The responsibility of the registered nurse in making practice decisions-CE 004

Continuing education: Scope of practice: The responsibility of the registered nurse in making practice decisions-CE 004

DiLillo, Angela

The goal of this program is to reinforce the registered nurse’s knowledge of scope of practice and to provide a model for decision making.

Based on this information, nurses will be able to:

* Discuss their responsibility in defining and determining their individual scope of practice

* Increase their knowledge of the Nurse Practice Act

* Identify the behaviors that can lead to disciplinary action

* Describe the function of the Connecticut Board of Examiners for Nursing

* Define the steps in the Connecticut Board of Examiners for Nursing Competency /Scope of Practice Decision-Making Model (revised May, 2002)


Nursing is a dynamic profession that has evolved in response to changing needs, demands and resources of our society. The complexity of the health care delivery system today is such that the role and responsibility of the nurse within this system can change.

Each registered nurse is responsible and accountable for making decisions and practicing in accordance with his/her educational background and experience in nursing within the statutory parameters of the Nurse Practice Act.

The Scope of Nursing Practice

Nursing, like other professions, is accountable for ensuring that its members act in the public interest and provide the unique service that has been designated to them by society. This process is called professional regulation. The profession of nursing regulates itself through defining practice, establishing an educational system, providing research to further develop the practice base and developing the standards of practice and a code of ethics.

In turn, the state, through statues, attests to the public that registered nurses meet minimal standards for practice and prohibits unlicensed individuals from practicing as registered nurses. The legal boundaries of the scope of practice are determined by the definition of nursing found in the Nurse Practice Act (NPA) and provide the basis for interpreting the practice of the individual registered nurse. Since each state has legal authority for the regulation of nursing, the definition, and therefore the scope of nursing practice may vary from state to state. However, the purpose of the law remains consistent to protect the public. Go to 2001/pub/Chap378.htm for the NPA

Nurse Practice Act

The Nurse Practice Act was enacted by the legislature to regulate the practice of nursing and to define the parameters of nursing practice for the purpose of protecting the public. The act does not address specific nursing duties that are proper to be performed by nurses, or hospital staffing patterns, labor practices or employment criteria.

The Nurse Practice Act is designed to protect the public from incompetent nursing practice, not to protect nurses from discriminatory or questionable employment practices. Each nurse is responsible and accountable for making decisions and practicing in accordance with that individual’s educational background and experience in nursing.

Individual RNs Responsibility

The registered nurse is responsible and accountable, professionally and legally, for determining his/her professional scope of nursing practice. Since the role and responsibilities of nurses, and consequently the scope of nursing practice, is ever changing and increasing in complexity, it is important that the nurse makes decisions regarding his/her own scope of practice.

The Nurse Manager & Nurse Executive’s Responsibility

As a registered nurse, the nurse manager is responsible and accountable, professionally and legally, for determining his/her professional scope of practice. Further, the nurse manger makes decisions regarding the roles and responsibilities for nurses within the institution or agency in order to provide quality care.

The nurse executive, in a changing and complex health delivery system, is knowledgeable regarding changes in rules and regulations, accreditation standards and standards of care and practice, in addition to evaluation of the boundaries specified in the Nurse Practice Act. The nurse executive and/or the nurse manager facilitate changes to assure quality patient care outcomes and develop mechanisms that will promote the same.

Legal Regulation

Nursing practice in Connecticut is regulated by Connecticut statutes (Chapter 378, 20-87-20-102). The professional nurse is responsible and accountable for making decisions that are based upon the individual’s educational preparation and experience in nursing.

Behaviors and activities of the nurse relating to the scope of practice that could lead to disciplinary action are:

* Performing acts beyond the authorized scope of practice for the level of nursing for which the individual is licensed.

* Assuming duties and responsibilities within the scope of nursing practice without adequate preparation or when competency has not been maintained.

* Failing to take appropriate action or to follow policies and procedures in the practice situation designed to safeguard the patient.

* Assigning or delegating unqualified persons to perform functions of licensed nurses contrary to the Nurse Practice Act or to the detriment of patient safety.

* Willfully or negligently failing to take appropriate action in safeguarding a patient or the public from incompetent practice performed by a registered professional nurse or a licensed practical nurse. “Appropriate action” may include reporting to the State Board of Examiners for Nursing (SBEN).

