At a recent gathering of nurse leaders in critical care, the discussion turned to conditions constraining the scope of nursing practice. There was broad agreement when Dr Kathy Dracup spoke of a need to “unleash the practice of nursing” in order to fully realize nursing’s contribution to meeting the needs of patients and families in critical care. The recent Institute of Medicine of the National Academies (IOM) report, The Future of Nursing: Leading Change, Advancing Health,1 also speaks to the importance of a strong nursing profession that is empowered to participate fully in shaping the future of health care.
Every discipline in critical care brings valuable contributions to patient care. We expect physicians to direct and assume responsibility of the medical care of patients. We should expect and support the same level of responsibility, authority, and autonomy for nurses in the provision of nursing care. Unleashing the practice—removing barriers to nurses practicing to the full extent of their education and training—is important to interdisciplinary care and to patient and family outcomes.
Models of Nursing Research Excellence
The power of unleashed nursing practice is exemplified by one of the American Association of Critical-Care Nurses’ (AACN’s) highest honors, the Distinguished Research Lectureship.2 This honor recognizes significant contributions to acute and critical care nursing research. Thirty Distinguished Research Lecturers have been named since the award was established in 1982, and their work is an uplifting view of nursing excellence. All of the Distinguished Research Lecturers have inspiring stories about the integration of nursing research and nursing practice that illustrate the power of nursing unleashed.
The 2012 Distinguished Research Lecturer, Dr Martha Curley, presented her lecture at the AACN National Teaching Institute & Critical Care Exposition in May, and the full text of her lecture is published in this issue of the American Journal of Critical Care.3
Curley’s work to improve outcomes for critically ill children and their families demonstrates the power of nursing practice and the importance of interdisciplinary care. The questions she has pursued emanate from the bedside and from patient issues that are central to nursing practice. Although her work has been focused in pediatric critical care, she has addressed seemingly universal nursing problems: skin breakdown, positioning, pain, sedation and agitation, weaning from mechanical ventilation, and empowering families.
Curley describes herself as a “nursist, a nurse activist,”3 and she is a strong advocate for nursing practice. She also readily acknowledges the contributions that her colleagues and mentors—including nurses, physicians, pharmacists, and respiratory therapists—made as she developed as a scientist and built nursing knowledge in the care of critically ill children. She is committed to interdisciplinary research and care. She provides strong evidence of the power of unleashing nursing practice and fully engaging her colleagues in other disciplines to optimize care for critically ill children.
“A nurse who is competent to perform a particular procedure in one state may be legally barred from doing that same procedure in another.”
Barriers to a Full Scope of Practice
Whereas there are encouraging examples of nursing unleashed, one of the most formidable barriers to nurses practicing to the full extent of their education and training is the variability of the legislation defining scope of nursing practice among states. Scope of practice is an important determinant of the level of responsibility, authority, and autonomy nurses can claim.
The scope of practice for registered nurses (RNs) and advanced practice registered nurses (APRNs) is defined by Nurse Practice Acts on the state level. All state boards of nursing use the National Council Licensure Examination for Registered Nurses (NCLEX-RN) as a requirement for licensure, and the NCLEX-RN is designed to ensure that newly licensed, entry-level nurses have the competencies needed to perform safely and effectively. Despite there being a national licensing examination for nursing competencies, the scope of practice for RNs is determined by individual state legislatures and varies from state to state.
The variability in state legislation results in scope of practice regulations that are incongruent with each other, and in many cases are inconsistent with RN and APRN education and training. Because of variability in state practice acts, a nurse who is competent to perform a particular procedure in one state may be legally barred from doing that same procedure in another. The rules governing what nurses can do are not based on education, training, experience, or competence, but on the judgments of each state’s legislature. To date, 24 states have joined the Nurse Licensure Compact (NLC), which enables multistate licensure for RNs; nurses with a multi-state license can practice in their home state and other party states. However, nurses with a multistate license must always be cognizant of and abide by the practice act in the state where they currently practice.
No licensure compacts currently exist for APRNs; three states (Utah, Texas, and Iowa) have passed legislation for an APRN Compact, but have not yet implemented it. The practice acts for APRNs are even more highly variable from state to state, although national certification examinations for APRNs test a standard level of advanced practice competency in a specialty area. When APRNs relocate, they must be vigilant regarding what practice is permitted in their new state; prescriptive authority rules vary greatly. This is confusing for patients and families, and particularly confusing for the physicians and other health professionals who work with APRNs.
A physician who has worked with APRNs in more progressive states will be surprised at the limitations imposed by less progressive states. Some responsibilities for which APRNs are educated (such as prescribing medications) overlap the traditional boundaries of medicine and have not been fully supported in all state practice acts. However, APRNs with prescriptive authority are clearly not physicians; they are practicing in an advanced scope of nursing practice. Restrictive practice acts and geographic variability in legislation constitute major barriers to unleashing nursing practice. Practice variability for RNs and APRNs that is based on geography rather than education and demonstrated competencies is counterproductive in a national environment where critical care providers, and nurses in particular, are in short supply.
A New Model of Nursing Practice
A model practice act was developed by the National Council of State Boards of Nursing (NCSBN); one of its purposes was to promote a common understanding of the scope of nursing practice. Model scope of practice language is articulated in the NCSBN Model Nursing Practice Act and Model Nursing Administrative Rules,4 and addresses RNs (in Article II, Chapter 2) and APRNS (in Article XVIII, Chapter 18). The model advocates independent practice for APRNs, control of APRN practice by the Board of Nursing, and an expanded scope of nursing that “includes, but is not limited to, performing acts of advanced assessment, diagnosing, prescribing and ordering.”
“Reformulating scope-of-practice laws to unleash the practice of nursing should be a high priority.”
A key message of the IOM Future of Nursing1 report is that scope of practice barriers should be removed. This is particularly important for acute and critical care practice, and for advanced practitioners caring for this vulnerable population. The report further issues a specific recommendation that state legislatures reform scope of practice regulations for APRNs to conform to the NCSBN Model Nursing Practice Act and Model Nursing Administrative Rules. Harmonizing practice acts across all states for both RNs and APRNs would standardize the expectations for nurses, create a more predictable work environment, and maximize the use of nursing talent. Maintaining scope of practice of acute care APRNs is critical. Reformulating scope of practice legislation to unleash the practice of nursing, particularly acute care nursing, should be a high priority.
Critical care practice and research require the contributions of strong disciplines that bring essential knowledge to the bedside, as well as systems that permit nurses to contribute to the full extent possible and encourage interdisciplinary work. Infringements on nursing practice should be actively opposed at every opportunity; in that way, we will unleash nursing at all levels.
Imagine what we can accomplish for patients and their families if we begin every day with a commitment to practice to the full extent of our education and training and to the full extent of our scope of practice? What can we accomplish for patients and families if we begin each day with a commitment to unleash ourselves and our coworkers? Everyone wins if we constantly remind ourselves how important it is to practice at our full potential. When we raise the bar for ourselves and our own performance, we raise the bar for our entire profession.
The statements and opinions contained in this editorial are solely those of the coeditors.
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