Legal Scope of Nurse Practitioner Practice
Having an adequate legal description of NPs’ scope of practice in state law is important for the following reasons:
To allow NPs to perform at their level of education and training
To avoid any charges of practicing medicine without a license
To avoid imputation of liability for medical malpractice to someone other than the NP, usually a physician
To place accountability for benefits to patients and harm to patients squarely on the NP
To provide a basis for inclusion of NPs in the legal definition of primary care providers, which is necessary for admission to provider panels
To establish that the NP is a professional entity, not just a “nonphysician,” a “physician extender,” or whatever an agency, employer, or delegating physician decides a NP is
To get reimbursement for physician services, when provided by a NP
State law is the most powerful source of authority for professional practice. However, federal agencies and private businesses may have policies on NP scope of practice, and professional societies may have accepted certain tasks, functions, and decisions as part of NP scope of practice.
▪ Professional Association Definition of Scope of Practice
Some associations define the scope of practice for NPs in general or for individual NPs. For example, the American Academy of Nurse Practitioners’ statement on scope of practice says:
Nurse practitioners are licensed independent practitioners who practice in ambulatory, acute, and long-term care settings as primary and/or specialty care providers. According to their practice specialty they provide nursing
and medical services to individuals, families, and groups. In addition to diagnosing and managing acute episodic and chronic illnesses, NPs emphasize health promotion and disease prevention. Services include but are not limited to ordering, conducting, and interpreting diagnostic and laboratory tests, prescription of pharmacologic agents and treatments and nonpharmacologic therapies. Teaching and counseling individuals, families, and groups are a major part of nurse practitioners’ practice. As licensed independent practitioners, nurse practitioners practice autonomously and in collaboration with healthcare professionals and other individuals to diagnose, treat, and manage the patient’s health problems. They serve as healthcare resources, interdisciplinary consultants, and patient advocates.1
and medical services to individuals, families, and groups. In addition to diagnosing and managing acute episodic and chronic illnesses, NPs emphasize health promotion and disease prevention. Services include but are not limited to ordering, conducting, and interpreting diagnostic and laboratory tests, prescription of pharmacologic agents and treatments and nonpharmacologic therapies. Teaching and counseling individuals, families, and groups are a major part of nurse practitioners’ practice. As licensed independent practitioners, nurse practitioners practice autonomously and in collaboration with healthcare professionals and other individuals to diagnose, treat, and manage the patient’s health problems. They serve as healthcare resources, interdisciplinary consultants, and patient advocates.1
▪ Statutory Versus Regulatory Scope of NP Practice
Some states define scope of practice in statutes enacted by the state legislature. In other states, the legislature gives the board of nursing the authority to define the scope of NP practice. Either way is enforceable, and regulations carry the same force of law as statutes.
Some states describe scope of practice specifically, and some define it generally. State statutes describing NP scope of practice fall into six categories:
Scope of practice is clearly defined by statute.
Scope of practice is clearly defined by regulation.
Scope of practice is vaguely defined by statute.
Scope of practice is not defined.
Scope of practice is defined by exception from a state law prohibiting practice of medicine without a license.
Scope of practice is defined by the individual physician, who may delegate to an NP by law.
The first category is most secure for the NP.
At a time when NPs are viewed by physicians as competitors, the first response to competitive pressures will be for physicians to point to state law and ask for strict interpretation. For example, physicians may counter NP efforts to be designated as primary care providers (PCPs) for managed-care organizations or a patient’s “medical home” by claiming that state law does not explicitly authorize NPs to perform the necessary functions. Then, only NPs in states where the NP scope of practice is clearly defined as including medical diagnosis and treatment, prescription of medication, and oversight of comprehensive healthcare services for patients will have legal grounds for arguing that NPs should be admitted to provider panels as PCPs or designated a “medical home.”
A vaguely worded nurse practice act that states, for example, that the scope of NP practice includes “acts of advanced nursing practice” will not provide sound legal basis for arguments that NPs should be admitted to managed care provider panels or get fees for providing physician services. It is difficult to argue to managed-care executives, state administrators, and legislators that “acts of nursing practice” are the acts necessary to perform physician services.
▪ Physician Challenges to NPs’ Scope of Practice
An example of a physician challenge to NPs’ scope of practice is a 1984 Missouri court case, Sermchief v. Gonzales [660 S.W.2d 683 (Mo. 1984)]. That case, which the NPs won only after it went to the state’s supreme court, could be repeated in other states today where state law is not specific enough about the authority of NPs to diagnose and treat.
In Sermchief, two obstetrical-gynecologic NPs were working in a family planning clinic under written protocols with the clinic’s physicians. The NPs were taking histories, performing physical examinations, treating minor illnesses, and prescribing contraceptives. There was no charge of malpractice. The Missouri Board of Medicine charged that the NPs were practicing medicine without a license.
