Ohio Nurse Practice Act (2 Hours)

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Continuing Education (CEU) course for healthcare professionals.View the course online at wildirismedicaleducation.com foraccreditation/approval information, course availability and otherdetails, and to take the test for CE credit. The information provided inthis course is to be used for educational purposes only. It is notintended as a substitute for professional healthcare.Contact Hours: 2Ohio Nurse Practice Act (2 Hours)Law and Rules – Category ACOPYRIGHT 2019, WILD IRIS MEDICAL EDUCATION, INC. ALL RIGHTS RESERVED.BY Adrianne E. Avillion, DEd, MSN, RN; Persis Mary Hamilton, EdD, MSN, BSN, RN, PHN, PMHNLEARNING OUTCOME AND OBJECTIVES: Upon completion of this continuing educationcourse, you will have increased your knowledge of the standards of safe nursing practice asoutlined in the Ohio Nurse Practice Act and the rules of the Ohio Administrative Code as writtenby the Ohio Board of Nursing in accordance with Section 4723 of the Ohio Revised Code.Specific learning objectives to address potential knowledge gaps include: Describe the Ohio Scope of Practice Decision-Making Model. Compare the roles of the Ohio Board of Nursing and Ohio professional associations. Summarize the American Nurses Association Code of Ethics for Nurses. Discuss the standards for competent nursing practice of RNs and LPNs in Ohio. Explain standards for the promotion of patient safety by licensed nurses in Ohio. Contrast the RN and LPN standards for applying the nursing process in Ohio. Describe violations of nursing laws and rules that may result in disciplinary action.The establishment of standards for nursing education and practice is the result of efforts bynursing associations that began over 100 years ago. Currently in each state or territory, a lawknown as the Nurse Practice Act designates an authoritative body that defines and regulatesthe nursing practice of every nurse in every role. This authoritative body, known as a board ofnursing, is responsible for ensuring that nurses who practice in the state for which they haveresponsibility are competent, safe, skilled, and knowledgeable about the standards set forth inthat state’s scope of practice for nurses (NCSBN, 2018). This course presents those standardsfor the state of Ohio written by the Ohio Board of Nursing in accordance with the NursePractice Act.

wildirismedicaleducation.comOhio Nurse Practice Act (2 Hours)OHIO BOARD OF NURSING AND OHIO ADMINISTRATIVECODEAll licensed medical professionals work under accepted standards derived from local, state, andfederal laws as well as professional guidelines. Licensed nurses are no exception. Their scope ofpractice is defined by the Nurse Practice Act (NPA) of the state in which they practice. In Ohio,the NPA is codified in Section 4723 of the Ohio Revised Code (ORC). It establishes an OhioBoard of Nursing (OBN) and defines its structure and function.Ohio Board of Nursing (OBN)The Nurse Practice Act (ORC 4723) authorizes the OBN to make and enforce rules andregulations for registered nurses, licensed practical nurses, dialysis technicians, and advancedpractice nurses (certified nurse-midwives, certified nurse practitioners, certified nurse specialists,and certified registered nurse anesthetists). In 2003, community health workers were placedunder the jurisdiction of the OBN.MISSION AND MEMBERSHIPThe mission of the Ohio Board of Nursing is to “actively safeguard the health of the publicthrough the effective regulation of nursing care” (OBN, 2019a). It accomplishes this mission byestablishing educational criteria for schools of nursing, promulgating rules to regulate the scopeand practice of nursing, issuing licenses, and disciplining licensees who fail to follow the rules.Board members are public officials and meetings are open to the public. The board is made up ofthirteen members: eight registered nurses, four licensed practical nurses, and one consumerappointed by the governor. At least two of the registered nurses shall hold a current, valid licenseissued under the ORC that authorizes the practice of nursing as an advanced practice registerednurse. The board has the legal authority to administer and enforce all provisions of the NPA. Itmust review each rule within the Ohio Administrative Code (OAC) at least once every fiveyears. The board is funded and supported by mandatory licensure fees paid by nurses wishing topractice legally in the state of Ohio. The board does not have authority over employers (ORC4723.02).SCOPE OF PRACTICEBecause nursing is a dynamic practice, questions may arise about whether certain tasks arewithin the nurse’s scope of practice. All nursing care should be consistent with the nurse’spreparation, education, experience, knowledge, and demonstrated competency.The Ohio Board of Nursing has developed a Scope of Practice Decision-Making Model to helpnurses determine whether a task is within their scope of practice. The model uses a decision treewith references and is based on legality, competency, safety, and accountability. 2019 WILD IRIS MEDICAL EDUCATION, INC.2

