registered Nurse Anesthetists A certified registered nurse anesthetist with the supervision and in the immediate presence of a physician, podiatrist, or dentist, may administer anesthesia and perform anesthesia induction, maintenance, and emergence, and may perform, with supervision, preanesthetic preparation and evaluation, postanesthesia care, and clinical support functions. A certified registered nurse anesthetist does not have to obtain a certificate to prescribe in order to provide such anesthesia care. The physician, podiatrist, or dentist supervising a certified registered nurse anesthetist must be actively engaged in practice in Ohio. When a certified nurse anesthetist is being supervised by a podiatrist, the nurse=s scope of practice is limited to the anesthesia procedures the podiatrist has the authority to perform. A certified registered nurse anesthetist may not administer general anesthesia under the supervision of a podiatrist in a podiatrist s office. When a certified registered nurse anesthetist is supervised by a dentist, the nurse=s scope of practice is limited to the anesthesia procedures the dentist has the authority to perform. Certified Nurse Practitioners Certified nurse practitioners, in collaboration with one or more physicians or podiatrists, may provide preventative and primary care services and evaluate and promote patient wellness within the nurse=s nursing specialty. Collaboration requires that one or more podiatrists or physicians have entered into a standard care arrangement with the nurse and are continuously available to communicate with the certified nurse practitioner either in person, or by radio or telephone. 24 A certified nurse practitioner who holds a certificate to prescribe may, in collaboration with one or more physicians or podiatrists, prescribe drugs and therapeutic devices. When a certified nurse practitioner is collaborating with a podiatrist, the nurse s scope of practice is limited to the procedures the podiatrist is authorized to perform. Clinical Nurse Specialists A nurse authorized to practice as a clinical nurse specialist, in collaboration with one or more physicians or podiatrists, may provide and manage the care of individuals and groups with complex health problems and provide health care services that promote, improve, and manage health care within the nurse=s nurse specialty. Collaboration requires that one or more physicians or podiatrists have entered into a standard care arrangement with the nurse and are continuously available to communicate with the nurse either in person, or by radio or telephone. A clinical nurse specialist who holds a certificate to prescribe may, in collaboration with one or more physicians or podiatrists, prescribe drugs and therapeutic devices. A clinical nurse specialist practicing mental health or psychiatric mental health nursing need not be practicing under a standard care arrangement but must have continuous availability to one or more physicians either in person or by radio or telephone. 25 When a clinical nurse specialist is collaborating with a podiatrist, the nurse=s scope of practice is limited to the procedures the podiatrist may legally perform

19 Title Protection Only a registered nurse holding the appropriate certificate of authority may use the following titles or initials: $ Certified Nurse-Midwife, CNM, or Certified Registered Nurse-Midwife, CRNM $ Clinical Nurse Specialist, CNS, or Clinical Registered Nurse Specialist, CRNS $ Certified Nurse Practitioner, CNP, or Certified Registered Nurse Practitioner, CRNP $ Certified Registered Nurse Anesthetist, CRNA A nurse authorized to practice as a certified registered nurse anesthetist, clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner may use the title Aadvanced practice nurse@ or the initials A.P.N. Certified nurse-midwives, certified nurse practitioners, certified registered nurse anesthetists, and clinical nurse specialists must display such identification indicating their advanced nursing practice title. 27 Standard Care Arrangement A standard care arrangement is defined as a written, formal guide for planning and evaluating patients health care. Except as discussed below, a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner (hereafter called advanced practice nurse) may practice advanced practice nursing only following a standard care arrangement entered into with each physician or podiatrist with whom the nurse collaborates. A copy of the standard care arrangement must be retained on file at each site where the nurse practices. Prior approval of the standard care arrangement is not required, but the Board may periodically review it for compliance with the requirements discussed below. If requested by the Board, the advanced practice nurse must immediately provide a copy of the standard care arrangement to the Board. A clinical nurse specialist practicing mental health or psychiatric mental health nursing is exempt from the standard care arrangement requirements listed below, but must practice in collaboration with one or more physicians. If such a clinical nurse specialist holds a certificate to prescribe, the nurse shall enter into a standard care arrangement with one or more physicians, but only to the extent necessary to address the prescribing component of the nurse s practice. An advanced practice nurse may enter into a standard care arrangement with one or more collaborating physicians or podiatrists. Each physician or podiatrist must be actively engaged in direct clinical practice in Ohio and practicing in a specialty that is the same or similar to the nurse s nursing specialty. If a collaborating physician or podiatrist enters into standard care arrangements with more than three nurses who hold certificates to prescribe, the physician or podiatrist may not collaborate at the same time with more than three of such nurses in the prescribing component of their practices. 28 A standard care arrangement must be in writing and contain all of the following: $ The signatures of each individual nurse and each collaborating physician, the physician s designated representative, or podiatrist with whom the advanced practice nurse primarily collaborates indicating review of and agreement to abide by the terms of the arrangement; date when the arrangement is initially executed; and the date of the most recent review. For purposes of this rule, a physician s designated representative means a physician who serves as the department or unit director or chair, within the same institution, organization or facility, department, or unit, and within the same practice specialty, that the nurse practices, and with 14

20 respect to whom the physician has executed a legal authorization to enter into collaborating agreements on the physicians behalf. $ The complete name, specialty and practice area, business address, and business phone number or number at which the individual can be reached at any time for: B Each collaborating physician or podiatrist with whom the advanced practice nurse primarily collaborates and who is a party to the standard care arrangement; and B Each advanced practice nurse who is a party to the standard care arrangement. $ A statement of services offered by the advanced practice nurse. The statement must include a description of the scope of prescriptive practice for holders of certificates to prescribe. $ A plan for incorporation of new technology or procedures. $ Quality Assurance provisions, including at least: B A schedule for periodic review and reapproval of the arrangement. The arrangement must be reviewed at least annually and signed and dated by the advanced practice nurse and at least one collaborating physician or podiatrist. B Criteria for referral of patients by the advanced practice nurse to a collaborating physician or podiatrist. The criteria must include, for certified nurse-midwives, a plan for referral of breech or face presentation or any other abnormal condition. B A process for obtaining consultation with a collaborating physician or podiatrist. B A procedure for a regular review of referrals made by the advanced practice nurse to other health care professionals and the care outcomes for a random sample of all patients seen by the nurse. B A process for chart review, discussed below, if the nurse s practice includes any direct client care, education, or management. $ If the clinical nurse specialist or certified nurse practitioner regularly provides services to infants, a policy for care of infants up to age one, and recommendations for collaborating physician visits for children from birth to age three. $ A plan for coverage of clients in emergencies or planned absences of either the advanced practice nurse or the collaborating physician or podiatrist. $ A process for resolution of disagreements regarding patient management matters; and $ An arrangement regarding reimbursement by Medicaid. A standard care arrangement meeting these requirements may permit a clinical nurse specialist, certified nurse-midwife or certified nurse practitioner to supervise services provided by a home health agency. For nurses with certificates to prescribe, the arrangement must include: $ Provisions to ensure timely direct, personal evaluation of the patient with a collaborating physician or the physician=s designee. $ Additional prescribing parameters for those drugs or therapeutic devices established in the formulary, (discussed below) including: B Provisions for use of drugs with non-food and Drug Administration (FDA) approved indications; B Provisions for use of drugs approved by the FDA subsequent to the date of the standard care arrangement after review by the BON committee on prescriptive governance; and B Provisions for use of previously reviewed drugs approved by the FDA for new indications subsequent to the date of the standard care arrangement; 15