The lower court found that the NPs were practicing medicine without a license. However, the Missouri Supreme Court, on analyzing the nurse practice act, noted that the legislature had deleted a requirement that a physician directly supervise nursing functions and decided that by that deletion the legislature had intended to broaden the scope of nursing.
The NPs eventually prevailed in the Sermchief case, but that will not necessarily help NPs in other states if there is no express statutory authority for NPs’ medical functions. NPs need clear statutory definition of a scope of practice that includes medical diagnoses and treatment and prescriptive authority.
▪ Need for Clarity of Scope of Practice
Some state laws describe scope of practice succinctly, and others go into great detail. Longer is not necessarily better, and vague language should be avoided. Consider Oklahoma’s statute on nurse practitioner scope of practice.1
An advanced registered NP in accordance with the scope of practice of the advanced registered nurse practitioner shall be eligible to obtain recognition as authorized by the Board to prescribe, as defined by rules and subject to the medical direction of a supervising physician.
Citation: OKLA. STAT. ANN. tit. 59, § 567.3a(6).
Under Oklahoma’s statutory definition of NP scope of practice, an NP can prescribe, but it is unclear what else an NP can do. Oklahoma’s Administrative Code provides a detailed description of NP scope of practice, however.
An example of a general and succinct description of scope of practice is Pennsylvania’s law.
A CRNP … while functioning in the expanded role as a professional nurse, performs acts of medical diagnosis, or prescription of medical therapeutics, or corrective measures in collaboration with and under the direction of a physician.
Citation: 49 PA CODE § 21.251.
In one short sentence, Pennsylvania lawmakers give NPs authority to diagnose and treat medical conditions, including the writing of prescriptions.
See Exhibit 2-1 for a breakdown of elements of NP practice found in various state laws. See Appendix 2-A for the law of each of the states regarding NP scope of practice.
▪ NP Scope of Practice Compared with RN Scope of Practice
NP scope of practice usually includes medical diagnosis and treatment, while RN scope of practice usually includes “nursing diagnosis” and “nursing interventions” or “nursing treatments.”
Compare Oregon’s scope of practice for an RN to Oregon’s scope of practice for an NP. Oregon’s law on scope of practice of an RN states:
The Board recognizes that the scope of practice for the registered nurse encompasses a variety of roles, including, but not limited to:
Provision of client care;
Supervision of others in the provision of care;
Development and implementation of health care policy;
Consultation in the practice of nursing;
Nursing administration;
Nursing education;
Case management;
Nursing research;
Teaching health care providers and prospective healthcare providers;
Specialization in advanced practice;
Nursing informatics.
Citation: OR. ADMIN. § R. 851-045-0060.
Oregon’s board of nursing has elegantly defined scope of NP practice as follows:
… (3) The nurse practitioner provides holistic health care to individuals, families, and groups across the life span in a variety of settings, including hospitals, long-term care facilities, and community-based settings.
(4) Within his or her specialty, the nurse practitioner is responsible for managing health problems encountered by the client and is accountable for health outcomes. This process includes:
Assessment;
Diagnosis;
Development of a plan;
Intervention;
Evaluation.
The nurse practitioner is independently responsible and accountable for the continuous and comprehensive management of a broad range of health care, which may include:
Promotion and maintenance of health;
Prevention of illness and disability;
Assessment of clients, synthesis and analysis of data, and application of nursing principles and therapeutic modalities;
Management of health care during acute and chronic phases of illness;
Admission of his/her clients to hospitals and long-term care facilities and management of client care in these facilities;
Counseling;
Consultation and/or collaboration with other care providers and community resources;
Referral to other healthcare providers and community resources;
Management and coordination of care;
Use of research skills;
Diagnosis of health/illness status;
Prescribing, dispensing, and administration of therapeutic devices and measures, including legend drugs and controlled substances as provided in Division 56 of the Oregon Nurse Practice Act, consistent with the definition of the practitioner’s specialty category and scope of practice.
(6) The nurse practitioner’s scope of practice includes teaching the theory and practice of advanced practice nursing.
(7) The nurse practitioner is responsible for recognizing limits of knowledge and experience, and for resolving situations beyond his/her nurse practitioner expertise by consulting with or referring clients to other healthcare providers.
(8) The nurse practitioner will only provide healthcare services within the nurse practitioner’s scope of practice for which he/she is educationally
prepared and for which competency has been established and maintained. Educational preparation includes academic course work, workshops or seminars, provided both theory and clinical experience are included.
Citation: OR. ADMIN. § R. 851-050-0005.
