NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021.
You are probably wondering, “What is scope of practice? What does it mean for me and my nursing practice?” Scope of practice is defined as services that a trained health professional is deemed competent to perform and permitted to undertake according to the terms of their professional nursing license. [1] Nursing scope of practice provides a framework and structured guidance for activities one can perform based on their nursing license. As a nurse and a nursing student, is always important to consider: Just because your employer asks you to do a task…can you perform this task according to your scope of practice – or are you putting your nursing license at risk?
Nurses must also follow legal standards in when providing nursing care. Standards are set by several organizations, including the American Nurses Association (ANA), your state’s Nurse Practice Act, agency policies and procedures, and federal regulators. These standards assure safe, competent care is provided to the public.
This chapter will provide an overview of basic concepts related to nursing scope of practice and standards of care.
Before discussing scope and standards of nursing care, it is helpful to briefly review a history of the nursing profession. Florence Nightingale is considered to be the founder of modern nursing practice. In 1860 she established the first nursing school in the world. By establishing this school of nursing, Nightingale promoted the concept of nurses as a professional, educated workforce of caregivers for the sick. [1] See Figure 1.1 [2] for a portrait of Florence Nightingale. Florence Nightingale’s contributions to health care started during the Crimean War in 1854. Her team discovered that poor health care for wounded soldiers was being delivered by overworked medical staff in a dirty environment. Florence recorded the mortality rate in the hospital and created statistical models that demonstrated that out of every 1,000 injured soldiers, 600 were dying because of preventable communicable and infectious diseases. Florence’s nursing interventions were simple; she focused on providing a clean environment, clean water, and good nutrition to promote healing, such as providing fruit as part of the care for the wounded soldiers. With these simple actions, the mortality rate of the soldiers decreased from 60% to 2.2%. In 1859 Nightingale wrote a book titled Notes on Nursing that served as the cornerstone of the Nightingale School of Nursing curriculum. Nightingale believed in the importance of placing a patient in a environment that promoted healing where they could recover from disease. She promoted this knowledge as distinct from medical knowledge. Her emphasis on the value of the environment formed many of the foundational principles that we still use in creating a healing health care setting today. She also insisted on the importance of building trusting relationships with patients and believed in the therapeutic healing that resulted from nurses’ presence with patients. She promoted the concept of confidentiality, stating a nurse “should never answer questions about her sick except to those who have a right to ask them.” [3] These nursing concepts formed the foundation of nursing practice as we know it today.
Modern nursing has reinvented itself a number of times as health care has advanced and changed over the past 160 years. With more than four million members, the nursing profession represents the largest segment of the United States’ health care workforce. Nursing practice covers a broad continuum, including health promotion, disease prevention, coordination of care, and palliative care when cure is not possible. Nurses directly affect patient care and provide the majority of patient assessments, evaluations, and care in hospitals, nursing homes, clinics, schools, workplaces, and ambulatory settings. They are at the front lines in ensuring that patient care is delivered safely, effectively, and compassionately. Additionally, nurses attend to patients and their families in a holistic way that often goes beyond physical health needs and recognize social, mental, emotional, and spiritual needs. [4]
The American Nurses Association (ANA) is a national, professional nursing organization that was established in 1896. The ANA represents the interests of nurses in all 50 states of America while also promoting improved health care for everyone. The mission of the ANA is to “lead the profession to shape the future of nursing and health care.” [5] The ANA states that it exists to advance the nursing profession by doing the following:
Fostering high standards of nursing practice Promoting a safe and ethical work environment Bolstering the health and wellness of nurses Advocating on health care issues that affect nurses and the public [6]The ANA sets many standard of care for professional nurses that will be discussed in the next section.
Karimi H., Masoudi Alavi N. Florence Nightingale: The mother of nursing. Nursing and Midwifery Studies. 2015; 4 (2):e29475. https://www .ncbi.nlm .nih.gov/pmc/articles/PMC4557413/ ↵ [PMC free article : PMC4557413 ] [PubMed : 26339672 ]
Karimi H., Masoudi Alavi N. Florence Nightingale: The mother of nursing. Nursing and Midwifery Studies. 2015; 4 (2):e29475. https://www .ncbi.nlm .nih.gov/pmc/articles/PMC4557413/ ↵ [PMC free article : PMC4557413 ] [PubMed : 26339672 ]
Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. National Academies Press. https://www .ncbi.nlm .nih.gov/books/NBK209880/57413/ ↵. [PubMed : 24983041 ]
American Nurses Association. (n.d.). About ANA. https://www .nursingworld .org/ana/about-ana/ ↵. American Nurses Association. (n.d.). About ANA. https://www .nursingworld .org/ana/about-ana/ ↵.American Nurses Association. (2010, May 14). Discover the American Nurses Association (ANA). [Video]. YouTube. All rights reserved. https://youtu .be/PRwPhOjeqL4 ↵.
