How do you get certified and licensed in your state?

In Ohio, an individual qualifies to apply for Advance Practice Registered Nurse (APRN) licensure as defined by the state board of nursing nurse practice act (NPA; OBN, 2021a).  The NPA in Ohio requires that the individual applying for licensure have an active Ohio Registered Nurse (RN) license (OBN, 2021a).  Applicants must also hold a master’s or doctoral degree in a major that that qualifies the individual to sit for at minimum one of the certification exam administered by one of the national certified organizations approved by the Ohio Board of Nursing (OBN; OBN, 2021a).  The master’s or doctoral degree obtained for Certified Nurse Practitioners (CNP) in Ohio must include proof of an Advanced Pharmacology course that is 45 contact hours or greater and was completed in the five-year time before applying for APRN licensure (OBN, 2021a).

What is the application process for certification in your state?

Applicants for APRN licensure in Ohio apply through the eLicense Ohio Professional Licensure System that is located https://elicense.ohio.gov/OH_HomePage (OBN, 2021b).  The applicant’s school must email an official transcript showing the completion of a master’s or doctoral degree with a major in a nursing specialty that qualifies the individual to take an APRN national certification examination to licensureaprn@nursing.ohio.gov (OBN, 2021b).  This transcript must reflect the required 45 contact hours in Advanced Pharmacology completed in the last 5 years (OBN, 2021b).  Next, the applicant must submit proof of national certification emailed directly from a National Certification Organization approved by the OBN to licensureaprn@nursing.ohio.gov (OBN, 2021b).  For the Adult-Gerontology Primary Care Nurse Practitioner Ohio currently recognizes the American Association of Nurse Practitioners Certification Board (AANPCB) and American Nurses Credentialing Center (ANCC) as approved national testing agencies (OBN, 2021b).  Applicants that complete a program not located in Ohio must also provide continuing education in Ohio law and rules that govern schedule II prescribing (OBN, 2021b).  The application may be submitted conditionally before completing the APRN education program or before a national examination is taken (OBN, 2021b).  The OBN will hold onto the application for one year from receiving.  There is also a nonrefundable fee of $150.00 that is due at the time the application is submitted (OBN, 2021b).

How does your state define the scope of practice of a nurse practitioner/ State Practice Agreement?

The OBN defines the scope of practice of CNPs in Ohio as practicing in collaboration with one or more physicians or podiatrists.  Current Ohio law requires a Standard Care Agreement (SCA) to be entered with the collaborating physician (OBN, 2021a).  Ohio Revised Code (ORC) 4723.43 further defines the scope of practice for CNPs as providing preventative and primary care services, providing services for acute illness, evaluating and promoting patient wellness within one’s specialty, and consistent with the CNPs education and certification and rule of the OBN (ORC, 2020).   In addition to direct patient care, Ohio does allow CNP’s to perform research, education, and health policy advocacy (OBN, 2021a).  Despite requiring a SCA, CNPs in Ohio are qualified to make independent decisions and are accountable for their care decisions.  CNPs in Ohio also receive prescriptive authority to prescribe medications (OBN, 2021a).  The scope of practice differs slightly when the collaborating physician is a podiatrist and is limited to the podiatrist’s scope (OBN, 2021a).

Explain state-specific restrictions or limitations for practice

            Certified Nurse Practitioners in Ohio are required to practice in collaboration with a physician or podiatrist via a SCA (OBN, 2021a).   As stated above, specific practice limitations include not being able to prescribe schedule II mediations a physician has not previously prescribed that except in certain circumstances (OBN, 2021a).  APRNs are prohibited from prescribing any drug or device to perform or induce an abortion or to perform the abortion (OBN, 2021a).

How does your state describe a nurse practitioner’s controlled-substance prescriptive authority, and what nurse practitioner drug schedules are nurse practitioners authorized to prescribe?