EXHIBIT 2-1 Specific Functions Included in States’ Definitions of NP Scope of Practice
Diagnose | Treat | Prescribe | Admit to Hospital | LA |
AL | AL | AL | ME | |
AZ | AZ | AZ | AZ | MT |
CO | CO | CO | OR | NV |
CT | CT | CT | WA | NC |
DC | DE | DE | ND | |
FL | DC | DC | Refer | NH |
GA | FL | FL | AL | OK |
ID | GA | GA | AZ | OR |
IL | ID | ID | DC | SD |
IN | IL | IL | DE | |
LA | IN | IN | IN | Order Tests |
ME | KY | KS | LA | AL |
MD | LA | KY | ME | AZ |
MA | ME | LA | MD | DC |
MN | MD | MD | MT | DE |
MT | MA | MA | NC | FL |
NC | MN | ME | NE | GA |
ND | MT | MN | NH | HI |
NE | ND | NC | NJ | ID |
NH | NE | ND | NV | IL |
NJ | NV | NE | OK | KY |
NV | NH | NH | OR | LA |
NY | NJ | NJ | PA | MA |
OK | NY | NM | SD | MD |
OR | NC | NV | WA | ME |
PA | OK | NY | MT | |
SC | OR | OH | Repair | NE |
SD | PA | OK | Laceration | NH |
UT | SC | OR | NV | NJ |
VT | SD | PA | NV | |
WA | UT | RI | Teach | NC |
WV | VT | SC | AL | PA |
WA | SD | DE | WA | |
WV | TX | HI | WI | |
WY | UT | IN | ||
VT | KS | |||
WA | ||||
WI | ||||
WY |
In California, the scope of practice of an NP is defined as that of a registered nurse. A nurse practitioner or registered nurse gets the authority to perform medical acts through standardized procedures developed with physicians. Here is a statement from the California Board of Professional Nursing website about the scope of practice of a nurse practitioner:
The nurse practitioner (NP) is a registered nurse who possesses additional preparation and skills in physical diagnosis, psychosocial assessment, and management of health-illness needs in primary health care, who has been prepared in a program that conforms to Board standards as specified in California Code of Regulations, CCR, 1484 Standards of Education … The NP does not have an additional scope of practice beyond the usual RN scope and must rely on standardized procedures for authorization to perform overlapping medical functions (CCR Section 1485). Section 2725 of the Nursing Practice Act (NPA) provides authority for nursing functions that are also essential to providing primary health care, which do not require standardized procedures. Examples include physical and mental assessment, disease prevention and restorative measures, performance of skin tests and immunization techniques, and withdrawal of blood, as well as authority to initiate emergency procedures. Nurse practitioners frequently ask if they really need standardized procedures. The answer is that they do when performing overlapping medical functions. Standardized procedures are the legal authority to exceed the usual scope of RN practice. Without standardized procedures, the NP is legally very vulnerable, regardless of having been certified as an RN, who has acquired additional skills as a certified nurse practitioner.2
In general, NPs may make medical diagnoses and initiate and perform medical treatments, while RNs may not. RNs may make nursing diagnoses, carry out physician or NP orders, and perform nursing treatments, as well as many other functions. Ideally, NPs have clear authority under state law to perform comprehensive evaluations, make medical diagnoses, order tests, initiate and perform medical therapies, including the prescribing of medication, and admit patients to hospitals.
▪ NP and MD Scope of Practice Compared
When NP scope of practice is defined to include diagnosis, treatment, prescriptive authority, and admission of patients to hospitals, as in Oregon law, there is little legal difference between NP and physician scope of practice. However in most states, medical scope of practice is defined more broadly than the scope of practice for any other healthcare professional. Consider Mississippi’s definition of the practice of medicine:
The practice of medicine shall mean to suggest, recommend, prescribe, or direct for the use of any person, any drug, medicine, appliance, or other
agency, whether material or not material, for the cure, relief, or palliation of any ailment or disease of the mind or body, or for the cure or relief of any wound or fracture or other bodily injury or deformity, or the practice of obstetrics or midwifery, after having received, or with the intent of receiving therefore, either directly or indirectly, any bonus, gift, profit, or compensation; provided, that nothing in this section shall apply to females engaged solely in the practice of midwifery.
agency, whether material or not material, for the cure, relief, or palliation of any ailment or disease of the mind or body, or for the cure or relief of any wound or fracture or other bodily injury or deformity, or the practice of obstetrics or midwifery, after having received, or with the intent of receiving therefore, either directly or indirectly, any bonus, gift, profit, or compensation; provided, that nothing in this section shall apply to females engaged solely in the practice of midwifery.
Citation: MISS. CODE ANN. § 73-25-33.
The liberal use of the word “any” differentiates physician scope of practice from NP scope of practice. There are no laws that authorize as wide a scope of practice for NPs as the Mississippi law authorizes for physician practice.
▪ An Individual NP’s Portfolio
Individual NPs may want to develop portfolios—compilations of documentation of the NP’s education, training, and experience. The portfolio often is a binder containing pages, which may be removed and copied as needed.
There are at least three good reasons for keeping a portfolio.
First, in many states, NPs must submit to the Board of Nursing a written agreement stating the services the NP is authorized to perform. NPs may want to perform procedures, such as colposcopy or suturing. Boards are requiring NPs to document that they are qualified to perform such procedures. Qualifications might include formal course work, informal course work, or formal or informal one-to-one preceptorship experience. NPs can find it difficult to document such training, especially if the NP learned from a physician how to perform a procedure years ago while on the job. If NPs document the teaching at the time it is done, through a letter or form signed and dated by the instructor, the NP can produce the document as needed many years later, assuming the NP has keep such documents in a safe place—in the portfolio.
