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Departm ent of Health
N ursing Care Quality Assurance Com m ission
Advisory Opinion
The Nursing Care Quality Assurance Commission (NCQAC) issues this advisory opinion in accordance with WAC 246 - 840 - 800. An advisory opinion adopted by the NCQAC is an official opinion about safe nursing practice. The opinion is not legally binding and does not have the force and effect of a duly promulgated regulation or a declaratory ruling by the NCQAC. Institutional policies may restrict practice further in their setting and/or require additional expectations to assure the safety of their patient and/or decrease risk. Title: Registered Nurse and Licensed Practical Nurse Scope of Practice
Number: NCAO 13.
References: RCW 18.79 Nursing Care WAC 246-840 Practical and Registered Nursing Interactive Scope of Practice Decision Tree
Contact: Deborah Carlson, MSN, RN
Phone: 360-236- Email: NursingPractice@doh.wa.gov
Effective Date: September 13, 2019
Supersedes: November 9, 2018 March 8, 2019
Approved By: Nursing Care Quality Assurance Commission
Conclusion Statement The purpose of this advisory opinion is to clarify and provide distinction from the registered nurse and licensed practical nurse roles, responsibilities and functions as it relates solely to professional nursing care. While nursing care often includes personal care as the nurse uses the nursing process, this advisory opinion draws a distinction between a care-giver giving personal care services and professional nursing care services. The RN and the LPN must be knowledgeable and understand the laws and rules that mandate nursing scope of practice. The practice of nursing may occur in any setting. The Scope of Practice Decision Tree (pages 7 and 8) and the RN and LPN Scope of Practice Comparison Chart (pages 9 and 10) of this document assist a nurse in the decision-making process. The RN and LPN are professionally accountable for nursing practice that encompasses a range of roles, responsibilities and functions for which they are educated, competent and authorized to perform.This responsibility cannot be avoided by accepting orders or directions of another person. The Nursing Care Quality Assurance Commission (NCQAC) supports nurses working up to the full extent, within the legal boundaries, of their education and training. An agency or employer may restrict the nurse’s practice but never expand the practice beyond the legal scope.
Background and Analysis The boundaries of the scope of nursing practice must be flexible to be responsive to the evolving health- related needs of the public. Nursing practice takes place in the context of continuing change and development resulting from advances in research and technology, the introduction of new approaches to delivery of care, and a greater variety of practitioners sharing more areas of common ability. The
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dynamic nature of the health care environment requires that a nurse respond to patient needs by continually expanding knowledge and skills and making judgments about the limits of their practice. The overall scope of nursing practice refers to the outer limits or boundaries for the profession and everything therein. The actual scope of practice of individual nurses is always narrower than that of the scope of the nursing profession as a whole. The scope of practice of the individual nurse is influenced by the nurses’ competency and experience, practice setting, employer requirements, and patient needs.
Nursing practice includes activities the RN or LPN are educated to perform, as established through laws and regulations, definitions of nursing practice and complemented by standards, guidelines, and position statements issued by professional organizations and the NCQAC.
Laws and Rules
The Washington State nursing laws are broad and principle-based. Nursing practice is defined in the RCW 18.79 Nursing Care and WAC 246-840 Practical and Registered Nursing. Other State laws and rules address delegation, and facility requirements. An agency or employer may restrict the nurse’s scope of practice or require specialty certifications or specific training courses.
Registered Nurse
The RN practices nursing care independently using the nursing process. The RN functions interdependently when carrying out a medical regimen under the general direction of an authorized health care practitioner: Licensed physician and surgeon (MD), dentist (DDS), osteopathic physician and surgeon (DO), naturopathic physician (ND), optometrist (OD), podiatric physician and surgeon (DPM), physician assistant, osteopathic physician assistant (PA), advanced registered nurse practitioner (ARNP), or midwife. These activities include administering medications, treatments, tests, and inoculations whether or not the severing or penetrating of tissues is involved and whether or not a degree of independent judgment and skill is required. Such direction must be for acts which are within the scope of practice of the nurse. (RCW 18.79.260). RCW 18.79.240 Construction allows the RN to perform minor surgery.
Licensed Practical Nurse
The LPN scope of practice in the nursing process is limited and focused. The LPN practices in an interdependent role when carrying out nursing care and a dependent role when carrying out medical regimens. The LPN may administer drugs, medications, treatments, tests, injections, and inoculations, whether or not the piercing of tissues is involved and whether or not a degree of independent judgment and skill is required under the direction of an authorized health care practitioner or under the direction and supervision of the RN. Such direction must be for acts within the scope of licensed practical nurse practice and the authorized health care practitioner. (RCW 18.79.270). The LPN implements nursing care plans developed by the RN or other authorized health care practitioner. The LPN may perform nursing education to nursing assistants under the direction and supervision of the RN.