wildirismedicaleducation.comOhio Nurse Practice Act (2 Hours)OBN SCOPE OF PRACTICE DECISION-MAKING MODELThe Scope of Practice Decision-Making Model includes the following steps:1. Defining and describing the activity/task that is to be performed2. Determining whether the activity/task is within the scope of practice and not precludedor prohibited by any other law or rule3. Evaluating self-competency to perform the activity/task; meet the standards of safenursing practice; and demonstrate current knowledge, skills, and abilities4. Assessing the safety and appropriateness of performing the activity/task at this time5. Preparing to accept accountability for nursing actionsEach of these steps must be answered with a “yes” before proceeding to the next step. If at anypoint an answer is “no,” the nurse must not perform the action (OBN, 2015).CASE: Scope of Practice Decision-MakingMycee is a licensed practical nurse (LPN) with five years of experience who has recentlymoved from Indiana to Ohio. This is her first shift on a surgical floor following orientation, andshe is responsible for five patients who are 1 to 4 days post-op. A new order has been writtenfor Mr. Hansen, who is receiving patient-controlled analgesia (PCA). The order is for a changein PCA dosage.In Indiana, Mycee was not restricted from performing this task, but she does not recall whethershe is allowed to do so in Ohio. Since she can’t look up the Ohio Administrative Code rightnow to see if the task is within her scope of practice, she consults with her charge nurse. Thecharge nurse tells Mycee that this is not within the scope of the LPN in Ohio. As a registerednurse (RN), the charge nurse addresses the new order.Later, when Mycee has a break, she refers to “Using the Scope of Practice Decision-MakingModel” and then visits the Ohio Administrative Code website indicated in that document. Shereads Chapter 4723-17-03 (A) (4) of the code, which describes the role of the LPN inintravenous therapy procedures. There she finds that an LPN may not “program or set anyfunction of a patient-controlled analgesic,” thereby confirming that the task is not within herlegal scope of practice in Ohio.Applying the Model YourselfTake a moment to think of a situation that could arise in your practice. Then ask yourself thefollowing five questions. If you cannot answer yes to questions 2 through 5, you should notundertake the action. 2019 WILD IRIS MEDICAL EDUCATION, INC.3

wildirismedicaleducation.comOhio Nurse Practice Act (2 Hours)1. What patient care task am I being asked to do, and what is this patient’scurrent condition?2. Does the nurse practice act in my jurisdiction permit me to perform this task?3. Do I have current, evidence-based knowledge and skills to correctly and safelyperform what I am being asked to do for this patient?4. Is this the most appropriate action to take for this patient at this time?5. Do I accept accountability for completing this task?Ohio Administrative CodeThe rules of the Board of Nursing regulate nursing practice in Ohio and are contained inSection 4723 of the Ohio Administrative Code (OAC). This course reviews those chaptersin Section 4723 that set forth the standards of competency, safe nursing practice, delegation,application of the nursing process, and discipline for registered nurses and licensed practicalnurses in the state of Ohio.OHIO ADMINISTRATIVE CODE, SECTION 4723, BOARD OF 234723-254723-264723-27Board Organization and RecordsLicensing for Active Duty Military and VeteransDefinitionsStandards of Practice Relative to Registered Nurse or Licensed Practical NurseNursing Education ProgramsAlternative Program for Chemical Dependency/Substance Use Disorder MonitoringExamination and LicensureAdvanced Practice Registered Nurse Certification and PracticePrescriptive AuthorityCourses in Medication Administration [Rescinded]Peer Support Program [Rescinded]Personal Information System [Rescinded]Delegation of Nursing TasksContinuing EducationHearingsIntravenous Therapy Courses for Licensed Practical NursesPractice Intervention and Improvement Program (PIIP)Advanced Practice NursesPrevention of Disease TransmissionDelegation in MR/DD County Board Facilities [Rescinded]Delegation of the Authority to Give Oral and/or Apply Topical Medications inICFS/MR with Fifteen or Fewer Residents [Rescinded]Dialysis TechniciansNurse Education Grant ProgramCommunity Health Workers ChapterMedication Administration by Certified Medication Aide 2019 WILD IRIS MEDICAL EDUCATION, INC.4

