In early 2015, the Tri-Council for Nursing, consisting of the American Association of Colleges of Nursing (AACN), the American

www.journalofnursingregulation.com 19Volume 7/Issue 3 October 2016

Scope of Nursing Practice Decision-Making Framework Karen Ballard, MA, RN, FAAN; Deb Haagenson, BSN, RN; Linda Christiansen, EdD, JD, MSN, RN; Gloria Damgaard, MS, RN, FRE; Judith A. Halstead, PhD, RN, FAAN, ANEF; Ruby R. Jason, MSN, RN, NEA-BC; Jane Clare Joyner, MSN, RN, JD; Ann M. O’Sullivan, MSN, RN, CNE, NE-BC, ANEF; Josephine Silvestre, MSN, RN; Maureen Cahill, MSN, RN, APN-CNS; Beth Radtke, MS; and Maryann Alexander, PhD, RN, FAAN

In early 2015, the Tri-Council for Nursing, consisting of the American Association of Colleges of Nursing (AACN), the American

Nurses Association (ANA), the American Organization of Nurse Executives (AONE), and the National League for Nursing

(NLN), in collaboration with the National Council of State Boards of Nursing (NCSBN) determined that a uniform tool (scope of

practice decision-tree) was needed. Representatives from the ANA, NLN, and Boards of Nursing, along with NCSBN staff, hat

would assist nurses and their employers in determining the responsibilities a nurse can safely perform. Upon examination

of these existing algorithms and identification of essential elements, a uniform scope of practice decision-making framework

was developed.

Keywords: Decision-making tool, nurse practice acts, nursing regulation, scope of nursing practice

Upon graduating from nursing programs, new nurses have a relatively proficient understanding of the interventions, skills, and responsibilities they are able to perform under

the purview of their state Nurse Practice Act (NPA). However, at some juncture, a nurse may encounter a situation in which he or she is asked to perform a skill or assume a responsibility that he or she is uncertain about undertaking. This may be because the skill is one that is not traditionally a nursing responsibility, or he or she feels does not feel qualified to perform it safely. How do nurses decide if a responsibility is within their scope of practice?

As nursing knowledge and practice increases, questions about scope of practice emerge and present a quandary for nurses who want to expand their knowledge and skills yet still remain within the boundaries of regulation. To assist nurses and employers with this decision-making process, four major nursing organizations col- laborated and developed a scope of practice decision-tree that was developed by an expert panel and vetted by the board of directors of the American Association of Colleges of Nursing (AACN), the American Nurses Association (ANA), the American Organization of Nurse Executives (AONE), and the National League for Nursing (NLN), in collaboration with the National Council of State Boards of Nursing (NCSBN)

The tool could be adopted by state boards of nursing (BONs), used by facilities, and would help nurses determine whether specific activities, interventions or roles are permitted under a nurse’s level of education, licensure, and competence, and meet the standards estab- lished by the NPA and rules/regulations of each state/jurisdiction.

Members of the expert panel combined their knowledge, reviewed the literature, and methodically examined existing decision- making algorithms utilized by BONs. The algorithms across states/ jurisdictions addressed many similar questions; however, some states included specific nuances, such as directing the user to uti- lize the Cumulative Index of Nursing and Allied Health Literature (CINAHL) to explore current accepted practice if no specific practice decision existed. Some of the algorithms were complex, while a few were straightforward. One algorithm suggested that the chief nurse of an organization may decide what is within the scope of practice of a licensed nurse based on the use of the algorithm.

Upon completion of their review, , the panel determined that it was crucial for the scope of nursing practice decision-making framework to be applicable to all activities, interventions, and roles of all licensed nurses without being overly restrictive. Additionally, the panel believed that the framework should be applicable to all types of nurse practice settings. The panel determined the key questions to include in the decision-making framework, as well as specified the targeted population, the context for use, and key definitions. Using this information, a draft decision-making framework was developed and forwarded to the panel for review and comment. The frame- work (See Figure 1) was reviewed and approved by the Tri-Council in February 2016 and by the NCSBN Board of Directors in July 2016.

Purpose Recognizing that nursing practice is continually evolving, this docu- ment serves to provide a standardized, decision-making framework

20 Journal of Nursing Regulation

FIGURE 1

Scope of Nursing Practice Decision-making Framework

Identify, describe, or clarify the activity, intervention, or role under consideration.

Is the activity, intervention, or role prohibited by the NPA and rules/regulations or any other applicable laws, rules/regulations, or accreditation standards or professional nursing scope and standards?

YES STOP

NO

Is performing the activity, intervention, or role consistent with evidence-based nursing and health care literature?

NO STOP

YES

Are there practice setting policies and procedures in place to support performing the activity, intervention, or role?

NO STOP

YES

Has the nurse completed the necessary education to safely perform the activity, intervention, or role? NO STOP

YES

Is there documented evidence of the nurse’s current competence (knowledge, skills, abilities, and judgments) to safely perform the activity, intervention, or role?

NO STOP

YES

Does the nurse have the appropriate resources to perform the activity, intervention, or role in the practice setting?