The LPN performs care in routine nursing situations. WAC 246-840-705 Functions of a RN and LPN define a routine nursing situation as a relatively free of complexity, and the clinical and behavioral state of the client is relatively stable, requiring care based upon a comparatively fixed and limited body of knowledge The LPN may assist the RN in complex nursing situations by carrying out selected aspects of the care.
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Nursing Delegation
Several state laws and rules define delegation to assistive personnel (AP). The RN and LPN may delegate some nursing tasks in specific settings and circumstances to unlicensed assistive personnel AP including credentialed or registered AP (such as nursing assistants, medical assistances, home care aides, and surgical technologists.
- Only the RN may delegate to a surgical technologist;
- Only the RN may delegate to a medical assistant;
- Only the RN may delegate to nursing assistants and home care aides in community-based settings (adult family homes, assisted living facilities, and community residential programs for people with developmental disabilities) and in-home care settings;
- Only the RN may delegate to non-credentialed or credentialed UAP in a school setting;
- The RN or LPN may delegate to nursing assistants in other settings (hospitals, nursing homes, clinics, ambulatory surgical facilities).
For clarification, The RN or other authorized health care practitioner does not delegate to the LPN, but “directs” the LPN to perform nursing care or perform a medical regimen.
Nursing Process
Nursing Assessment
Nursing assessment consists of two parts:
- Data collection; and
- Analysis, synthesis, and evaluation of the data to create the nursing care plan.
Comprehensive Nursing Assessment
A comprehensive nursing assessment means collection, analysis, and synthesis of data performed by the RN used to establish a health status baseline, plan care and address changes in a patient’s condition as defined in the National Council State Boards of Nursing Model Act (2012). It is not within the scope of practice of the LPN to perform a comprehensive nursing assessment.
Focused Nursing Assessment
Focused nursing assessment means recognizing patient characteristics that may affect the patient’s health status, gathering and recording nursing assessment data and demonstrating attentiveness by observing, monitoring and reporting signs, symptoms, and changes in patient conditions in an ongoing manner to an authorized health care practitioner as defined in the National Council State Boards of Nursing Model Act (2012).
The RN may perform a focused nursing assessment and re-assessment based on the patient’s needs. The LPN may perform a focused nursing assessment and re-assessment at the direction of the RN or other authorized health care practitioner. The LPN may perform a physical assessment. The LPN may obtain health care history information. The LPN may perform specific assessments or screening activities, such as mental health status, suicidal risk, cognitive screening, substance use screening, oral health screening, growth and developmental screening, or nutritional assessments. The LPN may not analyze, synthesize, or evaluate the data or develop the nursing care plan. As a team member, the LPN should contribute to
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the development of the nursing care plan. The RN retains the overall responsibility for verifying data collected, interpreting and analyzing data, and formulating nursing diagnoses.
Initial, Admission, or Event-Focused Assessment
Different types of assessments, such as “initial”, “admission”, or “event-focused” assessment, are not defined in the nursing law and rules. These terms are often used by health care agencies to describe different types of assessment. Examples include post patient fall, pre-transfer assessments or others defined by agency policy based on laws and regulations, standards of care, accreditation standards, and reimbursement requirements applicable to specific practice settings. For example, if the Centers for Medicare and Medicaid Services (CMS) require than an RN perform the initial assessment, then a LPN cannot perform this assessment by proxy for the RN. The LPN may participate in collecting information and data as in any assessment process.
Nursing Diagnosis
A nursing diagnosis is used to determine the appropriate plan of care for the patient. The nursing diagnosis drives interventions and patient outcomes, enabling the nurse to develop the patient care plan. WAC 246-840-700 Standards of Nursing Conduct or Practice clarifies that only the RN is permitted to make a nursing diagnosis. The LPN may provide data to assist in the development of a nursing diagnosis. The LPN may document symptoms or other findings and may document using a nursing diagnosis already made by the RN. The LPN uses and applies nursing diagnosis (formulated by the RN) as a foundation for implementing interventions.