wildirismedicaleducation.comOhio Nurse Practice Act (2 Hours)CONTINUING EDUCATION FOR RENEWAL FOR RNs and LPNsFor the period immediately following Ohio licensure by NCLEX examination, the nurse is notrequired to complete any contact hours of CE for the first license renewal. Other than the firstrenewal immediately following licensure by exam, nurses must complete at least 24 contacthours of CE that includes at least one contact hour of Category A CE for each renewal. A nursewho has been licensed in Ohio by reciprocity for less than or equal to one year prior to the firstOhio license renewal must complete at least 12 contact hours, rather than 24 (OBN, 2019b).PROFESSIONAL ORGANIZATIONSOne of the hallmarks of a profession is that its members band together in collegial association toprovide a variety of services for its members. These services include such things as continuingeducation, collective bargaining, legislative advocacy, and information about the profession.These organizations are not set up by state laws or through the government.The American Nurses Association is the nationwide professional organization representing theinterests of nurses. In Ohio, professional associations include the Ohio Nurses Association,Licensed Practical Nurses Association of Ohio, Ohio Association for Advanced Practice Nurses,Ohio State Association of Nurse Anesthetists, and state chapters of other specialty associationssuch as perioperative nurses, critical care nurses, nephrology nurses, dialysis technicians, andother groups. Typically, associations are run by boards of trustees elected by members who payvoluntary membership dues.OHIO NURSES ASSOCIATION MISSIONThe mission of professional associations is characterized by that of the Ohio NursesAssociation (ONA).Its mission is to advance professional nursing in Ohio. This will be accomplished through: Evolving evidence-based practice Influencing legislators Promoting education Improving economic and general welfare Advocating for quality healthcare in a cost-effective and economicallystimulating manner(ONA, 2016) 2019 WILD IRIS MEDICAL EDUCATION, INC.5

wildirismedicaleducation.comOhio Nurse Practice Act (2 Hours)The primary difference between the Ohio Board of Nursing and professional organizations is thatprofessional organizations have no legal authority, whereas the Ohio Board of Nursing hasauthority because it was established by the Nurse Practice Act with the unambiguous function ofpromoting and protecting the health of citizens through safe nursing practice (OBN, n.d.).CODE OF ETHICS FOR NURSESIn addition to abiding by the laws established in the Nurse Practice Act, every member of aprofession is expected to read, understand, and abide by the ethical standards of its occupation.In the case of nursing, the American Nurses Association publishes the Code of Ethics forNurses with Interpretive Statements to guide nurses’ professional practice.The following provisions of the code broadly describe the ethical obligations of nurses:Provision 1. The nurse practices with compassion and respect for the inherent dignity, worth,and unique attributes of every individual.Provision 2. The nurse’s primary commitment is to the patient, whether an individual, family,group, community, or population.Provision 3. The nurse promotes, advocates for, and protects the rights, health, and safety ofthe patient.Provision 4. The nurse has authority, accountability, and responsibility for nursing practice;makes decisions; and takes action consistent with the obligation to provide optimal care.Provision 5. The nurse owes the same duties to self as to others, including the responsibility topromote health and safety, preserve wholeness of character and integrity, maintain competence,and continue personal and professional growth.Provision 6. The nurse, through individual and collective effort, establishes, maintains, andimproves the ethical environment of the work setting and conditions of employment that areconducive to safe, quality health care.Provision 7. The nurse, in all roles and settings, advances the profession through research andscholarly inquiry, professional standards development, and the generation of both nursing andhealth policy.Provision 8. The nurse collaborates with other health professionals and the public to protecthuman rights, promote health diplomacy, and reduce health disparities.Provision 9. The profession of nursing, collectively through its professional organizations,must articulate nursing values, maintain the integrity of the profession, and integrate principlesof social justice into nursing and health policy.(ANA, 2015) 2019 WILD IRIS MEDICAL EDUCATION, INC.6