Second, some states’ laws defer to scope of practice statements adopted by professional organizations. For example, Texas law states:
The advanced practice nurse provides a broad range of health services, the scope of which shall be based upon educational preparation, continued advanced practice experience, and the accepted scope of professional practice of the particular specialty area. Advanced practice nurses practice in a variety of settings and, according to their practice specialties and roles, they provide a broad range of healthcare services to a variety of patient populations.
The scope of practice of particular specialty areas shall be defined by national professional specialty organizations or advanced practice nursing organizations recognized by the Board. The advanced practice
nurse may perform only those functions which are within that scope of practice and which are consistent with the Nursing Practice Act, Board rules, and other laws and regulations of the State of Texas.
Citation: TX ADMIN. CODE § 221.12.
NPs living in states with laws similar to Texas should have the scope and standards of practice established by the national organization representing the NP’s specialty in their portfolios.
For example, if an NP in Texas is certified by the American Academy of Nurse Practitioners, the NP should keep in his/her portfolio a one-page document on the AANP website titled “Scope of Practice for Nurse Practitioners.” The document states, in part:
Nurse Practitioners are licensed independent practitioners who practice in ambulatory, acute and long-term care as primary and/or specialty care providers. According to their practice specialty they provide nursing and medical services to individuals, families, and groups. In addition to diagnosing and managing acute episodic and chronic illnesses, nurse practitioners emphasize health promotion and disease prevention. Services include, but are not limited to ordering, conducting, supervising, and interpreting diagnostic and laboratory tests, and prescription of pharmacologic agents and nonpharmacologic therapies. Teaching and counseling individuals, families, and groups are a major part of nurse practitioner practice.1
Third, some nurses are using their portfolios in place of resumes when interviewing for jobs. A portfolio could include the following:
Statement of career goals
Description of special interests or abilities
Description of special projects conducted by the individual
Articles or reports written by the individual
Articles written about the individual
Brochures from previous practices
Testimonials or letters of appreciation from patients
Letters of reference from former employers or coworkers
Awards, honors, or distinction earned by the individual
Transcripts
Diplomas
Certificates of certification as advanced practice nurse
Nursing and APN license
Photo of the individual
Certificates of continuing education or training
Letters of recommendation
Letters, forms, or photographs documenting one-on-one training
Listing of former jobs or projects
National Provider Identifier and any other provider numbers needed for reimbursement
DEA number and state-controlled substances prescriber number
Certificate of professional liability insurance
Copy of state law addressing NP scope of practice, prescribing, qualifications, and physician collaboration requirements, if any
Previous written agreements, if state law requires physician collaboration
Outcomes data, if the NP or an employer has tracked the NP’s outcomes
Data on performance measures, if the NP has participated in Medicare’s Voluntary Physician Reporting Program or other quality measurement programs
Productivity data, if the NP or an employer has tracked visits, revenues, and collections
Patient satisfaction data, if the NP or an employer has tracked patient satisfaction
EXHIBIT 2-2 Physician Involvement Required for NP Practice
Collaborate | Supervise | Protocols | None |
AL | FL | AL | AK |
AZ | ME* | AR | CO |
AR | NC | CA | DC |
CA | OK | CT | IA |
CT | TN | FL | ID |
DE | VA | GA | ME** |
DC | KS | MT | |
HI | Delegate | LA | NH |
IL | GA | MA | NM |
IN | MI | NV | OR |
KE | SC | NJ | RI |
LA | VA | NY | UT*** |
MA | SC | WA | |
MD | Direct | TX | WY |
MN | OK | WV | |
MO | None, But No Scope of Practice in State Law | ||
MS | Collegial Relationship | ||
NC | |||
ND | HI | MI | |
NE | |||
NJ | Referral | ||
NY | Process | ||
OH | MT | ||
PA | |||
RI | |||
SD | |||
TX | |||
VA | |||
VT | |||
WV | |||
* First 24 months of practice only. | |||
Finally, it saves time if one keeps the documents related to one’s professional practice in one place.
▪ Mandated Physician Involvement with NP Practice
In some states, there is no legal requirement for physician involvement in NP practice. However, in the majority of states, there is some legal requirement for physician involvement. That involvement may be “supervision,” “collaboration,” or some other form of involvement. It may be limited to situations where the NP is prescribing medications, or it may be required for all advanced practice.
See Exhibit 2-2 for a chart listing requirements of physician involvement by state. For text of state laws regarding physician involvement, see Appendix 2-B.