Standards for nursing care are set by several organizations, including the American Nurses Association (ANA), your state’s Nurse Practice Act, agency policies and procedures, federal regulators, and other professional nursing organizations. These standards assure safe, competent care is provided to the public.
The American Nurses Association (ANA) publishes two resources that set standards and guide professional nursing practice in the United States: The Code of Ethics for Nurses and Nursing: Scope and Standards of Practice. The Code of Ethics for Nurses establishes an ethical framework for nursing practice across all roles, levels, and settings. It is discussed in greater detail in the “Legal Considerations and Ethics” subsection of this chapter. The Nursing: Scope and Standards of Practice describes a professional nurse’s scope of practice and defines the who, what, where, when, why, and how of nursing. It also sets 18 standards of professional practice that all registered nurses are expected to perform competently. [1]
The “who” of nursing practice are the nurses who have been educated, titled, and maintain active licensure to practice nursing. The “what” of nursing is the recently revised definition of nursing: “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity.” [2] Simply put, nurses treat human responses to health problems and life processes and advocate for the care of others.
Nursing practice occurs “when” there is a need for nursing knowledge, wisdom, caring, leadership, practice, or education, anytime, anywhere. Nursing practice occurs in any environment “where” there is a health care consumer in need of care, information, or advocacy. The “why” of nursing practice is described as nursing’s response to the changing needs of society to achieve positive health care consumer outcomes in keeping with nursing’s social contract and obligation to society. The “how” of nursing practice is defined as the ways, means, methods, and manners that nurses use to practice professionally. [3] The “how” of nursing is further defined by the standards of practice set by the ANA. There are two sets of standards, the Standards of Professional Nursing Practice and the Standards of Professional Performance.
The Standards of Professional Nursing Practice are “authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently.” [4] These standards define a competent level of nursing practice based on the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. [5] Each of these standards is further discussed in the “Nursing Process” chapter of this book.
The Standards of Professional Performance are 12 additional standards that describe a nurse’s professional behavior, including activities related to ethics, advocacy, respectful and equitable practice, communication, collaboration, leadership, education, scholarly inquiry, quality of practice, professional practice evaluation, resource stewardship, and environmental health. All registered nurses are expected to engage in these professional role activities based on their level of education, position, and role. Registered nurses are accountable for their professional behaviors to themselves, health care consumers, peers, and ultimately to society. [6] The 2021 Standards of Professional Performance are as follows:
Ethics. The registered nurse integrates ethics in all aspects of practice. Advocacy. The registered nurse demonstrates advocacy in all roles and settings.Respectful and Equitable Practice. The registered nurse practices with cultural humility and inclusiveness.
Communication. The registered nurse communicates effectively in all areas of professional practice.Collaboration. The registered nurse collaborates with the health care consumer and other key stakeholders.
Leadership. The registered nurse leads within the profession and practice setting.Education. The registered nurse seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking.
Scholarly Inquiry. The registered nurse integrates scholarship, evidence, and research findings into practice.
Quality of Practice. The registered nurse contributes to quality nursing practice.Professional Practice Evaluation. The registered nurse evaluates one’s own and others’ nursing practice.
Resource Stewardship. The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, financially responsible, and judiciously used.
Environmental Health. The registered nurse practices in a manner that advances environmental safety and health. [7]
Years ago, nurses were required to recite the Nightingale pledge to publicly confirm their commitment to maintain the profession’s high ethical and moral values: “I will do all in my power to maintain and elevate the standard of my profession and will hold in confidence all personal matters committed to my keeping and family affairs coming to my knowledge in the practice of my calling, with loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care.” Although some of the words are outdated, the meaning is clear: Nursing is a calling, not just a job; to answer that call, you must be dedicated to serve your community according to the ANA standards of care and code of ethics. [8]
In addition to the professional standards of practice and professional performance set by the American Nurses Association, nurses must legally follow regulations set by the Nurse Practice Act and enforced by the Board of Nursing in the state where they are employed. The Board of Nursing is the state-specific licensing and regulatory body that sets standards for safe nursing care and issues nursing licenses to qualified candidates, based on the Nurse Practice Act enacted by that state’s legislature. The Nurse Practice Act establishes regulations for nursing practice within that state and defines the scope of nursing practice. If nurses do not follow the standards and scope of practice set forth by the Nurse Practice Act, they can have their nursing license revoked by the Board of Nursing.
