Nursing Scope of Practice

Douglas Long, RN, MBA, PhD

• Publisher: Universal Publishers
• Year: 2021
• Print ISBN: 9781627343435
• eBook ISBN: 9781627343442
• Topic: Medicine
• Subtopic: Nursing

Nursing Scope of Practice is every nurse's guidebook to understanding this terrain. It strips away the confusion and provides a comprehensive, coherent explanation of the nursing scope of practice so nurses can work to the full extent of their abil

1

What is the Nursing Scope of Practice?

Cynthia, a nurse manager of a large department in a city hospital in Middle America, was training a new nurse in the med-surg department and asked her how she should give the 118-milligrams (mg) of methadone the physician had ordered when it comes in a 120-milligram vial. The RN answered that she could put the entire vial in a syringe, and then squirt out a little bit, and that should amount to the difference of 2 milligrams. Cynthia did not like that answer.

Legally, the nurse had only two choices: give the dosage exactly as written, assuming it was safe and appropriate for the clinical situation, or contact the prescribing physician to adjust the order. My first answer would be this: go back to the physician to get the order changed. After some more thought, it occurred to me that the problem is not about how to resolve that small difference of dosage, but that it’s about the nurse’s scope of practice (SoP; I sometimes refer to it simply as “scope”).

This is an example of how nurses are prevented from doing their jobs because of our scope of practice. An RN should simply be able to give the full 120mg dose. The vial comes in units of measure appropriate for that clinical environment, and a quick look at their references would show 120mg is a typical dosage. Also, the error factor is less than 1 percent (in other words, the difference between 118mg and 120mg is less than 1%). Anyone with an understanding of pharmacokinetics knows the effect of a medicine on an adult patient is not so precise that this difference would be a safety problem. If it would be, that patient should be in the ICU. Finally, it should come as no surprise that the medication came in 120mg vials.

Nurses have better things to do that worry about than giving such an exact amount when it has little clinical significance. An RN needs to prioritize her time, and spending it trying to give such a specific amount just because of a physician’s order is not a good use of her time. The physician’s time is also valuable, and should not be wasted adjusting orders to accommodate such a limitation on the nurse’s scope.

The nursing profession is rapidly growing, and technology is changing. Having a clearly stated legal mandate to do our jobs should be of the utmost importance. But we nurses have an odd relationship with our scope. We continue to work, day after day, thinking we are covered or constrained by some law that, in the end, doesn’t actually exist—or, at least, it doesn’t state what we think it does. Still, we get the job done. One of the most important ways for our profession to grow is to allow nurses to work at the full extent of the scope we currently have and expand our scope to allow us to make full use of our knowledge, skills, and abilities.

We are told from our first days in nursing school about the importance of knowing and following our scope. We’re reminded throughout our careers. Our employers routinely remind us to stay within our scope—especially when mistakes occur. That does not seem to translate into better understanding. In every study I could find in which nurses where asked to explain their scope, they could provide no more than vague notions of what they are and are not allowed to do in their jobs. Nurse researchers Nelly Oelke and Debbie White did a qualitative study in which they asked nurses to identify the facilitators and barriers to working at their full scope, and even the experienced nurses admitted openly that they do not really know what is in their scope or how it works.1 Still, these same nurses could articulate what they felt helped them in their practice or held them back. In other words, not knowing a formal scope did not impede them from performing their duties day after day without major difficulties (the researchers don’t mention whether anyone expressed concern over not knowing their formal scope). This ability of nurses to perform their job despite the lack of guidance is what I refer to as the paradox of the nursing scope of practice.

Even our experts and leaders seem ill informed when it comes to the SoP. I was in an island nation, not wealthy but not poor, meeting its Chief Nurse Officer (CNO). The country’s nursing system as a whole impressed me, given its small size and modest economic wealth. I described my research project and how many U.S. states and countries have no laws specifying an SoP. She quickly stated that her country has a large body of nursing law that covers all aspects of the profession. But in mid-sentence, she hesitated.

As CNO, she was responsible for advising her nation in the development of these laws. I could see in her eyes what I already knew: her country’s laws made no mention of scope of practice.

“But we need to have flexibility in some matters,” she continued, “and that means leaving things up to other … uh … other processes.” It was jarring.

Lack of Guidance

The nursing scope of practice is important for a lot of reasons, which is why it should be clearly stated in the law, easy to find, and easy to follow.

Go ahead and look for it on your state nursing board’s website.