wildirismedicaleducation.comOhio Nurse Practice Act (2 Hours)STANDARDS OF COMPETENCY FOR RNs[This section covers subsections (A) thru (K) of the OAC 4723-4-03, Standards relating to competent practice as aregistered nurse.]Registered nurses (A) provide nursing care within the scope of practice described in the OhioRevised Code and the rules of the Ohio Board of Nursing and (B) maintain current knowledgeof the duties, responsibilities, and accountabilities of safe nursing practice.RNs must (C) be competent and accountable in all areas of practice, including consistentperformance of all aspects of nursing care and appropriate recognition, referral or consultation,and intervention when complications arise.RNs may (D) provide nursing care beyond basic nursing preparation for an RN provided they: Obtain additional education Demonstrate appropriate knowledge, skills, and abilities Maintain documentation of their additional education and training Have a specific current order from an authorized professional Do not carry out a function or procedure prohibited by any law or rule. The RN must actwithin the course of his/her professional practice.RNs must (E) implement any order in a timely manner unless they believe or have reason tobelieve the order is: Inaccurate Not properly authorized Not current or valid Harmful or potentially harmful to a patient Contraindicated by other documented informationRNs must (E) clarify an order that meets any of the above criteria by consulting with anappropriate licensed practitioner.When RNs (F) decide not to follow an order or prescribed medication or treatment afterconsulting with an appropriate licensed practitioner, the RN must: Notify the ordering practitioner of the decision not to follow the order Document that fact and state the reason for not following the direction Take any other action to ensure the safety of the patient 2019 WILD IRIS MEDICAL EDUCATION, INC.7

wildirismedicaleducation.comOhio Nurse Practice Act (2 Hours)RNs (G) report to and consult with other nurses or members of the healthcare team and makereferrals as appropriate in a timely manner.RNs must (H) maintain the confidentiality of patient information, communicating patientinformation with other members of the healthcare team for healthcare purposes only andaccessing patient information only for healthcare and patient care purposes or for fulfillingnursing responsibilities. This includes not disseminating patient information through socialmedia, texting, emailing, or any other form of communication for purposes other thanpatient care.To the maximum extent feasible, RNs must (I) not directly disclose identifiable patienthealthcare information unless the patient has consented to such disclosure and must reportindividually identifiable patient information without written consent in limited circumstancesonly and in accordance with authorized laws and rules.RNs must (J) use acceptable standards of safe nursing care as a basis for any observation,advice, instruction, teaching, or evaluation and communicate information that is consistent withacceptable standards of safe nursing care.When RNs (K) give direction to LPNs, they must first assess: Condition and stability of the patient who needs nursing care The type of care required The complexity and frequency of care required The training, skill, and ability of the LPN who is to perform the care The availability and accessibility of resources needed to safely perform thefunction or procedureThe tasks assigned to LPNs must also be within the licensed practical nurse’s legal scopeof practice.STANDARDS OF COMPETENCY FOR LPNs[This section covers subsections (A) thru (J) of the OAC 4723-4-04, Standards relating to competent practice as alicensed practical nurse.]A licensed practical nurse (LPN) must (A) function within the scope of practice of an LPN asset forth in division (F) of Section 4723.01 of the Ohio Revised Code and the rules of the OhioBoard of Nursing.An LPN must (B) maintain current knowledge of the duties, responsibilities, andaccountabilities for safe nursing practice. 2019 WILD IRIS MEDICAL EDUCATION, INC.8