To read more about the the Wisconsin Board of Nursing, Standards of Practice, and Rules of Conduct, use the hyperlinked PDFs provided below. [9]
Nursing students must understand their scope of practice outlined in their state’s Nurse Practice Act. Nursing students are legally accountable for the quality of care they provide to patients just as nurses are accountable. Students are expected to recognize the limits of their knowledge and experience and appropriately alert individuals in authority regarding situations that are beyond their competency. A violation of the standards of practice constitutes unprofessional conduct and can result in the Board of Nursing denying a license to a nursing graduate.
In addition to professional nursing standards set by the American Nurses Association and the state Nurse Practice Act where they work, nurses and nursing students must also practice according to agency policies, procedures, and protocols. For example, hospitals often set a policy that requires a thorough skin assessment must be completed and documented daily on every patient. If a nurse did not follow this policy and a patient developed a pressure injury, the nurse could be held liable. In addition, every agency has their own set of procedures and protocols that a nurse and nursing student must follow. For example, each agency has specific procedural steps for performing nursing skills, such as inserting urinary catheters. A protocol is defined by the Wisconsin Nurse Practice Act as a “precise and detailed written plan for a regimen of therapy.” For example, agencies typically have a hypoglycemia protocol that nurses automatically implement when a patient’s blood sugar falls below a specific number. The hypoglycemia protocol includes actions such as providing orange juice and rechecking the blood sugar. These agency-specific policies, procedures, and protocols supersede the information taught in nursing school, and nurses and nursing students can be held legally liable if they don’t follow them. Therefore, it is vital for nurses and nursing students to always review and follow current agency-specific procedures, policies, and protocols when providing patient care.
Nurses and nursing students must continue to follow their scope of practice as defined by the Nurse Practice Act in the state they are practicing when following agency policies, procedures, and protocols. Situations have occurred when a nurse or nursing student was asked by an agency to do something outside their defined scope of practice that impaired their nursing license. It is always up to you to protect your nursing license and follow the state’s Nurse Practice Act when providing patient care.
In addition to nursing scope of practice and standards being defined by the American Nurses Association, state Nurse Practice Acts, and employer policies, procedures, and protocols, nursing practice is also influenced by federal regulations enacted by agencies such as the Joint Commission and the Centers for Medicare and Medicaid.
The Joint Commission is a national organization that accredits and certifies over 20,000 health care organizations in the United States. The mission of The Joint Commission (TJC) is to continuously improve health care for the public by inspiring health care organizations to excel in providing safe and effective care of the highest quality and value. [10] The Joint Commission sets standards for providing safe, high-quality health care.
The Joint Commission establishes annual National Patient Safety Goals for various types of agencies based on data regarding current national safety concerns. [11] For example, National Patient Safety Goals for hospitals include the following:
Identify Patients Correctly Improve Staff Communication Use Medicines Safely Use Alarms Safely Prevent Infection Identify Patient Safety Risks Prevent Mistakes in SurgeryNurses, nursing students, and other staff members are expected to incorporate actions related to these safety goals into their daily patient care. For example, SBAR (Situation, Background, Assessment, and Recommendation) handoff reporting techniques, bar code scanning equipment, and perioperative team “time-outs” prior to surgery are examples of actions incorporated at agencies based on National Patient Safety Goals. Nursing programs also use National Patient Safety Goals to guide their curriculum and clinical practice expectations. National Patient Safety Goals are further discussed in the “Safety” chapter of this book.
Use the hyperlinks provided below to read more about The Joint Commission and National Patient Safety Goals.
The Joint Commission Center for Transforming Healthcare was developed in 2008 to help agencies develop effective solutions for critical safety problems with a goal to ultimately achieve zero harm to patients. Some of the projects the Center has developed include improved hand hygiene, effective handoff communications, and safe and effective use of insulin. The Center has also been instrumental in creating a focus on a safety culture in health care organizations. A safety culture empowers nurses, nursing students, and other staff members to speak up about their concerns about patient risks and to report errors and near misses, all of which drive improvement in patient care and reduce the incidences of patient harm. [12] Many health care agencies have implemented a safety culture in their workplace and successfully reduced incidences of patient harm. An example of a safety culture action is a nurse or nursing student creating an incident report when an error occurs when administering medication. The incident report is used by the agency to investigate system factors that contribute to errors. To read more about creating a safety culture, use the hyperlink provided below.
