What Can a Nurse Do? How to Make Scope-of-Practice Decisions

Carolyn Buppert, MSN, JD

Disclosures

September 11, 2018

A Simple Order Isn't Enough

Beware of taking on roles, activities, and interventions that you think might be outside your legal authority and competence just because your employer wants you to take on that task. Employers don't have the legal authority to expand nursing scope of practice. An employer can restrict nursing scope of practice but can't expand it. Only the state legislature and state regulatory agencies can set nursing scope of practice. Boards of nursing have reprimanded nurses for practicing outside scope when the nurse was just doing what told to do by the employer. Just because another hospital or practice is doing something doesn't mean it is legal, prudent, or safe.

It's also risky for a nurse to do something outside his or her competency and/or scope of practice and think it is justified because a physician has ordered it. In some states, notably Michigan, physicians can delegate their authority to perform medical acts to whomever they want, but the physician needs to ascertain the competency of the person who carries out the delegated act. And any nurse carrying out a delegated medical act is going to be on thin ice defending himself or herself, if something goes wrong and the delegation is not in writing.

If on-the-job training is how you are planning to become competent to perform a new role, intervention, or activity, be sure to get your trainer to document what you have been trained to do and that the trainer has evaluated your competency and finds you competent to perform the procedure on your own. Include documentation on how the trainer has evaluated your competency.

Remember that you have responsibility for your practice. It is almost always easier to do the work up front to prevent—rather than dig out from under—a legal problem. Ultimately, the Boards of Nursing have the authority to say "yes" or "no" to whether a nurse can perform any specific function. I think it is safe to assume that Boards of Nursing use the NCSBN's algorithm in making a determination. If your employer won't agree to go through the algorithm above and provide the answers that permit you to get past question 8, you have a choice to make: Refuse to perform the procedure, role, or activity until you can get through question 8, or leave the employer and find an employer who is willing to do what is necessary to support patient safety.

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