That’s what I did as a new nurse. And again, in my graduate program, as part of an assignment. The second time searching for it, I figured all my experience and newfound knowledge would help me locate it online, and understand it at a deeper level. Not so. On the California Board of Registered Nursing (BRN) website, there’s a multipage explanation of the state’s regulation of the SoP, including an emphasis on the importance of following it strictly as a way to avoid being disciplined. Consequences of not doing so may include losing one’s job and nursing license, getting sued, and even being subjected to criminal prosecution. Every state, including California, has a nurse practice act (NPA) that is the main law relating to nursing. But the words “scope of practice” appear nowhere in California’s NPA. To be clear, there are many laws related to scope, but one would think the NPA would address the issue.

California’s nursing laws are not just an exception. Many states claim to have such laws when, in fact, there is little or nothing to be found.

The most common guidance I see in the nursing literature and from our state nursing boards (referred to in other countries as councils; henceforth, I refer to them as boards or Boards of Nursing, BoNs) is the admonition to “consult your supervisor” when a nurse has a question about what she is allowed to do. That is a non-answer.

When a nurse doesn’t know what to do, it’s because of a deficiency in her training and guidance. Her supervisor, or the facility in which she works, has the same deficiency—lack of guidance on the scope. It’s missing from our laws. Many well-used nursing textbooks neglect to mention it. Cherry and Jacob’s book on contemporary nursing issues doesn’t mention SoP,2 nor does Kozier and Erb’s book—the top-selling basic textbook.3 Even when scope is mentioned, the discussion is brief and unenlightening. I searched through my books on nursing documentation, nursing law, ethics, and other topics, and either there was no mention or it was a generic statement about its important and a suggestion to look at your licensing authority’s website for more information.

This is not to say there are no statements on our scope. Quite the opposite. There are many, virtually all written either by professional associations or government entities. These are the basic laws for all RNs. Advanced practice nursing entails a different set of rules, which will be discussed shortly. But before a nurse gets to advanced practice, she still needs to be licensed and work as an RN. In my California example, there was mention of a scope but no real substance to the laws. Other states have published SoP laws or rules, but with varying degrees of specificity. This is actually part of the problem. Having so many statements spelling out our scope adds to the confusion.

Scope of Practice Terminology

The terms used to describe the various forms of guidance provided from different quarters to establish or explain the nurse SoP can be confusing because of how synonymous they seem to be. The explanations here are aimed at clarifying their meaning.

Laws—enacted by governments; carry penalties for noncompliance; often difficult for the average person to understand because of centuries-old conventions regarding how laws are written. California’s Nursing Practice Act is an example.

Rules and regulations—generally, laws rewritten to make more specific the actions they intend, but may also be written independent of any laws; typically carry penalties for noncompliance. In this book, rule is used to indicate both, and the act of regulation or regulating is used to indicate government implementation and enforcement of those rules. An example can be found in the California Code of Regulations. Its section “Title 16. Professional and Vocational Regulations, Division 14. Board of Registered Nursing, Article 7. Standardized Procedure Guidelines” explains specifically how to write a standardized procedure that gives a nurse her right to perform a given nursing skill.

Policies—issued by hospitals, companies, the government and in some cases even by individuals (e.g., a nurse manager in a given facility). Policies do not carry the weight of law, but may still include penalties for noncompliance (such as a bank charge for bouncing a check). A hospital in California may, for example, require its nurses to perform only those skills for which it has a standardized policy.

What Is a Scope?

What I have just done thus far is make the case that the nursing profession has a problem, in which we lack guidance and a proper legal mandate to perform our jobs. To put it in a positive light, we have an opportunity to move the nursing profession forward by addressing this important issue.

What exactly is a nursing SoP, or any scope of practice for that matter? There is no short answer, and there is no gold-standard definition. A scope of practice, for any healthcare profession, does three things:4 define the practice of profession; limit the practice to certain people; and restrict the use of titles and credentials to holders of a license. Barbara Safriet of Yale Law School, who wrote one of the most widely cited articles on the subject, describes the SoP as “legislatively-defined spheres of activity within which various types of health-care providers…are authorized to practice.” We will see that the legislatures’ involvement does not carry as much weight as has been credited to these bodies. Nurses tend to look to government regulators for the scope, but a majo...

Table of contents

• Cover Page
• Half Title
• Full Title
• Copyright
• Table of Contents
• Preface
• Acknowledgments
• Introduction
• Chapter 1: What is the Nursing Scope of Practice?
• Chapter 2: Comparative Scopes of Practice in the United States
• Chapter 3: Competition with Physicians
• Chapter 4: Nursing Leadership and Growth
• Chapter 5: Wrong Directions
• Chapter 6: Conclusions
• Appendix A: Research Methods
• Appendix B: Global Perspectives
• Appendix C: Arab Gulf Nursing Scope of Practice Study
• Appendix D: Historical Timeline of the Nurse Scope of Practice
• Bibliography
• Index