Implementation
The RN is responsible to initiate data collection and perform analysis of the data to create the nursing care plan. The LPN may perform the following activities related to implementation of the care plan:
- Procuring resources needed;
- Implementing nursing interventions and medical orders consistent with nursing rules and within an environment conducive to patient safety;
- Prioritizing performance of nursing interventions within the assignment;
- Recognizing responses to nursing interventions;
- Modifying immediate nursing interventions based on changes in the patient’s status; and
- Delegating specific nursing tasks as outlined in the plan of care and consistent with nursing delegation laws and rules.
Evaluation
The RN is responsible to evaluate the responses of the nursing interventions, analysis and modification of the nursing care plan consistent with intended outcomes. The LPN, in collaboration with the RN, assists in making adjustments in the care plan and reporting outcomes of are to the RN or other authorized health care practitioner.
Documentation
The nursing laws and rules do not require a RN to co-sign LPN medical records or other documentation. The LPN is individually accountable and responsible for the care the LPN provides. A RN or LPN never
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Scope of Practice Decision Tree
Identify, describe, or clarify the activity, intervention, or role under consideration.
Is the activity, intervention, or role prohibited by Washington State nursing laws and rules/regulations or any other applicable laws, rules/regulations, or accreditation standards or professional nursing scope and standards? NO
Is performing the activity, intervention, or role consistent with evidence-based nursing and health care literature?
YES
Are there practice setting policies and procedures in place to support performing the activity, intervention, or role?
YES
Has the nurse completed the necessary education to safely perform the activity, intervention, or role?
YES
Is there documented evidence of the nurse's current competence (knowledge, skills, abilities, and judgments) to safely perform the activity, intervention, or role?
YES
Does the nurse have the appropriate resources to perform the activity, intervention, or role in the practice setting?
YES
Would a reasonable and prudent nurse perform the activity, intervention, or role in this setting?
YES
Is the nurse prepared to accept accountability for the activity, intervention, or role and for the related outcomes?
YES
STOP
STOP
STOP
STOP
STOP
STOP
STOP
STOP
The nurse may perform the activity, intervention, or role to acceptable and prevailing standards of safe nursing care.
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Nursing Scope of Practice Decision Tree Step Considerations Define the Activity (^) • Problem or care need
- Clinical environment in which the task will be performed
- Stability and complexity of the patient care needs
- Equipment or supplies needed to safely complete the activity
- Requirement for directions or orders from an authorized health care practitioner¹
- Independent or interdependent action based on nursing licensure Legality (^) • Explicitly permitted or prohibited by Washington State nursing law or rule
- Other state laws or rules apply (facility licensing, health care professionals, etc.)
- Federal regulations
- Supervision or professional licensure requirements Practice Standards
- Evidence to support the activity within current standards of safe nursing care (National nursing organizations, associations, evidence-based literature and research, position statements, or community standards)
- NCQAC advisory opinions, interpretive statements, policy statements, declaratory statements, or other guidance about the activity Institutional Policy
- Prohibited or permitted by institutional policies and procedures
- Reimbursement requirements Safety & Competency
- Consistent with training in a pre-licensure program, post-basic program, continuing education program, certification program, or self-structured study
- Documentation of appropriate education and competency assessment specific to the activity
- Safe to perform the activity for the specific patient, in a specific setting, and at a specific time
- Specific environment or special equipment or personnel is needed in case of unexpected responses to assure patient safety and quality of care
- Potential outcome for the patient if the procedure is not performed Accountability • Reasonable and prudent nurse would complete the activity for this patient in this circumstance
- Willingness to be accountable and responsible, and accept consequences ¹ Licensed physician and surgeon, dentist, osteopathic physician and surgeon, naturopathic physician, optometrist, podiatric physician and surgeon, physician assistant, osteopathic physician assistant, advanced registered nurse practitioner, or midwife acting under the scope of their licensure. (RCW 18.79.260 and RCW 18.79.270).