wildirismedicaleducation.comOhio Nurse Practice Act (2 Hours)An LPN must (C) demonstrate competency and accountability in all areas of practice,including consistent performance of all aspects of nursing care and appropriate recognition,referral or consultation, and intervention when complications arise.An LPN may (D) provide nursing care beyond basic preparation for an LPN provided the LPNobtains appropriate education; demonstrates knowledge, skills, and abilities; and maintainssatisfactory records of meeting these requirements. The LPN must have a valid order or directionfrom an authorized individual and the nursing care cannot involve a function or procedureprohibited by any law or rule.LPNs must (E) implement or clarify an order in a timely manner unless or whenever theybelieve or have reason to believe the order is: Inaccurate Not properly authorized Not current or valid Harmful or potentially harmful to a patient Contraindicated by other documented informationWhen (F) clarifying an order or direction, the LPN must consult with an authorized practitioneror directing RN. If the LPN decides not to follow the direction, the LPN, in a timely manner,must: Notify the ordering practitioner of the decision not to follow the order Document that fact and state the reason for not following the direction Take any other action to ensure the safety of the patientAn LPN must (G) report to and consult with other nurses or other members of the healthcareteam and make referrals as appropriate.An LPN must (H) maintain the confidentiality of patient information, communicating patientinformation with other members of the healthcare team for healthcare purposes only andaccessing patient information only for healthcare and patient care purposes or for fulfillingassigned job responsibilities. This includes not disseminating patient information throughsocial media, texting, emailing, or any other form of communication for purposes other thanpatient care.An LPN (I) does not disclose identifiable patient healthcare information unless the patient giveswritten consent by a properly executed release of information. Only in limited circumstances inaccord with authorized legal authority does an LPN release individually identifiable patienthealthcare information without a written consent of the patient.When directed to observe, advise, instruct, or evaluate the performance of a nursing task, theLPN (J) uses acceptable standards of safe nursing care as a basis for that observation, advice, 2019 WILD IRIS MEDICAL EDUCATION, INC.9

wildirismedicaleducation.comOhio Nurse Practice Act (2 Hours)instruction, teaching, or evaluation and communicates information consistent with acceptablestandards of safe nursing care with respect to the nursing task.STANDARDS OF COMPETENCY FOR ADVANCED PRACTICENURSES[This section covers subsections (A) thru (D) of the OAC 4723-4-05, Standards relating to competent practice as acertified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nursespecialist.]A certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, andclinical nurse specialist must (A): Function within the scope of practice of nursing for a registered nurse as set forthin division (B) of Section 4723.01 of the Ohio Revised Code and the rules of theOhio Board of Nursing. Function within the nurse’s applicable scope of practice. If authorized by Ohio law to prescribe, practice according to Section 4723.481 of theRevised Code and Section 4723-9 of the Administrative Code.When the practice of a certified nurse-midwife, certified nurse practitioner, or clinical nursespecialist is evaluated, the (B) evaluation must be done by a collaborating licensed physician orpodiatrist, or an advanced practice registered nurse holding a current, valid license with the samedesignation as the individual being evaluated.When the practice of a certified registered nurse anesthetist is evaluated, the (C) evaluation mustbe done by a supervising licensed physician, podiatrist, dentist, or certified registered anesthetistwhose license is current and valid.A certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, orclinical nurse specialist may provide care within their specialty, provided the nurse (D): Obtains appropriate education from a recognized body of knowledge Demonstrates knowledge, skills, and abilities Maintains documented evidence of these skills and abilities 2019 WILD IRIS MEDICAL EDUCATION, INC.10

wildirismedicaleducation.comOhio Nurse Practice Act (2 Hours)STANDARDS THAT PROMOTE PATIENT SAFETY[This section covers subsections (A) thru (Q) of the OAC 4723-4-06, Standards of nursing practice promotingpatient safety.](A–C) When providing direct nursing care to patients or engaging in nursing practice in personor by telecommunication, licensed nurses, certified nurse-midwives, certified nurse practitioners,certified registered nurse anesthetists, or clinical nurse specialists must display and identifytheir applicable title or initials (degree) or identify to each patient the nurse’s title or initials(degree) as a registered nurse or licensed practical nurse.Licensed nurses must (D) delegate nursing tasks, including medication administration, onlyin accordance with chapters 4723-13, 4723-23, 4723-26, or 4723-27 of the OAC. (See also“Delegation Guidelines” below.)Licensed nurses must (E) report and document their nursing assessments and observations,care provided, and the patient’s response to that care in a timely and accurate manner. Licensednurses must document any (F) errors or deviations from a prescribed regimen to the appropriatepractitioner in a timely, complete, and accurate manner.Licensed nurses must (G) not falsify, or conceal by any method, patient records or any otherdocument prepared or used in the course of nursing practice. This includes case managementdocuments or reports, time records, reports, and other documents related to billing for nursingservices.Licensed nurses must (H) implement measures to promote a safe environment for patients and(I) maintain a professional boundary between themselves and patients. They must (J) provideprivacy during examination and care and treat each patient with courtesy, respect, and fullrecognition of dignity and individuality.Licensed nurses must (K) not engage in behavior that causes or may cause physical, verbal,mental, or emotional abuse to a patient or engage in behavior that a reasonable person wouldinterpret as physical, verbal, mental, or emotional abuse.A licensed nurse must not (L) misappropriate the property of patients or: Engage in behavior to seek or obtain personal gain at the patient’s expense, or that mayreasonably be interpreted as such Engage in behavior that constitutes inappropriate involvement in the patient's personalrelationships or financial matters, or that may reasonably be interpreted as suchA licensed nurse must not (M): Engage in sexual conduct with a patient, or conduct that may be interpreted as sexual Engage in verbal behavior that is seductive or sexually demeaning to a patient, or thatmay be interpreted as such 2019 WILD IRIS MEDICAL EDUCATION, INC.11