The Centers for Medicare & Medicaid Services (CMS) is another federal agency that establishes regulations that affect nursing care. CMS is a part of the U.S. Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid. The CMS establishes and enforces regulations to protect patient safety in hospitals that receive Medicare and Medicaid funding. For example, one CMS regulation states that a hospital’s policies and procedures must require confirmation of specific information before medication is administered to patients. This CMS regulation is often referred to as “checking the rights of medication administration.” You can read more information about checking the rights of medication administration in the “Administration of Enteral Medications” chapter of the Open RN Nursing Skills textbook. [13]
CMS also enforces quality standards in health care organizations that receive Medicare and Medicaid funding. These organizations are reimbursed based on the quality of their patient outcomes. For example, organizations with high rates of healthcare-associated infections (HAI) receive less reimbursement for services they provide. As a result, many agencies have reexamined their policies, procedures, and protocols to promote optimal patient outcomes and maximum reimbursement.
Now that we have discussed various agencies that affect a nurse’s scope and standards of practice, let’s review various types of health care settings where nurses work and members of the health care team.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs .legis.wisconsin .gov/code/admin_code/n/6.pdf ↵.
The Joint Commission. (n.d.). https://www .jointcommission.org/ ↵. This work is a derivative of Nursing Skills by Open RN and is licensed under CC BY 4.0 ↵.There are several levels of health care including primary, secondary, and tertiary care. Each of these levels focuses on different aspects of health care and is typically provided in different settings.
Primary care promotes wellness and prevents disease. This care includes health promotion, education, protection (such as immunizations), early disease screening, and environmental considerations. Settings providing this type of health care include physician offices, public health clinics, school nursing, and community health nursing.
Secondary care occurs when a person has contracted an illness or injury and requires medical care. Secondary care is often referred to as acute care. Secondary care can range from uncomplicated care to repair a small laceration or treat a strep throat infection to more complicated emergent care such as treating a head injury sustained in an automobile accident. Whatever the problem, the patient needs medical and nursing attention to return to a state of health and wellness. Secondary care is provided in settings such as physician offices, clinics, urgent care facilities, or hospitals. Specialized units include areas such as burn care, neurosurgery, cardiac surgery, and transplant services.
Tertiary care addresses the long-term effects from chronic illnesses or conditions with the purpose to restore a patient’s maximum physical and mental function. The goal of tertiary care is to achieve the highest level of functioning possible while managing the chronic illness. For example, a patient who falls and fractures their hip will need secondary care to set the broken bones, but may need tertiary care to regain their strength and ability to walk even after the bones have healed. Patients with incurable diseases, such as dementia, may need specialized tertiary care to provide support they need for daily functioning. Tertiary care settings include rehabilitation units, assisted living facilities, adult day care, skilled nursing units, home care, and hospice centers.
No matter the setting, quality health care requires a team of health care professionals collaboratively working together to deliver holistic, individualized care. Nursing students must be aware of the roles and contributions of various health care team members. The health care team consists of health care providers, nurses (licensed practical nurses, registered nurses, and advanced registered nurses), unlicensed assistive personnel, and a variety of interprofessional team members.
The Wisconsin Nurse Practice Act defines a provider as, “A physician, podiatrist, dentist, optometrist, or advanced practice nurse.” [1] Providers are responsible for ordering diagnostic tests such as blood work and X-rays, diagnosing a patient’s medical condition, developing a medical treatment plan, and prescribing medications. In a hospital setting, the medical treatment plan developed by a provider is communicated in the “History and Physical” component of the patient’s medical record with associated prescriptions (otherwise known as “orders”). Prescriptions or “orders” include diagnostic and laboratory tests, medications, and general parameters regarding the care that each patient is to receive. Nurses should respectfully clarify prescriptions they have questions or concerns about to ensure safe patient care. Providers typically visit hospitalized patients daily in what is referred to as “rounds.” It is helpful for nurses and nursing students to attend provider rounds for their assigned patients to be aware of and provide input regarding the current medical treatment plan, seek clarification, or ask questions. This helps to ensure that the provider, nurse, and patient have a clear understanding of the goals of care and minimize the need for follow-up phone calls.
There are three levels of nurses as defined by each state’s Nurse Practice Act: Licensed Practical Nurse/Vocational Nurse (LPN/LVN), Registered Nurse (RN), and Advanced Practice Nurse (APRN).
The NCSBN defines a licensed practical nurse(LPN) as, “An individual who has completed a state-approved practical or vocational nursing program, passed the NCLEX-PN examination, and is licensed by a state board of nursing to provide patient care.” [2] In some states, the term licensed vocational nurse (LVN) is used. LPN/LVNs typically work under the supervision of a registered nurse, advanced practice registered nurse, or physician. [3] LPNs provide “basic nursing care” and work with stable and/or chronically ill populations. Basic nursing care is defined by the Wisconsin Nurse Practice Act as “care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable.” [4] LPN/LVNs typically collect patient assessment information, administer medications, and perform nursing procedures according to their scope of practice in that state. The Open RN Nursing Skills textbook discusses the skills and procedures that LPNs frequently perform in Wisconsin. See the following box for additional details about the scope of practice of the Licensed Practical Nurse in Wisconsin.
