In our last post, we met LPN Linda, who had closed a 3 cm laceration on the forehead of her patient with Dermabond, even though she had not been formally trained in the procedure.  She was instructed to perform the closure by the on-call provider, Dr. Smith. The wound healed well without any complications.  When her supervisor questioned her the next day and told her that the state Nurse Practice Act did not allow LPNs to perform any type of wound closure, LPN Linda stated that she knew the Nurse Practice Act in her state of residency, but was unaware of the Nurse Practice Act in the state in which she was working because she was there under the authorization of a multi-state license. She also stated that she believed that it was okay to do the closure because Dr. Smith had authorized her to do it.

Scope of Practice Decision-Making Framework

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.  It is very straightforward. Most states have implemented /recommended this decision-making algorithm, and I encourage all nurses to use it in their practice.  This framework includes a series of questions that should be asked before performing a nursing act about which you are uncertain.  Components of the framework include whether the act is prohibited by the state Nurse Practice Act;  whether it is consistent with evidence-based nursing and healthcare literature; whether there are policies and procedures in your practice setting that allow performance of the act; whether the nurse has completed the necessary education to safely perform the act; whether there is documented evidence of competency; whether the nurse has the resources to perform the act; whether a reasonable and prudent nurse would perform the act; and whether the nurse is prepared to accept accountability for the act.  If all criteria are met, then the nurse can perform the act, as long as it is performed to acceptable and current standards of safe nursing care.  While using the Scope of Practice Decision Making Framework, if at any time the STOP sign is encountered, then the nurse should stop the analysis and not perform the act in question.  

It is also very important to note that even if the act is allowed by the Nurse Practice Act, nursing standards and facility policy and procedures, if the nurse has not been trained, or there is no documented verification of competency in the act, then the nurse should not perform the act.

A Word About Multi-State Licenses

The NCSBN also oversees the Nurse Licensure Compact, legislation in individual States that allows nurses licensed in one member state to practice in all member states under their “home” multi-state license.  The Compact requires that nurses meet uniform licensing requirements before they are licensed under a “compact” or “multi-state” license.  Today many of us have a multi-state license, which allows us to practice in over 33 states.  It is vitally important to note that you must know the Nurse Practice Act and the state Nursing Board’s rules and regulations governing your practice in all states in which you practice.  While they may be different from your primary state of licensure, you are held accountable for practicing according to that state’s Nurse Practice Act and that state’s Nursing Board’s rules and regulations. 

Do you use the Scope of Practice Decision-Making Framework in your practice? Please share your experiences with decisions about your scope of practice and practicing in a Compact state in the comments section below.