Connecticut State Board of Examiners for Nursing (SBEN)

The SBEN was established in 1905 by the state government to protect the public’s health and safety by overseeing certain aspects of the practice of nursing of licensed practical nurses, registered nurses and advanced practice registered nurses, but not certified nurse aides. The SBEN achieves this mission pursuant to Connecticut General Statutes Section 20-88 and 20-90 by advising the commissioner of public health about regulations for nursing programs and approving programs within schools of nursing and by adjudicating complaints filed against licensed practitioners and imposing sanctions when appropriate. The SBEN takes action against the licenses of those nurses who have exhibited unsafe nursing practice. In addition, the SBEN reviews and provides advisory guidance regarding scope of practice questions using the “Nursing Competency/ Scope of Practice Decision– Making Model.” (see Model at end of article on page 9).

The SBEN has the authority to suspend or revoke a license or discipline a nurse for misconduct, incompetence or negligence. The burden is upon the nurse, the licensee, to act at all times as a reasonable and prudent professional should act, in accordance with the prevalent professional standards. **The SBEN can give direction before a given act is performed about whether it is permissible to perform that particular act. However, this direction must be specifically requested.

A routine function of the SBEN is to respond to or comment upon practice questions. The majority of such requests are for clarification of a given activity with regard to the nurse’s “proper” scope of practice. In specific instances specific guidance is given in a position statement. It is not a reasonable expectation that the SBEN can respond to each and every nurse’s specific practice questions with position statements. Nurses need to recognize that, because they are individually licensed, they are liable for nursing judgment and action and obligated to make responsible practice decisions.

The SBEN is authorized by the state to discipline nurses who are unable or unwilling to practice competently, but it has no authority over health facilities or other health care providers.

Guidelines for Decision-Making

The nurse is constantly involved in the decision– making and problem-solving process, whether as a staff nurse or a manager, regardless of the practice setting. Although the process is the same, each views the situation from a different perspective. Basic to this process, though, are the following steps:

1. CLARIFY. What is the problem or need? Who are the people involved in the decision? What is the decision to be made and where (what setting or organization) will it take place?

Why is the question being raised now? Has it been discussed previously?

2. ASSESS: What are your resources? What are your strengths? What skills and knowledge are required? What or who is available to assist you?

3. IDENTIFY OPTIONS: What are possible solutions? What are the characteristics of an ideal solution? Is it feasible? What are the risks? What are the costs? Are they feasible? What are the implications of your decision? How serious are the consequences?

4. POINT OF DECISION: What is the best decision? When should it be done? By whom? What are the implications or consequences of your decision? How will you judge the effectiveness of your decision?

Application of the Guidelines for Decision Making – Staff Nurses’ Perspective

As a staff nurse you are asked to perform a procedure that is unfamiliar.


* Are there written policies or procedures available to describe how and under what conditions you will perform this task? Does the new responsibility require professional judgment or simply the acquisition of a new skill?

* Is this a new expectation for all RNs? Has this been done before by others in your unit or health care facility? Is it just new to you? What about the other facilities in your community or region?

* What are the nurse manager’s expectations about you or other RNs becoming responsible for this procedure? When will this become effective? Will there be an opportunity to help you attain the needed clinical competency? Who will be responsible for the initial supervision and evaluation of this newly performed task? Will you be given additional time to learn the skill if you need it?


* Are you clinically competent to perform this procedure? Do you currently have the knowledge and skills to perform the procedure? Have you had experience in previous jobs with this procedure?

* Do you believe you will be able to learn the new skill in the allotted time?

* How can you determine that you are practicing within your scope of nursing? What is the potential outcome for the patient if you do or do not perform the procedure?


a. The responsibility/task is not prohibited by the Nurse Practice Act. If you believe that you can provide safe patient care based upon your current knowledge base, or with additional education and skill practice, you are ready to accept this new responsibility. You will then be ethically and legally responsible for performing this new procedure at an acceptable level of competency.

b. If you believe you will be unable to perform the new task competently, then further discussion with the nurse manager is necessary. At this point, you may also ask to consult with the next level of management or nurse executive so that you can talk about the various perspectives of this issue.

It is important that you continue to assess whether this is an isolated situation just affecting you, or whether there are broader implications. In other words, is this procedure new to you, but nurses in other units or health care facilities with similar patient populations already are performing? To what do you relate your reluctance to accept this new responsibility? Is it a work load issue or is it a competency issue?

