Procedures a Primary Nurse Practitioner May Perform

Question

Which procedures would you consider to be outside the scope of practice for a primary care nurse practitioner (NP)? State practice acts are vague in terms of specific procedures or acts. Do they include performing procedures such as a colonoscopy or skin biopsies?

Response From the Expert

Carolyn Buppert, CRNP, JD
Nurse practitioner and attorney who specializes in the legal issues affecting medical practices and nurse practitioners. She is the author of 5 books. Ms. Buppert counsels clients, and lectures extensively on reimbursement issues, how to avoid malpractice, and contract negotiation. She is also president of Better Life Health Care Systems, which contracts with businesses and educational institutions for nurse practitioner services. Through that company she serves as Director of Student Health at St. John's College in Annapolis, Maryland. Her Web site is www.buppert.com

You are correct. The state nurse practice acts can be vague, and in no state is there direct legal authority for NPs to perform a colonoscopy. Note that state laws on physician scope of practice do not name specific procedures either, but authorize physicians to do anything related to medicine and surgery. For example, California law states that "The physician's and surgeon's certificate authorizes the holder to use drugs or devices in or upon human beings and to sever or penetrate the tissues of human beings and to use any and all other methods in the treatment of diseases, injuries, deformities, and other physical and mental conditions."^[1] In California, the NP scope of practice is "within the scope of practice as specified in the Nurse Practice Act and as it applies to all registered nurses."^[2] California NPs might perform colonoscopies under a standardized procedure, developed collaboratively with a physician.^[3]

New Hampshire law provides NPs with more direct authority to perform medical acts than does California law, but still does not give direct authority to perform specific procedures. New Hampshire law says:

The ARNP shall have the ability to:

Elicit and record physical and mental health status, psychosocial history, including review of bodily systems
Perform physical examination
Initiate appropriate diagnostic tests to screen or evaluate the care-recipient's current health status
Assess findings of history, review of systems, physical examination and diagnostic tests, and formulate a diagnosis prior to implementing a treatment regimen
Identify health problems and learning needs of the care recipient
Plan, teach, promote and manage physical and mental health-care in a continuous program
Implement and manage treatment regiments and administer, prescribe, dispense and procure pharmacological agents
Arrange appropriate referrals
Initiate appropriate emergency treatment in life-threatening or unusual situations in order to stabilize the care-recipient; and
Provide other functions common to the NP for which the ARNP is educationally and experientially prepared.^[4]

However, there is evidence that NPs are performing colonoscopies.

^[5]

In every state, there is a process for determining whether the Board of Nursing would approve an NP to perform colonoscopy.

To determine whether a specific procedure is within the scope of practice, follow this process:

Gather documentation of the education and experience of the NP in performing the procedure.
Obtain and read the section of state law which addresses NP scope of practice.
Visit the state board of nursing Web site to see whether the board has produced an advisory regarding that procedure, or technical procedures in general.
If state law requires that NPs practice under a collaborative agreement with physicians, name the procedure in the collaborative agreement to be filed with the board of nursing. If the NP already has filed a collaborative agreement and wants to add a procedure, submit the procedure as an addendum to the existing collaborative agreement, along with documentation of the NP's competency to perform the procedure. The board will put the agreement through its review process and either will approve the agreement or deny the agreement, and will specify why.
If state law requires NPs to practice under standardized procedures, as California law requires, write a standardized procedure with a physician collaborator.
If state law requires neither a collaborative agreement nor a standardized procedure, and the procedure is one which primary care NPs do not usually perform, write to the board of nursing, asking for a determination about whether that procedure is within the scope of practice of the specific NP.

Comments

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.