The Wisconsin Nurse Practice Act defines the scope of practice for Licensed Practical Nurses as the following: “In the performance of acts in basic patient situations, the LPN shall, under the general supervision of an RN or the direction of a provider:
Accept only patient care assignments which the LPN is competent to perform.
Provide basic nursing care.
Record nursing care given and report to the appropriate person changes in the condition of a patient.
Consult with a provider in cases where an LPN knows or should know a delegated act may harm a patient.
Perform the following other acts when applicable:
Assist with the collection of data.
Assist with the development and revision of a nursing care plan.
Reinforce the teaching provided by an RN provider and provide basic health care instruction.
Participate with other health team members in meeting basic patient needs.” [5]
The NCSBN defines a Registered Nurse as “An individual who has graduated from a state-approved school of nursing, passed the NCLEX-RN examination and is licensed by a state board of nursing to provide patient care.” [6] Registered Nurses (RNs) use the nursing process as a critical thinking model as they make decisions and use clinical judgment regarding patient care. The nursing process is discussed in more detail in the “Nursing Process” chapter of this book. RNs may be delegated tasks from providers or may delegate tasks to LPNs and UAPs with supervision. See the following box for additional details about the scope of practice for Registered Nurses in the state of Wisconsin.
GENERAL NURSING PROCEDURES. An RN shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process:
Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.
Planning. Planning is developing a nursing plan of care for a patient, which includes goals and priorities derived from the nursing diagnosis.
Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to LPNs or less skilled assistants.
Evaluation. Evaluation is the determination of a patient’s progress or lack of progress toward goal achievement, which may lead to modification of the nursing diagnosis.
PERFORMANCE OF DELEGATED ACTS. In the performance of delegated acts, an RN shall do all of the following:
Accept only those delegated acts for which there are protocols or written or verbal orders.
Accept only those delegated acts for which the RN is competent to perform based on his or her nursing education, training or experience.
Consult with a provider in cases where the RN knows or should know a delegated act may harm a patient.
Perform delegated acts under the general supervision or direction of provider.
SUPERVISION AND DIRECTION OF DELEGATED ACTS. In the supervision and direction of delegated acts, an RN shall do all of the following:
Delegate tasks commensurate with educational preparation and demonstrated abilities of the person supervised.
Provide direction and assistance to those supervised.
Observe and monitor the activities of those supervised.
Evaluate the effectiveness of acts performed under supervision. [7]
Advanced Practice Nurses (APRN) are defined by the NCSBN as an RN who has a graduate degree and advanced knowledge. There are four categories of Advanced Practice Nurses: certified nurse-midwife (CNM), clinical nurse specialist (CNS), certified nurse practitioner (CNP), and certified registered nurse anesthetist (CRNA). APRNs can diagnose illnesses and prescribe treatments and medications. Additional information about advanced nursing degrees and roles is provided in the box below.
Nurse Practitioners: Nurse practitioners (NPs) work in a variety of settings and complete physical examinations, diagnose and treat common acute illness and manage chronic illness, order laboratory and diagnostic tests, prescribe medications and other therapies, provide health teaching and supportive counseling with an emphasis on prevention of illness and health maintenance, and refer patients to other health professionals and specialists as needed. In many states, NPs can function independently and manage their own clinics, whereas in other states physician supervision is required. NP certifications include, but are not limited to, Family Practice, Adult-Gerontology Primary Care and Acute Care, and Psychiatric/Mental Health.
To read more about NP certification, visit Nursing World’s Our Certifications web page.
Clinical Nurse Specialists: Clinical Nurse Specialists (CNS) practice in a variety of health care environments and participate in mentoring other nurses, case management, research, designing and conducting quality improvement programs, and serving as educators and consultants. Specialty areas include, but are not limited to, Adult/Gerontology, Pediatrics, and Neonatal.
To read more about CNS certification, visit NACNS’s What is a CNS? web page.
Certified Registered Nurse Anesthetists: Certified Registered Nurse Anesthetists (CRNAs) administer anesthesia and related care before, during, and after surgical, therapeutic, diagnostic, and obstetrical procedures, as well as provide airway management during medical emergencies. CRNAs deliver more than 65 percent of all anesthetics to patients in the United States. Practice settings include operating rooms, dental offices, and outpatient surgical centers.
To read more about CRNA certification, visit NBCRNA’s website.
Certified Nurse Midwives: Certified Nurse Midwives provide gynecological exams, family planning advice, prenatal care, management of low-risk labor and delivery, and neonatal care. Practice settings include hospitals, birthing centers, community clinics, and patient homes.