Some states require that NPs practice using written protocols. Some states require a written agreement between the NP and the physician that states how the physician will participate in NP practice, what medications the NP may prescribe, what procedures an NP may perform, how often a physician will review NP documentation, and under what circumstances an NP must contact a physician. A protocol is a written instrument that guides the NP in collecting data from the patient and recommends specific action based upon the collected data. It consists of mutually agreed-upon medical guidelines between the physician and the NP that define the individual and shared responsibilities of the physician and NP. The protocol is considered a standard because it provides a guideline for a minimum level of safe practice in specific situations.3
Here is an example of a protocol:
EXHIBIT 2-3 Urinary Tract Infection Protocol: Initial Visit
RATIONALE
This protocol will assist in the differentiation between pyelonephritis and urinary tract symptoms sufficiently to eradicate the symptoms per se rather than an attempt to eradicate any bacteriuria that may or may not be present. The design of the protocol for UTI encompasses these principles.
II. SYMPTOMS
CYSTITIS
FEMALE PATIENTS
Order a STAT CVMS UA for female patients with any of the following symptoms;
Dysuria
Frequency
Urgency
Inability to empty bladder completely
Male patients
Male patients with any of the above symptoms should be seen by an MD, not by a NP, unless they have a uretheral discharge (possible VD—follow VD protocol).
PYELONEPHRITIS
In addition to the above symptoms, patients with pyelonephritis may have:
Fever greater than 100.0 F. or
Flank pains, or
Chills, or
Nausea, vomiting, or abdominal pain.
Continue with protocol through the physical exam with these patients, but then consult supervising physician before deciding on treatment.
HISTORY
Consult supervising physician if patient has:
A history of kidney problems, or
Is currently pregnant. To ascertain this, always ask for LMP date and record for all female patients.
Diabetes or insulin.
Three or more UTIs in past 12 months.
Continue with UTI protocol, but also refer patient to GYN if history of:
Vaginal discharge, or
Perineal inflammation.
PHYSICAL EXAM
Perform the following examinations:
Abdominal
CVA
Temperature
Consult supervising physician if findings of:
Fever greater than 100.0 F. or
CVA tenderness.
LAB TESTS
INITIAL URINALYSIS
Consult supervising physician if:
Casts
RBCs or protein are positive (with associated WBC abnormality).
If UA shows 10 or more WBCs/hpf and patient is symptomatic, give patient antibiotic prescription as described in the treatment section.
If UA revealed 0-10 WBCs, review symptoms. If the symptoms are definite and very severe, treat with antibiotics; if symptoms are vague and poorly defined, then give patient symptomatic treatment as described in the treatment section and consider referral to GYN for pelvic.
Should the initial UA be “positive”: (defined in guidelines below), then give patient a repeat UA slip for the abnormality found with instructions to have the UA one week following completion of treatment.
Positive UA findings are defined as:
Casts: any except occasional hyaline or rare granular
RBCs > 3 (if not menstruating) and WBC < 5
Protein > trace and WBC < 5
TREATMENT
ANTIBACTERIAL TREATMENT
To be given if initial UA reveals 10 or more WBC/hpf, or in any case where symptoms are severe, even if UA revealed, WBC/hpf.
Prescribe appropriate antibiotic drug (see below)
Instruct patient to call in if symptoms do not subside within 72 hours. If patient does call back, information for treatment failure instructions.
SYMPTOMATIC TREATMENT
To be given only if initial UA reveals, 10 WBC/hpf, and patient has minimal or uncertain symptoms. Consider GYN referral for pelvic.
Prescribe either Propantheline 15 mg #20 sig: 1-2 QID prn or Belladonna with Pb tabs #15, sig: 1 tab QID prn.
Instruct patient to call in if symptoms persist be yond 72 hours or if symptoms worsen at any time.
REPEAT URINALYSIS (CVMS)
Consult supervising physician if UA shows casts.
If repeat UA conforms abnormality (protein and/or RBC as listed below) refer to Proteinuria and/or Hematuria protocols.
Positive UA findings are defined as:
Casts: any, except occasional hyaline or rare granular
RBCs > 3 (if not menstruating) and WBC < 5
Protein > trace and WBC < 5
UTC PROTOCOL: ANTIBIOTIC TREATMENT
If organism found in patient’s urine is not listed in the table below, consult supervising physician for treatment.
If this is the first antibiotic course (initial visit), assume E. coli and use the first listed drug to which patient is not allergic, as listed for E. coli in the drug table on the following page.
If this is a second antibiotic course (treatment failure), go to the first drug for the organism listed that is not the same as that previously used and to which the patient is not allergic. If the patient is allergic to all drugs listed, consult supervising physician for treatment.
Prescribe according to the prescription table which follows:
If symptoms have been present within the past 48 hours, use 1 dose treatment.
If symptoms have been present longer than 48 hours, use 5-day treatment.
If symptoms persists after treatment with first drug, repeat UA and culture and consult supervising physician.
UTI PROTOCOL: TREATMENT FAILURE
If the patient calls in with persisted or recurrent symptoms after the first course of antibiotic treatment, obtain a CVMS urine specimen for UA and culture and sensitivity.