Current legislation in Ohio allows CNPs the authority to prescribe.  The prescribing practice of the CNP must be in line with their scope of practice, national certification, SCA, standards of practice, and the prescriptive authority of their collaborating physician (ORC, 2011).  CNPs in Ohio must prescribe by the Exclusionary Formulary defined in the ORC and must comply with current state and federal laws (ORC, 2011).  All APRNs in Ohio with prescriptive authority are required to register with the Ohio Automated Rx Reporting System (OARRS) Furthermore, to review OARRS reports for controlled substances (OBN, 2021a).  A collaborating physician is limited to not collaborate in prescribing with more than five CNP’s (ORC, 2011).  Schedule II controlled substances are also in the prescribing authority of CNP’s in Ohio with some specific regulations, including that a physician had previously prescribed the medication, and the supply will not exceed 72 hours and in any thirty days the amount that exceeds 2500 dosage units (OBN, 2021a).  Opioid analgesics may be prescribed by CNP’s in Ohio to treat acute pain, subacute pain, and chronic pain (OBN, 2021a).  The prescriptive authority of a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner shall not exceed the prescriptive authority of the collaborating physician (ORC, 2011).  APRNs are permitted to prescribe a schedule II-controlled substance in circumstances where a patient has a terminal illness (OBN, 2021a).

Explain nurse practitioner prescriptive authority and DEA registration processes

Federal law requires that nurse practitioners obtain a DEA number to write prescriptions for medications classified as controlled substances (DEA, 2021). Nurse practitioners may not write for even common controlled substances such as medication for attention deficit and hyperactivity and restless leg syndrome without a DEA number.  Before applying for DEA licensure, potential applicants must be licensed to practice by the state (DEA, 2021).  Applicants apply for a DEA number directly on the Department of Justice website located at https://apps.deadiversion.usdoj.gov/webforms2/spring/main?execution=e1s1 (DEA, 2021). The application consists of 6 sections, with one requiring the CNP to select which classes of medications they can prescribe following state laws (DEA, 2021).  In Ohio, CNP’s with a DEA waiver can prescribe and administer medications in classes 2, 2N, 3, 3N, 4, 5 (DEA, 2021).  The cost of DEA registration is quite hefty, with current rates being $888 per 3-year renewal (DEA, 2021).  It takes approximately 4 to 6 weeks from when the application is submitted until the DEA number is issued (DEA, 2021).

In what legislative and advocacy activities are your state nurse practitioner organization(s) involved?

The Ohio Association of Advanced Practice Nurses (OAAPN) is the primary organization responsible for legislation at the state level in the advocacy of standards of care for nurse practitioners (OAAPN, 2021).  The OAAPN was founded in 1996 and is the only full-service statewide organization for APRNs in Ohio of all specialties.  The OAAPN’s 12,800 members participate in advocacy at the state, local, state, and federal levels intending to provide high-quality, cost-effective, accessible healthcare for Ohio residents (OAAPN, 2021).

In 2019 the OAAPN introduced House Bill 177, the Better Access, Better Care Act aimed at allowing APRNs in Ohio to treat patients without the current required SCA (OAAPN, 2021).  While HB 117 did receive backing from the Federal Trade Commission (FTC), and it never made it out of the House of Representatives (OAAPN, 2021).  In March of 2021, the OAAPN worked with Representative Thomas Brinkman to reintroduce the new Better Access, Better Care Act as HB 221 which would allow an APRN to practice without a SCA after completing 2000 hours of practice time (OAAPN, 2021).  Passage of HB 221 would be monumental for APRNs in Ohio who have been shown to provide safe and equitable care in setting such as primary care (OAAPN, 2021).  The OAAPN also was instrumental in the revision of HB 203- 133^rd General Assembly to expand the type of providers with whom a pharmacist may enter into a consulting agreement to include clinical nurse specialists, certified nurse-midwives, or certified nurse practitioners if they have an active SCA with a physician (OAAPN, 2021).  This law went into effect in December 2020.

Other notable legislation by the OAAPN includes the introduction and passing of HB 111 in 2018 (OAAPN, 2021).  The bill allows psychiatric certified clinical nurse specialists (CNS) and psychiatric mental health nurse practitioners (PMHNP) the authority to pink slip individual who demonstrates behavior that would pose harm to another or oneself (OAAPN, 2021).   Before HB 111, only physicians, psychologists, police, and public health officers could issue pink slips to patients (OAAPN, 2021).

Barriers

            Barriers to independent practice in Ohio seem to be centered around current physician views of APRNs and their role.  The Ohio State Medical Association (OSMA) released a statement in response to the proposed Better Access Better Care Act in opposition of the act (OSMA, 2020).  The current view of the OSMA is that there is not a shortage of physicians in Ohio and that a healthy pipeline of students in medical schools and physicians in residency is available in Ohio (OSMA, 2020).  As part of their statement, OSMA argues that argue nurse practitioners do not have the training to care for patients without physician safely supervision (OSMA, 2020).  While current Ohio legislation is slowly evolving to support the future independence of APRNs, outdated rules such as the requirement for an SCA and the inability to start a patient on a controlled substance that was not originally ordered by a Physicians also continue to be barriers.