To read more about CNM certification,visit AMCB Midwife’s website.
Unlicensed Assistive Personnel (UAP) are defined by the NCSBN as, “Any unlicensed person, regardless of title, who performs tasks delegated by a nurse. This includes certified nursing aides/assistants (CNAs), patient care assistants (PCAs), patient care technicians (PCTs), state tested nursing assistants (STNAs), nursing assistants-registered (NA/Rs), or certified medication aides/assistants (MA-Cs). Certification of UAPs varies between jurisdictions.” [9]
CNAs, PCAs, and PCTs in Wisconsin generally work in hospitals and long-term care facilities and assist patients with daily tasks such as bathing, dressing, feeding, and toileting. They may also collect patient information such as vital signs, weight, and input/output as delegated by the nurse. The RN remains accountable that delegated tasks have been completed and documented by the UAP.
Nurses, as the coordinator of a patient’s care, continuously review the plan of care to ensure all contributions of the multidisciplinary team are moving the patient toward expected outcomes and goals. The roles and contributions of interprofessional health care team members are further described in the following box.
Dieticians: Dieticians assess, plan, implement, and evaluate interventions including those relating to dietary needs of those patients who need regular or therapeutic diets. They also provide dietary education and work with other members of the health care team when a client has dietary needs secondary to physical disorders such as dysphagia.
Occupational Therapists (OT): Occupational therapists assess, plan, implement, and evaluate interventions, including those that facilitate the patient’s ability to achieve their highest possible level of independence in their activities of daily living such as bathing, grooming, eating, and dressing. They also provide patients adaptive devices such as long shoe horns so the patient can put their shoes on, sock pulls so they can independently pull on socks, adaptive silverware to facilitate independent eating, grabbers so the patient can pick items up from the floor, and special devices to manipulate buttoning so the person can dress and button their clothing independently. Occupational therapists also assess the home for safety and the need for assistive devices when the patient is discharged home. They may recommend modifications to the home environment such as ramps, grab rails, and handrails to ensure safety and independence. Like physical therapists, occupational therapists practice in all health care environments including the home, hospital, and rehabilitation centers.
Pharmacists: Pharmacists ensure the safe prescribing and dispensing of medication and are a vital resource for nurses with questions or concerns about medications they are administering to patients. Pharmacists ensure that patients not only get the correct medication and dosing, but also have the guidance they need to use the medication safely and effectively.
Physical Therapists (PT): Physical therapists are licensed health care professionals who assess, plan, implement, and evaluate interventions including those related to the patient’s functional abilities in terms of their strength, mobility, balance, gait, coordination, and joint range of motion. They supervise prescribed exercise activities according to a patient’s condition and also provide and teach patients how to use assistive aids like walkers and canes and exercise regimens. Physical therapists practice in all health care environments including the home, hospital, and rehabilitation centers.
Podiatrists: Podiatrists provide care and services to patients who have foot problems. They often work with diabetic patients to clip toenails and provide foot care to prevent complications.
Prosthetists: Prosthetists design, fit, and supply the patient with an artificial body part such as a leg or arm prosthesis. They adjust prosthesis to ensure proper fit, patient comfort, and functioning.
Psychologists and Psychiatrists: Psychologists and psychiatrists provide mental health and psychiatric services to patients with mental health disorders and provide psychological support to family members and significant others as indicated.
Respiratory Therapists: Respiratory therapists treat respiratory-related conditions in patients. Their specialized respiratory care includes managing oxygen therapy; drawing arterial blood gases; managing patients on specialized oxygenation devices such as mechanical ventilators, CPAP, and Bi-PAP machines; administering respiratory medications like inhalers and nebulizers; intubating patients; assisting with bronchoscopy and other respiratory-related diagnostic tests; performing pulmonary hygiene measures like chest physiotherapy; and serving an integral role during cardiac and respiratory arrests.
Social Workers: Social workers counsel patients and provide psychological support, help set up community resources according to patients’ financial needs, and serve as part of the team that ensures continuity of care after the person is discharged.
Speech Therapists: Speech therapists assess, diagnose, and treat communication and swallowing disorders. For example, speech therapists help patients with a disorder called expressive aphasia. They also assist patients with using word boards and other electronic devices to facilitate communication. They assess patients with swallowing disorders called dysphagia and treat them in collaboration with other members of the health care team including nurses, dieticians, and health care providers.