wildirismedicaleducation.comOhio Nurse Practice Act (2 Hours)The patient is always presumed incapable of giving free, full, or informed consent to thebehaviors by the nurse set forth in (L) and (M) above.When licensed nurses (N) function in administrative roles, they must make sure that there areprocedures in place and implemented to verify that every nurse, dialysis technician, ormedication aide working under their administration has a current valid license or valid certificatein Ohio to practice in the role to which they are assigned.Only RNs may (O) supervise or evaluate the nursing practice of RNs and LPNs; however, nonnursing supervisors may evaluate nurse employees in matters other than the practice of nursing.A licensed nurse must not (P) make or submit or cause to be submitted any false, misleading, ordeceptive statements to the OBN, current or prospective employers, facilities or organizationsfor whom the nurse is working, members of the healthcare team, or law enforcement personnel.A nurse must (Q) not use social media, texting, emailing, or other forms of communication withor about a patient for non-healthcare purposes or for purposes other than fulfilling the nurse'sassigned job responsibilities.DELEGATION GUIDELINESWhen all conditions for delegation set forth in Chapter 4723-13-05 of the OAC are met, aregistered nurse may delegate a nursing task to an unlicensed person and a licensed practicalnurse may delegate a nursing task to an unlicensed person at the direction of the registerednurse. These conditions are summarized below.Except as otherwise authorized by law or this chapter, a licensed nurse may delegate to anunlicensed person the administration of only the following medications: Over-the-counter topical medications to be applied to intact skin for the purpose ofimproving a skin condition or providing a barrier Over-the-counter eye drop, ear drop, and suppository medications, foot soak treatments,and enemasPrior to delegating a nursing task to an unlicensed person, the delegating nurse must makecertain determinations regarding the nature of the task and the qualifications of theunlicensed person who will carry it out. The nursing task is within the scope of practice of the delegating nurse The nursing task is within the knowledge, skill, and ability of the nurse delegatingthe nursing task The nursing task is within the training, ability, and skill of the unlicensed person whowill be performing the delegated nursing task 2019 WILD IRIS MEDICAL EDUCATION, INC.12

wildirismedicaleducation.comOhio Nurse Practice Act (2 Hours) Appropriate resources and support are available for the performance of the task andmanagement of the outcome Adequate and appropriate supervision by a licensed nurse of the performance of thenursing task is available That:o The nursing task requires no judgment based on nursing knowledge and expertiseon the part of the unlicensed person performing the tasko The results of the nursing task are reasonably predictableo The nursing task can be safely performed according to exact, unchangingdirections, with no need to alter the standard procedures for performing the tasko The performance of the nursing task does not require that complex observationsor critical decisions be made with respect to the nursing tasko The nursing task does not require repeated performance of nursing assessmentso The consequences of performing the nursing task improperly are minimal and notlife-threateningPrior to delegating a nursing task, the delegating nurse must also make certain determinationsregarding the patient and the conditions: Identify the individual on whom the nursing task may be performed and a specific timeframe during which it may be performed. Complete an evaluation of the conditions that relate to task to be performed, including:o An evaluation of the individual who needs nursing careo The types of nursing care the individual requireso The complexity and frequency of the nursing care neededo The stability of the individual who needs nursing careo A review of the evaluations performed by other licensed healthcare professionalsThe delegating

The Nurse Practice Act (ORC 4723) authorizes the OBN to make and enforce rules and regulations for registered nurses, licensed practical nurses, dialysis technicians, and advanced practice nurses (certified nurse-midwives, certified nurse practitioners, certified nurse specia

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