How Is Scope of Practice Determined for Nurses?
The Registered Nurse, or RN, is required to follow the Scope of Practice as mandated by each state. The nursing Scope of Practice is defined by the American Nurses Association (ANA) as, “the ‘who,’ ‘what,’ ‘where,’ ‘when,’ and ‘how’ of nursing.” It provides a legal definition of what nurses can and cannot do, legally.
Once the RN passes the NCLEX-RN and accepts licensure in a state he or she agrees to follow the Scope of Practice for that state. This is a legal and ethical requirement and the RN is held, by the State, to this standard. This is important because of the many areas of nursing and the many types of employers a RN may have.
The RN is covered, legally, by the state’s Scope of Practice and not necessarily by the job description or employer policies and procedures. These may hold up to some extent in a court of law but it is generally understood that the Scope of Practice is the standard for nurses. No policy or procedure should ask nurse to step outside of the state’s Scope of Practice.
Once the RN specializes in a certain area, such as, aesthetic nursing, the ANA in conjunction with each specialty organization offers resources to promote understanding of the individual Scope of Practice. Certification in a specialty area is a way to further the RNs legal responsibilities as each certification has it’s own Scope of Practice. It ensures competency in a new skill set to which the RN is now legally held.
For example, an inexperienced new graduate RN is not allowed, by state Scope of Practice, to perform laser hair removal. This makes sense because the new graduate RN has had no training in school to perform this task. But if the RN is hired by laser hair removal clinic, trained, and certified to perform this task, he or she is now covered by the Scope of Practice to perform this skill. Additionally, the general skill set of nonmaleficence is promoted because it ensures that an inexperienced RN without any training will not be performing laser hair removal on a patient, hence, doing ‘no harm.’
Another example, the new graduate would not be qualified to monitor a patient with an Intraventricular Device, which are placed for patients with traumatic brain injuries, because the RN has had no training with such devices and is not competent in this skill directly out of school. But once the RN is hired and trained to monitor a patient with this device he or she is now covered under the Scope of Practice. Later, the employer may require certification to promote learning and hold the RN to the high-standard of that certifying body, the American Association of Critical Care Nurses.
Each state’s Nurse Practice Act (NPA) is determined through the Boards of Nursing. As states are responsible to protect the public, nurse boards are charged with ensuring nurses practice within defined laws of practice.
Ignorance of the law is not an excuse to not follow the Nurse Practice Act. Nurses are responsible to know the details of the NPA in the states where they practice. Nurses can be held accountable when they, even mistakenly, violate NPA standards. For example, certain states require a nurse to report a driving while under the influence (DUI) violation. If not reported to the Board of Nursing, a nurse may face disciplinary action through the board.
Each state’s NPA is governed and enacted by that state’s legislature. Because the NPA is not detailed or sufficient enough to stand alone, the boards of nursing were created to further define and interpret laws around the NPA. Each Board of Nursing (BON) may enact more stringent laws related to the NPA, but may not go beyond the boundaries of the act. Each BON reports to the National Council of State Boards of Nursing (NCSBN) who oversees the laws and standards.
According to the NCSBN, each state’s Nurse Practice Act language must include:
- Authority, power, and composition of a state nursing board
- Education program standards
- Standards and scope of nursing practice
- Types and titles of licenses
- Requirements for licensure
- Grounds for disciplinary action, other violations, and remediation
The NCSB collaborates with many nursing authorities to set, revise, and define nursing practice. The American Association of Colleges of Nursing (AACN), the American Nurse Association (ANA), the American Organization of Nurse Executives (AONE), and the National League for Nursing (NLN) are some of the major players used to interpret regulations and determine standards of care.
A Standard of Care is different than a Scope of Practice. Standard of Care refers to care that is performed in consistence with other nurses of similar education, competency, and experience. Nursing practice and standards of care are often referenced together. For example, professional organizations such as the American Nursing Association publish authoritative statement documents, by interpreting the NPA and Standards of Practice, to define the overall practice of nursing.
As the practice of nursing requires knowledge, skill, and autonomous decision making, the Nurse Practice Act is the law that governs those decisions to protect the community from harm. Nurses are expected to know the NPA for the state in which they practice. The NCSB’s Scope of Practice Decision-Making Framework tool is a useful tool nurses can utilize to determine nursing practice responsibilities.