NO STOP

YES

Would a reasonable and prudent nurse perform the activity, intervention, or role in this setting? NO STOP

YES

Is the nurse prepared to accept accountability for the activity, intervention, or role and for the related outcomes?

NO STOP

YES

The nurse may perform the activity, intervention, or role to acceptable and prevailing standards of safe nursing care

www.journalofnursingregulation.com 21Volume 7/Issue 3 October 2016

for all licensed nurses in all settings with respect to their education, role, function, and accountability within the scope of nursing prac- tice. It will assist nurses, including direct care nurses, in navigating current nursing practice with all of its challenges. As practice trans- forms, licensed nurses need to communicate any ongoing issues/con- cerns to their BONs so that regulators can evaluate whether changes to the NPA, rules/regulations, or standards need to be considered.

Targeted Population The population for which this framework was devised includes all licensed nurses (LPN/VN, RN, and APRN) at all experience levels (novice to expert) in all practice settings and in all roles such as: ⦁ Direct care nurses ⦁ Nurse managers ⦁ Nurse administrators ⦁ Nurse educators ⦁ Nurse researchers ⦁ Nurse regulators ⦁ Nurse policymakers

Context for Use To promote safety of patients, nurses would use this framework to: ⦁ Determine individual accountability for practice decisions ⦁ Communicate with other health care professionals regarding the

scope of nursing practice and the nurse’s accountability ⦁ Inform health care and other employing organizations about the

scope of nursing practice and nursing accountability ⦁ Educate nursing students about their accountability for practice

decisions ⦁ Guide professional nursing organizations, and credentialing and

regulatory agencies in the formulation of scope and standards of practice, policy, and position statements.

Key Definitions The panel determined that the following key definitions are an important part of the decision-making framework:

Accountability: The panel is using the ANA’s definition of accountability, which states that accountability means “to be answer- able to oneself and others for one’s own choices, decisions and actions as measured against a standard such as that established by the Code of Ethics for Nurses with Interpretive Statements.” (American Nurses Association [ANA], 2015, page 41)

Furthermore, the ANA sets forth that “to be accountable, nurses follow a code of ethical conduct that includes moral principles such as fidelity, loyalty, veracity, beneficence, and respect for the dig- nity, worth, and self-determination of patients, as well as adhering to the scope and standards of nursing practice. Nurses in all roles are accountable for decisions made and actions taken in the course of nursing practice. Systems and technologies that assist in clinical

practice are adjunct to, not replacements for, the nurse’s knowledge and skill.

Therefore, nurses are accountable for their practice even in instances of system or technology failure” (ANA, 2015a, page 15-16).

Appropriate resources: Appropriate resources means that nurses have the human and material support to perform the activ- ity, intervention, or role safely, including any necessary emergency management.

Education: By education, the panel is referring to basic nurs- ing education, advanced nursing education, or professional develop- ment to support in the activity, intervention, or role

Professional nursing standards: According to the National Federation of Licensed Practice Nurses, “professional nursing stan- dards” refers to a set of standards for the practice of safe and effective nursing care such as Nursing: Scope and Standards of Practice, Third Edition (ANA, 2015) and Nursing Practice Standards for the Licensed Practice/Vocational Nurse (National Federation of Licensed Practical Nurses, 2003).

Reasonable and prudent nurse: The panel defines a “rea- sonable and prudent nurses” as a nurse who uses good judgment in providing nursing care according to accepted standards and that another nurse with similar education and experience in similar cir- cumstances would provide.

Conclusion When the need arises to determine the scope of nursing practice, this decision-making framework should provide guidance to all lev- els of nurses in all roles and settings. As nursing practice continues to evolve, licensed nurses should refer ongoing practice concerns or questions to their BON so regulators can determine whether revi- sions to the NPA or rules/regulations should be considered.

References American Nurses Association. (2015). Code of ethics for nurses with interpre-

tive statements. Accessed from: http://nursingworld.org/Document- Vault/Ethics_1/Code-of-Ethics-for- Nurses.html.

American Nurses Association. (2015). Nursing: Scope and Standards of Prac- tice, Third Edition. Silver Spring, Maryland: Nursebooks.org.

The advisory panel was represented by the following individuals: Karen Ballard, MA, RN, FAAN – ANA; Deb Haagenson, BSN, RN – NCSBN; Linda Christiansen, EdD, JD, MSN, RN – NLN; Gloria Damgaard, MS, RN, FRE – NCSBN; Judith A. Halstead, PhD, RN, FAAN, ANEF – NLN; Ruby R. Jason, MSN, RN, NEA-BC – NCSBN; Jane Clare Joyner, MSN, RN, JD – ANA; Ann M. O’Sullivan, MSN, RN, CNE, NE-BC, ANEF – ANA; Josephine Silvestre, MSN, RN – NCSBN; Maureen Cahill, MSN, RN, APN-CNS – NCSBN; Beth Radtke, MS – NCSBN; Maryann Alexander, PhD, RN, FAAN – NCSBN