www.journalofnursingregulation.com 19Volume 7/Issue 3 October 2016
Scope of Nursing Practice
Decision-Making Framework
Karen Ballard, MA, RN, FAAN; Deb Haagenson, BSN, RN; Linda Christiansen, EdD, JD, MSN, RN; Gloria Damgaard,
MS, RN, FRE; Judith A. Halstead, PhD, RN, FAAN, ANEF; Ruby R. Jason, MSN, RN, NEA-BC; Jane Clare Joyner,
MSN, RN, JD; Ann M. O’Sullivan, MSN, RN, CNE, NE-BC, ANEF; Josephine Silvestre, MSN, RN; Maureen Cahill,
MSN, RN, APN-CNS; Beth Radtke, MS; and Maryann Alexander, PhD, RN, FAAN
In early 2015, the Tri-Council for Nursing, consisting of the American Association of Colleges of Nursing (AACN), the American
Nurses Association (ANA), the American Organization of Nurse Executives (AONE), and the National League for Nursing
(NLN), in collaboration with the National Council of State Boards of Nursing (NCSBN) determined that a uniform tool (scope of
practice decision-tree) was needed. Representatives from the ANA, NLN, and Boards of Nursing, along with NCSBN staff, hat
would assist nurses and their employers in determining the responsibilities a nurse can safely perform. Upon examination
of these existing algorithms and identification of essential elements, a uniform scope of practice decision-making framework
was developed.
Keywords: Decision-making tool, nurse practice acts, nursing regulation, scope of nursing practice
Upon graduating from nursing programs, new nurses have
a relatively proficient understanding of the interventions,
skills, and responsibilities they are able to perform under
the purview of their state Nurse Practice Act (NPA). However, at
some juncture, a nurse may encounter a situation in which he or she
is asked to perform a skill or assume a responsibility that he or she
is uncertain about undertaking. This may be because the skill is one
that is not traditionally a nursing responsibility, or he or she feels
does not feel qualified to perform it safely. How do nurses decide if a
responsibility is within their scope of practice?
As nursing knowledge and practice increases, questions about
scope of practice emerge and present a quandary for nurses who
want to expand their knowledge and skills yet still remain within
the boundaries of regulation. To assist nurses and employers with
this decision-making process, four major nursing organizations col-
laborated and developed a scope of practice decision-tree that was
developed by an expert panel and vetted by the board of directors
of the American Association of Colleges of Nursing (AACN), the
American Nurses Association (ANA), the American Organization
of Nurse Executives (AONE), and the National League for Nursing
(NLN), in collaboration with the National Council of State Boards
of Nursing (NCSBN)
The tool could be adopted by state boards of nursing (BONs),
used by facilities, and would help nurses determine whether specific
activities, interventions or roles are permitted under a nurse’s level of
education, licensure, and competence, and meet the standards estab-
lished by the NPA and rules/regulations of each state/jurisdiction.
Members of the expert panel combined their knowledge,
reviewed the literature, and methodically examined existing decision-
making algorithms utilized by BONs. The algorithms across states/
jurisdictions addressed many similar questions; however, some
states included specific nuances, such as directing the user to uti-
lize the Cumulative Index of Nursing and Allied Health Literature
(CINAHL) to explore current accepted practice if no specific practice
decision existed. Some of the algorithms were complex, while a few
were straightforward. One algorithm suggested that the chief nurse
of an organization may decide what is within the scope of practice of
a licensed nurse based on the use of the algorithm.
Upon completion of their review, , the panel determined that
it was crucial for the scope of nursing practice decision-making
framework to be applicable to all activities, interventions, and roles of
all licensed nurses without being overly restrictive. Additionally, the
panel believed that the framework should be applicable to all types
of nurse practice settings. The panel determined the key questions to
include in the decision-making framework, as well as specified the
targeted population, the context for use, and key definitions. Using
this information, a draft decision-making framework was developed
and forwarded to the panel for review and comment. The frame-
work (See Figure 1) was reviewed and approved by the Tri-Council in
February 2016 and by the NCSBN Board of Directors in July 2016.
Purpose
Recognizing that nursing practice is continually evolving, this docu-
ment serves to provide a standardized, decision-making framework
20 Journal of Nursing Regulation
FIGURE 1
Scope of Nursing Practice Decision-making Framework
Identify, describe, or clarify the activity, intervention, or role under consideration.
Is the activity, intervention, or role prohibited by the NPA and rules/regulations or any other applicable
laws, rules/regulations, or accreditation standards or professional nursing scope and standards?
YES STOP
NO
Is performing the activity, intervention, or role consistent with evidence-based nursing and health care
literature?
NO STOP
YES
Are there practice setting policies and procedures in place to support performing the activity,
intervention, or role?
NO STOP
YES
Has the nurse completed the necessary education to safely perform the activity, intervention, or role? NO STOP
YES
Is there documented evidence of the nurse’s current competence (knowledge, skills, abilities, and
judgments) to safely perform the activity, intervention, or role?
NO STOP
YES
Does the nurse have the appropriate resources to perform the activity, intervention, or role in the
practice setting?