Ancillary Department Members: Nurses also work with ancillary departments such as laboratory and radiology departments. Clinical laboratory departments provide a wide range of laboratory procedures that aid health care providers to diagnose, treat, and manage patients. These laboratories are staffed by medical technologists who test biological specimens collected from patients. Examples of laboratory tests performed include blood tests, blood banking, cultures, urine tests, and histopathology (changes in tissues caused by disease). [11] Radiology departments use imaging to assist providers in diagnosing and treating diseases seen within the body. They perform diagnostic tests such as X-rays, CTs, MRIs, nuclear medicine, PET scans, and ultrasound scans.
Nurses rarely make patient decisions in isolation, but instead consult with other nurses and interprofessional team members. Concerns and questions about patient care are typically communicated according to that agency’s chain of command. In the military, chain of command refers to a hierarchy of reporting relationships – from the bottom to the top of an organization – regarding who must answer to whom. The chain of command not only establishes accountability, but also lays out lines of authority and decision-making power. The chain of command also applies to health care. For example, a registered nurse in a hospital may consult a “charge nurse,” who may consult the “nurse supervisor,” who may consult the “director of nursing,” who may consult the “vice president of nursing.” In a long-term care facility, a licensed practical/vocational nurse typically consults the registered nurse/charge nurse, who may consult with the director of nursing. Nursing students should always consult with their nursing instructor regarding questions or concerns about patient care before “going up the chain of command.”
Registered nurses can obtain several types of certifications as a nurse specialist. Certification is the formal recognition of specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty. See the following box for descriptions of common nurse specialties.
Critical Care Nurses provide care to patients with serious, complex, and acute illnesses or injuries that require very close monitoring and extensive medication protocols and therapies. Critical care nurses most often work in intensive care units of hospitals.
Public Health Nurses work to promote and protect the health of populations based on knowledge from nursing, social, and public health sciences. Public Health Nurses most often work in municipal and state health departments.
Home Health/Hospice Nurses provide a variety of nursing services for chronically ill patients and their caregivers in the home, including end-of-life care.
Occupational/Employee Health Nurses provide health screening, wellness programs and other health teaching, minor treatments, and disease/medication management services to people in the workplace. The focus is on promotion and restoration of health, prevention of illness and injury, and protection from work-related and environmental hazards.
Oncology Nurses care for patients with various types of cancer, administering chemotherapy and providing follow-up care, teaching, and monitoring. Oncology nurses work in hospitals, outpatient clinics, and patients’ homes.
Perioperative/Operating Room Nurses provide preoperative and postoperative care to patients undergoing anesthesia or assist with surgical procedures by selecting and handling instruments, controlling bleeding, and suturing incisions. These nurses work in hospitals and outpatient surgical centers.
Rehabilitation Nurses care for patients with temporary and permanent disabilities within inpatient and outpatient settings such as clinics and home health care.
Psychiatric/Mental Health Nurses specialize in mental and behavioral health problems and provide nursing care to individuals with psychiatric disorders. Psychiatric nurses work in hospitals, outpatient clinics, and private offices.
School Nurses provide health assessment, intervention, and follow-up to maintain school compliance with health care policies and ensure the health and safety of staff and students. They administer medications and refer students for additional services when hearing, vision, and other issues become inhibitors to successful learning.
Other common specialty areas include a life span approach across health care settings and include maternal-child, neonatal, pediatric, and gerontological nursing. [12]
Now that we have discussed various settings where nurses work and various nursing roles, let’s review levels of nursing education and the national licensure exam (NCLEX).
Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs .legis.wisconsin .gov/code/admin_code/n/6.pdf ↵.
Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs .legis.wisconsin .gov/code/admin_code/n/6.pdf ↵.
Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs .legis.wisconsin .gov/code/admin_code/n/6.pdf ↵.
Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs .legis.wisconsin .gov/code/admin_code/n/6.pdf ↵.
Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. National Academies Press. https://www .nap.edu/catalog /12956/the-future-of-nursing-leading-change-advancing-health ↵. [PubMed : 24983041 ]
This work is a derivative of StatPearls by Bayot and Naidoo and licensed under CC BY 4.0 ↵.Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. National Academies Press. https://www .nap.edu/catalog /12956/the-future-of-nursing-leading-change-advancing-health ↵. [PubMed : 24983041 ]
Everyone who wants to become a nurse has a story to tell about why they want to enter the nursing profession. What is your story? Perhaps it has been a lifelong dream to become a Life Flight nurse, or maybe you became interested after watching a nurse help you or a family member through the birth of a baby, heal from a challenging illness, or assist a loved one at the end of life. Whatever the reason, everyone who wants to become a nurse must do two things: graduate from a state-approved nursing program and pass the National Council Licensure Exam (known as the NCLEX).
There are several types of nursing programs you can attend to become a nurse. If your goal is to become a Licensed Practical Nurse (LPN), you must successfully complete a one-year nursing program, pass the NCLEX-PN exam, and apply to your state board of nursing to receive a LPN license.