If the UA is negative, wait for the culture results before treating. If the UA is positive, treat with the next drug listed on the Antibiotic Prescription Table and review treatment choice when the culture and sensitivity results are available.
If culture is positive and patients symptoms are improving, stay with the same antibiotic. If not responding after 3 days, switch to a new antibiotic based on culture sensitivity.
Adapted from protocol developed by: ____________________, NP
____________________, MD
(List names of nurse practitioners and physicians who developed the standardized procedure, including the protocol section.)
______________________________
ANTIBIOTIC PRESCRIPTION TABLE | ||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| ||||||||||||||||||||||||||||||||
Notes
1. Website of the American Academy of Nurse Practitioners (AANP). http://www.aanp.org. Retrieved September 1, 2010.
2. http://www.rn.ca.gov/pdfs/regulations/npr-b-23.pdf. Retrieved December 1, 2010.
3. Phillips, R. S. (1985). Nurse practitioners: Their scope of practice and theories of liability. Journal of Legal Medicine, 6, 391-414.
Appendix 2-A
Scope of Practice
In some states scope of practice is specified by statute; in other states it is specified by regulation. Both statutes and regulations carry the same legal weight. Statutes are legislature-made law and are changed by a vote of the legislature. Regulations are executive agency-made law, and can be changed by the agency or be overridden by statute.
The following are excerpts from state law. For the complete language, see the state’s Nurse Practice Act, usually available online through the state’s Board of Nursing website.
Alabama
Practice as a certified registered nurse practitioner (CRNP) means the performance of nursing skills by a registered nurse who has demonstrated by certification advanced knowledge and skills in the delivery of nursing services within a healthcare system that provides for consultation, collaborative management, or referral as indicated by the health status of the client.
Citation: ALA. CODE § 34-21-81(4a).
Functions and activities. CRNP is responsible for continuous and comprehensive management of a broad range of health services for which the CRNP is educationally prepared and for which competency is maintained. These services could include:
Evaluate current health status and risk factors based on comprehensive health history and physical examination and assessment;
Formulate a working diagnosis, develop and implement a treatment plan, and evaluate/modify therapeutic regimens to promote positive patient outcomes;
Prescribe, administer, and provide therapeutic measures, tests, procedures, and drugs;
Counsel, teach, and assist individuals/families to assume responsibility for self-care in prevention of illness, health maintenance, and health restoration;
Consult with and refer to other healthcare providers as appropriate. A CRNP can request that additional functions be added to the protocol.
Citation: ALA. ADMIN. CODE r. 610-X-5-.10.
Alaska
The board recognizes advanced and specialized acts of nursing practice as those described in the scope of practice statements for nurse practitioners certified by national certifying bodies recognized by the board.
Citation: ALASKA ADMIN. CODE tit. 12, § 44.430.
Arizona
Nurse practitioners
Examine patients and establish medical diagnoses by client history, physical exam, and other criteria
Admit patients to healthcare facilities
Order, perform, and interpret laboratory, radiographic, and other diagnostic tests
Identify, develop, implement, and evaluate a plan of care for a patient to promote, maintain, and restore health
Perform therapeutic procedures that the RNP is qualified to perform
Prescribe treatments
Prescribe and dispense medications when granted authority under Section R4-19-511
Perform additional acts that the RNP is qualified to perform
Citation: ARIZ. ADMIN. CODE § R4-19-508.
Arkansas
“Practice of advanced nurse practitioner nursing” means the performance for compensation of nursing skill by a registered nurse who, as demonstrated by national certification, has advanced knowledge and practice skills in the delivery of nursing services.
Citation: ARK. CODE ANN. § 17-87-102.(4)(B)(i).
“Practice of registered nurse practitioner nursing” means the delivery of healthcare services for compensation in collaboration with and under the direction of a licensed physician or under the direction of protocols developed with a licensed physician.
Citation: ARK. CODE ANN. § 17-87-102.(8)(A).
California
The nurse practitioner shall function within the scope of practice as specified in the Nurse Practice Act and as it applies to all registered nurses.
Citation: CAL. CODE REG. tit.16, § 1485.
Colorado
A nurse who meets the definition of advanced practice nurse … may be granted prescriptive authority as a function in addition to those defined in Section 12-38-103(10).
Citation: COLO. REV. STAT. ANN. § 12-38-111.5.
The scope of practice for an advanced practice nurse may be determined by the Board in accordance with this article.
Citation: COLO. REV. STAT. ANN. § 12-38-111.6(8)(a).
Connecticut
Advanced nursing practice is defined as the performance of advanced level nursing practice activities, which by virtue of post-basic specialized education and experience are appropriate to and may be performed by an Advanced Practice Registered Nurse. The advanced practice registered nurse performs acts of diagnosis and treatment of alteration in health status as described in subsection (a) of this section, and shall collaborate with a physician licensed to practice medicine in this state. In all settings, the advanced practice registered nurse may, in collaboration with a physician licensed to practice medicine in this state, prescribe, dispense, and administer medical therapeutics and corrective measures and may request, sign for, receive, and dispense drugs in the form of professional samples….