Biggest Insight

I enjoyed performing this exercise in preparation for my AGPCNP licensure.  Knowledge of the current regulations and the application process will certainly be helpful as I begin the application process soon.  Among the most important insights, I took away from this exercise is that the process of licensure ideally should begin far before graduating from Walden.  I have committed time each week over the next month to begin the application process.  Other insights include the hefty cost of obtaining a DEA license.  This knowledge is important as I enter future negotiations in obtaining my NP contract.

References

Drug Enforcement Administration (DEA). (2021). Mid-Level practitioners authorization by state. U.S. Department of Justice. https://www.deadiversion.usdoj.gov/drugreg/practioners/mlp_by_state.pdf

Ohio Association of Advanced Practice Nurses (OAAPN). (2021). Our accomplishments and legislative efforts.  https://oaapn.org/2021/03/our-accomplishments-and-legislative-efforts/

Ohio Board of Nursing. (2021a). APRN licensure and practice in Ohio. https://nursing.ohio.gov/wp-content/uploads/2021/02/APRN-Licensure-and-Practice.pdf

Ohio Board of Nursing. (2021b). Advanced practice registered nurse application certified nurse practitioner.  https://nursing.ohio.gov/wp-content/uploads/2021/04/CNP-Sample-APP.pdf

Ohio State Medical Association (OSMA). (2020). Ohio legislative update. https://osma.org/aws/OSMA/pt/sd/news_article/302869/_PARENT/layout_details-news/false

Ohio Rev. Code. § 4723.43 (2020). https://codes.ohio.gov/ohio-revised-code/section-4723.43

Ohio Rev. Code. § 4723.481 (2011). https://codes.ohio.gov/ohio-revised-code/section-4723.481

 

 

 

Discussion: Certification and Licensure

Although there is a movement called the APRN Consensus Model to standardize NP regulations nationally, it is still the case that requirements vary state to state. In some states, NPs may establish independent practice without the supervision of an MD. Additionally, states are currently categorized as either allowing full practice, reduced practice, or restricted practice. Full practice states allow NPs to evaluate, order diagnostics, diagnose, and treat patients. They are licensed under the exclusive authority of the state board of nursing for the appropriate state. Many states may require prescriptive authority protocols in addition to collaborative agreement.

Another important area to consider and plan for is prescriptive authority. Prescriptive authority is granted under state law by the appropriate board. The board granting prescriptive authority may be the medical board, state board of pharmacy, or nursing board for the appropriate state licensure being pursued. The authority to write for a controlled substance is granted at a federal level and is verified through the Drug Enforcement Administration (DEA) by the appropriate state board. Drug Enforcement Agency registration is granted at the federal level and has additional requirements/fees for the registration process.

Finally, the legal landscape for NPs is constantly changing as the status of NPs as providers improves on a national level. Legislative changes may occur annually, bi-annually, or during an emergency legislative meeting at the state or federal level. These legislative sessions and any subsequent changes will significantly impact your scope of practice as a nurse practitioner.

For this Discussion, you examine professional issues for your state, including certification and licensure, scope of practice, independent practice, prescriptive authority, and legislative activities.

To prepare:

• Review practice agreements in your state.
• Identify whether your state requires physician collaboration or supervision for nurse practitioners and, if so, what those requirements are.
• Research the following:
  • How do you get certified and licensed in your state?
  • What is the application process for certification in your state?
  • What is the primary nurse licensure office resource website in your state?
  • How does your state define the scope of practice of a nurse practitioner?
  • What is included in your state’s practice agreement?
  • How do you get a Drug Enforcement Agency (DEA) license?
  • How does your state describe a nurse practitioner’s controlled-substance prescriptive authority and what nurse practitioner drug schedules are nurse practitioners authorized to prescribe?
  • In what legislative and advocacy activities are your state nurse practitioner organization(s) involved?

By Day 3

Post a summary of your findings on your state based on the questions listed above. Explain the types of regulations that exist and the barriers that may impact nurse practitioner independent practice in your state. Be specific. Also, describe what surprised you from your research.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on 2 different days in one or more of the ways listed below.

• Share an insight from having viewed your colleagues’ posts.
• Suggest additional actions or perspectives.
• Share insights after comparing state processes, roles, and limitations.
• Suggest a way to advocate for the profession.
• Share resources with those who are in your state.