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Reporting
and Recording
- Documents in the medical record
- Communicates (verbally or in writing) with LPN and other health care practitioners/health care team as appropriate - Documents in the medical record - Communicates (verbally or in writing) with RN and other health care practitioners/health care team as appropriate
Case Management
- Identifies case management needs
- Refers patients to appropriate resources
- Assists the RN in identifying case management needs
- Refers patients to appropriate resources based on nursing care plan
Delegation
(^) • Delegates nursing care plan activities to UAP
- Delegates medical regimens to UAP
- Delegates nursing care plan activities to UAP
- Delegates medical regimens to UAP
Supervision
- Performs nursing care independently
- Carries out medical regimens under the direction of an authorized health care practitioner
- Supervises care given by LPNs, and UAP
- Authorized health care practitioner is not required to be on the premises when RNs carry out medical regimens - Carries out medical regimens under the direction and supervision of an RN or other authorized health care practitioner - Performs nursing care under the direction and supervision of an RN - Supervises delegated care given by UAP - RN or other authorized health care practitioner is not required to be on the premises when carrying out medical regimens or nursing activities
Complexity
(^) • Performs nursing care and carries out medical regimens in complex situations
- Clinically and behaviorally stable and unstable patients - Performs basic nursing care in routine situations - Clinically and behaviorally stable patients - Assists in giving nursing care and carries out medical regimens in complex nursing situations
Health Education, Promotion and Prevention
- Provides health education, health promotion and preventive activities to patients, families and groups
- Identifies learning needs
- Develops and evaluates education plans
- Participates in developing, providing, and evaluating health education, health promotion and preventive activities to patients, families, and groups under the direction and supervision of an RN or other authorized health care practitioner
Prescribing Medication and
Therapies
- Under direction of an authorized health care practitioner may give medications, treatments, tests, injections, vaccines (whether or not piercing or puncturing of tissues is involved and whether or not a degree of independent judgment and skill is required) - Under direction of an authorized health care practitioner may give medications, treatments, tests, injections, vaccines (whether or not piercing or puncturing of tissues is involved and whether or not a degree of independent judgment and skill is required)
Responsibility
- Responsible and accountable for the quality of nursing care given
- Responsible and accountable for delegated activities
- Responsible and accountable for following the standards of nursing conduct or practice
- Accountable for delegation and supervision when delegating tasks to others
- May only perform activities within the RN’s individual scope of practice - Use Scope of Practice Decision Tree - Responsible and accountable for the quality of nursing care given - Responsible and accountable for delegated activities - Responsible and accountable for following the standards of nursing conduct or practice - Accountable for delegation and supervision when delegating tasks to others - May only perform activities within the LPN’s individual scope of practice - Use Scope of Practice Decision Tree
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References and Resources
Nursing Care Quality Assurance Commission Website: http://www.doh.wa.gov/LicensesPermitsandCertificates/NursingCommission
Nursing Care Quality Assurance Commission Patient Abandonment Interpretive Statement: https://www.doh.wa.gov/portals/1/Documents/6000/PatientAbndmt.pdf
NCSBN (October 2009). Changes in Health Care Professions’ Scope of Practice: https://www.ncsbn.org/ScopeofPractice_09.pdf
NCSBN Model Act (2012): https://www.ncsbn.org/14_Model_Act_0914.pdf
Office of the Superintendent of Public Instruction Health Services: http://www.k12.wa.us/HealthServices/Resources.aspx
Washington State Department of Health Facility Licensing Laws, Rules, and Other Information: http://www.doh.wa.gov/LicensesPermitsandCertificates/FacilitiesNewReneworUpdate
Washington State Department of Labor and Industries: http://www.lni.wa.gov/
Washington State Department of Social and Health Services Aging and Long-Term Support Administration: https://www.dshs.wa.gov/altsa
State Laws and Regulations
- RCW 18.88A Nursing Assistants: http://app.leg.wa.gov/rcw/default.aspx?cite=18.88A
- WAC 246-841 Nursing Assistants: https://app.leg.wa.gov/wac/default.aspx?cite=246-
- RCW 18.360: Medical Assistants: http://app.leg.wa.gov/rcw/default.aspx?cite=18.360&full=true
- WAC 246-827 Medical Assistants: http://apps.leg.wa.gov/wac/default.aspx?cite=246-
- RCW 18.215 Surgical Technologists: http://app.leg.wa.gov/rcw/default.aspx?cite=18.
- WAC 246-939 Surgical Technologists: http://apps.leg.wa.gov/wac/default.aspx?cite=246- 939&full=true
- RCW 18.88b Long-Term Care Workers: http://app.leg.wa.gov/rcw/default.aspx?cite=18.88b
- WAC 246-980 Home Care Aide: http://apps.leg.wa.gov/wac/default.aspx?cite=246-
- RCW 28.A.210 Health-Screening and Requirements: http://app.leg.wa.gov/RCW/default.aspx?cite=28A.
- RCW 43.214 Department of Early Learning: http://apps.leg.wa.gov/rcw/default.aspx?cite=43.215&full=true
- WAC 170-295 Minimum Licensing Requirements for Child Care Centers: http://apps.leg.wa.gov/WAC/default.aspx?cite=170-295&full=true
- RCW 70.02 Medical Records-Health Care Information Access and Disclosure: http://apps.leg.wa.gov/Rcw/default.aspx?cite=70.
