LPN Linda is on duty at the county jail when Mr. Martin strikes his head on the top bunk metal frame.  She is called to the pod, and after determining that Mr. Martin is stable with only a 3 cm laceration to the middle of his forehead, she brings him to the medical unit.  After she cleans the wound and the bleeding is stopped with pressure, she notes that the wound is gaping.  She calls the provider on-call, Dr. Smith, who tells her to “use the superglue” on Mr. Martin’s laceration.  LPN Linda tells Dr. Smith that she has seen the procedure done many times, but she has not been formally trained on the application of Dermabond and she has never done it herself.  Dr. Smith tells her she is a great nurse and to go ahead and do it.  

LPN Linda does the application and the wound heals without a problem.

LPN Linda is working in a state where the Nurse Practice Act does not allow LPNs to suture or provide any type of wound closure, although LPN Linda is not aware of her scope of practice in that state because she is there working under a multi-state license. 

Did LPN Linda practice beyond her scope?  Could she be reported to the Board of Nursing even though there was no negative outcome in Mr. Martin’s care?  The answers are simple – yes, she did practice beyond her scope as an LPN and yes, she could be reported to the Board of Nursing, even with a successful intervention.  

How did we determine this? 

The Nurse Practice Act in each state determines the professional nursing activities of the LPNs, RNs and APRNs licensed in that state.  It is typically authored by the state Board of Nursing and is enacted into law by the state legislature.  In most states, the Nurse Practice Act is purposefully written broadly. The State Boards of Nursing define and interpret the state Nurse Practice Act, and monitor the nursing activities of the nurses in their state. Nursing activities reported to the State Board of Nursing often are the result of a negative patient outcome, but any instance of a nurse practicing beyond her/his scope of practice can result in an investigation by the Board. The State Board of Nursing may implement rules and regulations for its nurses that are stricter than those in the Nurse Practice Act, but it cannot expand or change the Nurse Practice Act itself.  Any changes must be presented to and passed by the state legislature. All nurses are required to know the Nurse Practice Act in their state and practice accordingly.  Not knowing these parameters is not an excuse for practicing beyond its standards.

The nurse’s scope of practice is also dictated by national accreditation standards, specialty nursing scope and standards of practice (such as the Correctional Nurse: Scope and Standards of Practice), and the policies and procedures of the employer. However, it is important to note that none of these documents can authorize the nurse to have an expanded role beyond that set forth by the state Nurse Practice Act.  So, for example, if a policy of the healthcare company providing services at your facility allows LPNs to suture patients, but the Nurse Practice Act in your state prohibits this activity, then the policy should be changed to reflect the current legal parameter in the state. It is your responsibility as the licensed nurse to ensure that you are practicing within the requirements of the Nurse Practice Act and Board of Nursing in your state at all times.  

To assist nurses, employers and patients, the National Council of State Boards of Nursing (NCSBN) has developed a Scope of Practice Decision-Making Framework to be used when determining whether a particular nursing activity is within the nurse’s scope of practice.  In our next post, we will review the framework in more detail and discuss the implications of working under a multi-state license.

With regard to Linda’s specific actions, even without knowing if LPN practice in her state was prohibited from using the Dermabond, she performed an act knowing that she was not trained properly and had not demonstrated competence in the activity. This violated the Nurse Practice Act.

Do you know your state Nurse Practice Act and Board of Nursing rules and regulations? How do you handle being asked to perform a nursing act that you are not sure is allowed by your Nurse Practice Act? Please share your experiences in our comments section.