Citation: CONN. GEN. STAT. ANN § 20-87a.
Delaware
“Independent practice by an advanced practice nurse” shall include those advance practice nurses who practice and prescribe without written guidelines or protocols but with a collaborative agreement with a licensed physician, dentist, podiatrist, or licensed Delaware healthcare delivery system and with the approval of the Joint Practice Committee.
Citation: DEL. CODE ANN. TIT. 24, § 1902(g).
Generic functions of the advanced registered nurse practitioner within the specialized scope of practice include, but are not limited to:
Eliciting detailed health history(s)
Defining nursing problem(s)
Performing physical examination(s)
Collecting and performing laboratory tests
Interpreting laboratory data
Initiating requests for essential laboratory procedures
Initiating requests for essential X-rays
Screening patients to identify abnormal problems
Initiating referrals to appropriate resources and services as necessary
Initiating or modifying treatment(s) within established guidelines
Assessing and reporting changes in the health of individuals, families, and communities
Providing health education through teaching and counseling
Planning and/or instituting healthcare programs in the community with other healthcare professionals and the public
Delegating tasks appropriately
Removing epidural catheters
Prescribing medications and treatments independently pursuant to Rules and Regulations …
Citation: DEL. NURSING REGS. tit. 24, ch 1900, § 8.7.
District of Columbia
An advanced practice registered nurse may:
Initiate, monitor, and alter drug therapies
Initiate appropriate therapies or treatments
Make referrals for appropriate therapies or treatments
Perform additional functions within his or her specialty determined in accordance with rules and regulations promulgated by the Board.
Citation: D.C. STAT. Div. 1, Tit. 3, Subtit. I, Ch. 12, Subchapter VI, § 3-1206.04.
The advanced practice registered nurse may perform actions of medical diagnosis, treatment, prescription, and other functions authorized by this subchapter.
Citation: D.C. STAT. Div. 1, Tit. 3, Subtit. I, Ch. 12, Subchapter VI, § 3-1206.01.
“Practice of advanced practice registered nursing” means the performance of advanced-level nursing actions, with or without compensation, by a licensed registered nurse with advanced education, knowledge, skills, and scope of practice who has been certified to perform such actions by a national certifying body acceptable to the Board of Nursing. The practice of advanced practice registered nursing includes:
Advanced assessment;
Medical diagnosis;
Prescribing;
Selecting, administering, and dispensing therapeutic measures;
Treating alterations of the health status; and
Carrying out other functions identified in subchapter VI of this chapter and in accordance with procedures required by this chapter.
Citation: D.C. STAT. § 3-1201.02(a).
Florida
An ARNP shall perform those functions authorized in this section within the framework of an established protocol that is filed with the board upon biennial license renewal and within 30 days after entering into a supervisory relationship with a physician or changes to the protocol. Within the established framework, an ARNP may:
Monitor and alter drug therapies.
Initiate appropriate therapies for certain conditions.
Perform additional functions as may be determined by rule …
Order diagnostic tests and physical and occupational therapy.
Citation: FLA. STAT. Ch. 464.012(3).
The nurse practitioner may perform any or all of the following acts within the framework of an established protocol:
Manage selected medical problems.
Order physical and occupational therapy.
Initiate, monitor, or alter therapies for certain uncomplicated acute illnesses.
Monitor and manage patients with stable chronic diseases.
Establish behavioral problems and diagnose and make treatment recommendations.
Citation: FLA. STAT. Ch. 064.012(10)(c).
Georgia
The nurse practitioner provides advanced practice nursing care and medical services specific to the nurse practitioner respective specialty to individuals, families, and groups, emphasizing health promotion and disease prevention as well as the diagnosis and management of acute and chronic diseases. The nurse practitioner collaborates as necessary with a variety of individuals to diagnose and manage clients’ healthcare problems.
Citation: GA. COMP. R. & REGS. r. 410-12-.03(2)(a).
The advanced practice registered nurse is authorized to perform advanced nursing function and certain medical acts which include, but are not limited to, ordering drugs, treatments, and diagnostic studies as provided in O.C.G.A. 43-24-26.1 and Chapter 410.13.
Citation: GA. COMP. R. & REGS. r. 410-12-.01(b).
Hawaii
In addition to those functions specified for the registered nurse, the advanced practice registered nurse may perform the following generic acts [that] include, but are not limited to:
Provide direct nursing care by utilizing advanced practice scientific knowledge, nursing theory, and skills to assess, plan, and implement appropriate health and nursing care to patients;
Provide indirect nursing care. Plan, guide, evaluate, and direct the nursing care given by other personnel associated with the healthcare team;
Teach and counsel individuals or groups. Utilize theories and skills to increase communication and knowledge among all members of the healthcare team;
Serve as a consultant and resource of advanced nursing knowledge and skills to those involved directly or indirectly in patient care; and
Participate in joint and periodic evaluation of services rendered.