At this point, it is important for you to be aware of the legal rights of your employer. Even though you may have legitimate concerns for patient safety and your own legal accountability in providing competent care, your employer has the right to initiate employee disciplinary action, including termination, if you refuse to accept an assigned task. Therefore, it is important to continue to explore options in a positive manner, recognizing that both you and your employer share the responsibility for safe patient care. Be open to alternatives.

In addition, consider resources which you can use for additional information and support. These include your professional organization, state and national, and various publications. The ANA Code of Ethics for Nurses, standards on practice and your employer’s policies and procedures manual are valuable resources. The Nurse Practice Act serves as your guide for the legal definition of nursing and the parameters that indicate deviation from or violation of the law.


a. Accept the newly assigned task. You have now made an agreement with your employer to incorporate this new responsibility, under the conditions outlined in the procedure manual. You are now legally accountable for its performance.


b. Agree to learn the new procedure according to the plans established by the employer for your education, skills practice and evaluation. You will be responsible for letting your nurse manager know when you feel competent to perform this skill. Make sure documentation is in your personnel file validating this additional education. If you do not believe you are competent enough to proceed after the initial inservice, then it is your responsibility to let the educator and nurse manager know you need more time. Together you can develop an action plan for gaining competency.


c. Refuse to accept the newly assigned task. You will need to document your concerns for patient safety as well as the process you use to inform your employer of your decisions. Keep a copy of this documentation and send a copy to the nurse executive. Courtesy requires you also send a copy to your nurse manager. When you refuse to accept the assigned task, be prepared to offer options such as transfer to another unit (if this new role is just for your unit) or perhaps a change in work assigned tasks with your colleagues. Keep in mind, though, when you refuse an assignment you may face disciplinary action, so it is important that you be familiar with your employer’s grievance procedure.


Each nurse must determine his/her own individual scope of practice. To determine one’s scope of practice, the nurse must understand the Nurse Practice Act and assess his/her own evolving set of competencies. A nurse’s scope of practice will change over time, with additional experience and education. Determining scope of practice is an obligation and responsibility jointly shared by individual nurses, nurse managers, nurse executives and educators, as well as the regulatory agencies and professional organizations. This article is intended to provide nurses with information and tools to assist them in determining their scope of practice.

Information excerpted from “Kansas Guidelines for the Registered Nurse in Determining Scope of Practice” with permission from Kansas State Nurses Association (Revised, April 2002) and the State of Connecticut Board of Examiners for Nursing “What is the SBEN?”

The Connecticut Board of Examiners for Nursing Nursing Practice Decision-Making Model follows on page 9.

How to Earn Continuing Education Credit– Contact Hours (CH)

Read the Continuing Education article, Scope of Practice: The Responsibility of the Registered Nurse in Making Practice Decisions and review SBEN Nursing Competency/Scope of Practice Decision– Making Model on pages 6, 7, 8 and 9.

Take the test on page 11

Complete the answer form (photocopies accepted).

Mail or fax by 9/5/03 the completed answer form to the address below. Include a $15.00 processing fee-check or money order (payable to Connecticut Nurses’ Association) or with credit card information (VISA, MasterCard, American Express or Discover).

MAIL: Connecticut Nurses’ Association 377 Research Parkway Meriden, CT 06450-7160

FAX. 203-238-3437, Credit card payments only.

SCORING: To earn 1.2 contact hours (CH) of continuing education, you must achieve a score of 75% (9 of 12 answers correct). Test results will be sent to you within four weeks of receipt of your answer form at Connecticut Nurses’ Association (CNA) headquarters. Certificates indicating successful completion of this continuing education activity will bear the date your answer form is received at CNA.

ACCREDITED: Connecticut Nurses’ Association (CNA) is accredited as a provider of continuing education in nursing through the American Nurses Credentialing Center’s Commission on Accreditation (ANCC);

QUESTIONS: Phone: 203-238-1207 ext. 12 Fax: 203-238-3437


By Angela DiLillo, MS, RN and

Frances W. Adams, MS, RN

Copyright Connecticut Nurses’ Association Sep-Nov 2002

Provided by ProQuest Information and Learning Company. All rights Reserved