If you want to become a Registered Nurse, you can obtain either a two-year associate degree (ADN) or a four-year baccalaureate of science in nursing degree (BSN). Associate degree nursing graduates often enroll into a baccalaureate or higher degree program after they graduate. Many hospitals hire ADN nurses on a condition they complete their BSN within a specific time frame. A BSN is required for military nursing, case management, public health nursing, and school-based nursing services. Another lesser-known option to become an RN is to complete a three-year hospital-based diploma program, which was historically the most common way to become a nurse. Diploma programs have slowly been replaced by college degrees, and now only nine states offer this option. [ 1 ] After completing a diploma program, associate degree, or baccalaureate degree, nursing graduates must successfully pass the NCLEX-RN to apply for a registered nursing license from their state’s Board of Nursing.
Nursing graduates must successfully pass the National Council Licensure Examination (NCLEX) to receive a nursing license. Registered nurses must successfully pass the NCLEX-RN exam, and Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) must pass the NCLEX-PN exam.
The NCLEX-PN and NCLEX-RN are online, adaptive tests taken at a specialized testing center. The NCLEX tests knowledge, skills, and abilities essential to the safe and effective practice of nursing at the entry level. NCLEX exams are continually reviewed and updated based on surveys of newly graduated nurses every three years.
Both the NCLEX-RN and the NCLEX-PN are variable length tests that adapt as you answer the test items. The NCLEX-RN examination can be anywhere from 75 to 265 items, depending on how quickly you are able to demonstrate your proficiency. Of these items, 15 are unscored test items. The time limit for this examination is six hours. The NCLEX-PN examination can be anywhere from 85 to 205 items. Of these items, 25 are unscored items. The time limit for this examination is five hours. [ 2 ]
In 2023, the Next Generation NCLEX (NGN) is anticipated to go into effect. Examination questions on the NGN will use the new Clinical Judgment Measurement Model as a framework to measure prelicensure nursing graduates’ clinical judgment and decision-making. The critical thinking model called the “Nursing Process” (discussed in Chapter 4 of this book) will continue to underlie the NGN, but candidates will notice new terminology used to assess their decision-making. For example, candidates may be asked to “recognize cues,” “analyze cues,” “create a hypothesis,” “prioritize hypotheses,” “generate solutions,” “take actions,” or “evaluate outcomes.” [ 3 ] For this reason, many of the case studies and learning activities included in this book will use similar terminology as the NGN.
There will also be new types of examination questions on the NGN, including case studies, enhanced hot spots, drag and drop ordering of responses, multiple responses, and embedded answer choices within paragraphs of text. View sample NGN questions in the following hyperlink. NCSBN’s rationale for including these types of questions is to “measure the nursing clinical judgment and decision-making ability of prospective entry-level nurses to protect the public’s health and welfare by assuring that safe and competent nursing care is provided by licensed nurses.” [ 4 ] Similar questions have been incorporated into learning activities throughout this textbook.
Use the hyperlinks below to read more information about the NCLEX and the Next Generation NCLEX.
The Nurse Licensure Compact (NLC) allows a nurse to have one multistate nursing license with the ability to practice in their home state, as well as in other compact states. As of 2020, 33 states have implemented NLC legislation.
After obtaining an RN license, nurses can receive advanced degrees to expand their opportunities in the nursing profession.
A Master’s of Science in Nursing Degree (MSN) requires additional credits and years of schooling beyond the BSN. There are a variety of potential focuses in this degree, including Nurse Educator and Advanced Practice Nurse (APRN). Certifications associated with an MSN degree are Certified Nurse Educator (CNE), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Certified Registered Nurse Anesthetist (CRNA), and Certified Nurse Midwife (CNM). Certifications require the successful completion of a certification exam, as well as continuing education requirements to maintain the certification. Scope of practice for advanced practice nursing roles is defined by each state’s Nurse Practice Act.
Doctoral nursing degrees include the Doctor of Philosophy in Nursing (PhD) and the Doctor of Nursing Practice (DNP). PhD-prepared nurses complete doctoral work that is focused on research. They often teach in a university setting or environment to conduct research. DNP-prepared nurses complete doctoral work that is focused on clinical nursing practice. They typically have work roles in advanced nursing practice, clinical leadership, or academic settings.
No matter what nursing role or level of nursing education you choose, nursing practice changes rapidly and is constantly updated with new evidence-based practices. Nurses must commit to lifelong learning to continue to provide safe, quality care to their patients. Many states require continuing education credits to renew RN licenses, whereas others rely on health care organizations to set education standards and ongoing educational requirements.
Now that we have discussed nursing roles and education, let’s review legal and ethical considerations in nursing.