Citation: HAW. ADMIN. 1R. §16-89-81(b).
Nurse practitioner scope of practice:
Evaluate the physical and psychosocial health status of the patient through a comprehensive health history and physical examination, using skills of observation, inspection, palpation, percussion, and auscultation, and using or ordering diagnostic instruments or procedures that are basic to the nursing evaluation of physical signs and symptoms;
Assess the normal and abnormal findings from the history, physical examination, and diagnostic reports;
Plan, implement, and evaluate care;
Consult with the patient, support systems, and members of the healthcare team to provide for acute and ongoing health care or referral of the patient;
Manage the plan of care prescribed for the patient;
Initiate and maintain accurate records, appropriate legal documents, and other health and nursing care reports;
Develop individualized teaching plans with the patient based on overt and covert health needs;
Counsel individuals, families, and groups about health and illness and promotion of health maintenance;
Recognize, develop, and implement professional and community educational programs related to health care;
Participate in periodic and joint evaluation of services rendered;
Conduct research and analyze the health needs of individuals and populations and design programs which target at-risk groups and cultural and environmental factors which foster health and prevent illness;
Participate in policy analysis and development of new policy initiatives in the area of practice specialty; and
Contribute to the development, maintenance, and change of healthcare delivery systems to improve quality of healthcare services and consumer access to services.
Citation: HAW. ADMIN. R. § 16-89-81(c)(1).
Idaho
Nurse practitioners … may perform comprehensive health assessments, diagnosis, health promotion, and the direct management of acute and chronic illness and disease as defined by the nurse practitioner’s scope of practice. The scope of practice of an authorized nurse practitioner may include the prescribing and dispensing of pharmacologic and nonpharmacologic agents.
Citation: IDAHO ADMIN. CODE § 23.01.01:280-05.
Illinois
“Advanced practice nurse” or “APN” means a person who has a written collaborative agreement with a collaborating physician in the diagnosis of illness and management of wellness and other conditions as appropriate to the level and area of his or her practice in accordance with Section 15-15; and cares for patients (A) by using advanced diagnostic skills, the results of diagnostic tests and procedures ordered by the advanced practice nurse, a physician assistant, a dentist, a podiatrist, or a physician, and professional judgment to initiate and coordinate the care of patients; (B) by ordering diagnostic tests, prescribing medications and drugs in accordance with Section 15-20, and administering medications and drugs; and (C) by using medical, therapeutic, and corrective measures to treat illness and improve health status.
Citation: 225 ILL. COMP. STAT. § 65/15-5.
Indiana
Nurse practitioner means an advanced practice nurse who provides advanced levels of nursing client care in a specialty role, who meets the requirements of the advanced practice nurse as outlined in Section 3 of these rules.
Citation: IND. ADMIN. CODE tit. 848, r. 4-1-4.
[Indiana law does not use the words “scope of practice,” but describes “standards for each nurse practitioner” as follows:]
Assess clients by using advanced knowledge and skills to:
identify abnormal conditions;
diagnose health problems;
develop and implement nursing treatment plans;
evaluate patient outcomes; and
collaborate with or refer to a practitioner, as defined in IC 25-23-1-19.4, in managing the plan of care.
Use advanced knowledge and skills in teaching and guiding clients and other health team members.
Use appropriate critical thinking skills to make independent decisions, commensurate with the autonomy, authority, and responsibility of a nurse practitioner.
Function within the legal boundaries of their advanced practice area and shall have and utilize knowledge of the statutes and rules governing their advanced practice area; including the following:
State and federal drug laws and regulations.
State and federal confidentiality laws and regulations.
State and federal medical records access laws.
Consult and collaborate with other members of the health team as appropriate to provide reasonable client care, both acute and ongoing.
Recognize the limits of individual knowledge and experience, and consult with or refer clients to other healthcare providers as appropriate.
Retain professional accountability for any delegated intervention, and delegate interventions only as authorized by IC 25-23-1 and this title.
Maintain current knowledge and skills in the nurse practitioner area.
Conduct an assessment of clients and families, which may include health history, family history, physical examination, and evaluation of health risk factors.
Assess normal and abnormal findings obtained from the history, physical examination, and laboratory results.
Evaluate clients and families regarding development, coping ability, and emotional and social well-being.
Plan, implement, and evaluate care.
Develop individualized teaching plans with each client based on health records.
Counsel individuals, families, and groups about health and illness and promote attention to wellness.
Participate in periodic or joint evaluations of service rendered, including, but not limited to, the following:
Chart reviews.
Client evaluations.
Outcome statistics.
Conduct and apply research findings appropriate to the area of practice.
Participate, when appropriate, in the joint review of the plan of care.
Citation: IND. ADMIN. CODE tit. 848, r. 4-2-1.