NO STOP
YES
Would a reasonable and prudent nurse perform the activity, intervention, or role in this setting? NO STOP
YES
Is the nurse prepared to accept accountability for the activity, intervention, or role and for the related
outcomes?
NO STOP
YES
The nurse may perform the activity, intervention, or role to acceptable and prevailing standards of safe nursing care
www.journalofnursingregulation.com 21Volume 7/Issue 3 October 2016
for all licensed nurses in all settings with respect to their education,
role, function, and accountability within the scope of nursing prac-
tice. It will assist nurses, including direct care nurses, in navigating
current nursing practice with all of its challenges. As practice trans-
forms, licensed nurses need to communicate any ongoing issues/con-
cerns to their BONs so that regulators can evaluate whether changes
to the NPA, rules/regulations, or standards need to be considered.
Targeted Population
The population for which this framework was devised includes all
licensed nurses (LPN/VN, RN, and APRN) at all experience levels
(novice to expert) in all practice settings and in all roles such as:
⦁ Direct care nurses
⦁ Nurse managers
⦁ Nurse administrators
⦁ Nurse educators
⦁ Nurse researchers
⦁ Nurse regulators
⦁ Nurse policymakers
Context for Use
To promote safety of patients, nurses would use this framework to:
⦁ Determine individual accountability for practice decisions
⦁ Communicate with other health care professionals regarding the
scope of nursing practice and the nurse’s accountability
⦁ Inform health care and other employing organizations about the
scope of nursing practice and nursing accountability
⦁ Educate nursing students about their accountability for practice
decisions
⦁ Guide professional nursing organizations, and credentialing and
regulatory agencies in the formulation of scope and standards of
practice, policy, and position statements.
Key Definitions
The panel determined that the following key definitions are an
important part of the decision-making framework:
Accountability: The panel is using the ANA’s definition of
accountability, which states that accountability means “to be answer-
able to oneself and others for one’s own choices, decisions and actions
as measured against a standard such as that established by the Code
of Ethics for Nurses with Interpretive Statements.” (American Nurses
Association [ANA], 2015, page 41)
Furthermore, the ANA sets forth that “to be accountable,
nurses follow a code of ethical conduct that includes moral principles
such as fidelity, loyalty, veracity, beneficence, and respect for the dig-
nity, worth, and self-determination of patients, as well as adhering
to the scope and standards of nursing practice. Nurses in all roles
are accountable for decisions made and actions taken in the course
of nursing practice. Systems and technologies that assist in clinical
practice are adjunct to, not replacements for, the nurse’s knowledge
and skill.
Therefore, nurses are accountable for their practice even in
instances of system or technology failure” (ANA, 2015a, page 15-16).
Appropriate resources: Appropriate resources means that
nurses have the human and material support to perform the activ-
ity, intervention, or role safely, including any necessary emergency
management.
Education: By education, the panel is referring to basic nurs-
ing education, advanced nursing education, or professional develop-
ment to support in the activity, intervention, or role
Professional nursing standards: According to the National
Federation of Licensed Practice Nurses, “professional nursing stan-
dards” refers to a set of standards for the practice of safe and effective
nursing care such as Nursing: Scope and Standards of Practice, Third
Edition (ANA, 2015) and Nursing Practice Standards for the Licensed
Practice/Vocational Nurse (National Federation of Licensed Practical
Nurses, 2003).
Reasonable and prudent nurse: The panel defines a “rea-
sonable and prudent nurses” as a nurse who uses good judgment
in providing nursing care according to accepted standards and that
another nurse with similar education and experience in similar cir-
cumstances would provide.
Conclusion
When the need arises to determine the scope of nursing practice,
this decision-making framework should provide guidance to all lev-
els of nurses in all roles and settings. As nursing practice continues
to evolve, licensed nurses should refer ongoing practice concerns or
questions to their BON so regulators can determine whether revi-
sions to the NPA or rules/regulations should be considered.
References
American Nurses Association. (2015). Code of ethics for nurses with interpre-
tive statements. Accessed from:
Vault/Ethics_1/Code-of-Ethics-for- Nurses.html.
American Nurses Association. (2015). Nursing: Scope and Standards of Prac-
tice, Third Edition. Silver Spring, Maryland: Nursebooks.org.
The advisory panel was represented by the following individuals:
Karen Ballard, MA, RN, FAAN – ANA; Deb Haagenson,
BSN, RN – NCSBN; Linda Christiansen, EdD, JD, MSN, RN
– NLN; Gloria Damgaard, MS, RN, FRE – NCSBN; Judith
A. Halstead, PhD, RN, FAAN, ANEF – NLN; Ruby R. Jason,
MSN, RN, NEA-BC – NCSBN; Jane Clare Joyner, MSN, RN,
JD – ANA; Ann M. O’Sullivan, MSN, RN, CNE, NE-BC,
ANEF – ANA; Josephine Silvestre, MSN, RN – NCSBN;
Maureen Cahill, MSN, RN, APN-CNS – NCSBN; Beth
Radtke, MS – NCSBN; Maryann Alexander, PhD, RN, FAAN
– NCSBN
