The Texas Board of Nursing recognizes that advanced nursing practice is dynamic. The scope of advanced practice evolves through experience, acquisition of knowledge, evidence-based practice, technology development and changes in the health care delivery system. Therefore, advanced practice nurses may need to practice in new settings, perform new procedures, and develop new skills during their professional careers. It is common for the Board of Nurse Examiners to receive questions such as, "Can an advanced practice nurse treat a patient with that condition?", or "Is it within the scope of practice of an advanced practice nurse to perform that procedure?"
Scope of practice is defined as the activities that an individual health care provider performs in the delivery of patient care. Scope of practice reflects the types of patients for whom the advanced practice nurse can care; what procedures/activities the advanced practice nurse can perform; and influences the ability of the advanced practice nurse to seek reimbursement for services provided.
Determining scope of practice includes:
- Advanced practice education in a role and specialty
- Legal implications (e.g. compliance with the Nursing Practice Act and Board Rules)
- Scope of practice statements as published by national professional specialty and advanced practice nursing organizations
Both professional and individual scopes of practice exist. Professional scopes of practice are derived from professional specialty and advanced practice nursing organizations. An individual advanced practice nurse may or may not practice the full scope of the professional role and specialty. Decisions regarding individual scope of practice are complex and related to an advanced practice nurse's knowledge, skills and competencies. Each advanced practice nurse must practice within his/her individual scope.
National professional specialty and advanced practice nursing organizations broadly define scope of practice for each role. These documents address role, function, population served, and practice setting. They offer advanced practice nurses the broadest parameters for scope of practice. Therefore, professional scopes of practice are recommended as the initial resource in defining an individual's scope of practice.
Formal advanced practice nursing education is the foundation for the individual's scope of practice and evolves over the professional lifetime of the individual. Clinical experience in various settings, continuing education, formal course work and developments in healthcare all impact individual scope of practice. However, there are finite limits to expansion of scope of practice without completing additional formal education. Advanced practice nurses cannot change their legally recognized titles or designations through experience or continuing education; these changes may only be achieved through additional formal educational preparation and meeting all legal requirements to use that title and practice in that specialty set forth by the BON.
The following questions may help to clarify whether a new activity/procedure can be incorporated into an individual's scope of practice:
- Is it consistent with one's professional scope of practice?
- Is it consistent with statutory or regulatory laws?
- Is it consistent with one's education in the role and specialty?
- Is it consistent with the scope of one's recognized title or does it evolve into another advanced practice title recognized by the board requiring additional formal education and legal recognition?
- Is it consistent with the Standards of Nursing Practice outlined in Board Rule 217.11?
- Is it consistent with evidence-based care?
- Is it consistent with reasonable and prudent practice?
- Are you willing to accept accountability and liability for the activity and outcomes?
Adding New Procedures and/or Patient Care Activities
When adding a new procedure or patient care activity, the advanced practice nurse should maintain documentation of additional education and competency. An advanced practice nurse may add new procedures or patient care activities to his/her individual scope of practice by using the following suggestions:
- Identify the benefit for a new patient care activity, taking into consideration consumer demand, standards for safe practice, and interest of the advanced practice nurse.
- Ensure that state or federal statutes and regulations do not constrain the advanced practice nurse from incorporating the activity into practice.
- Identify established professional standards, if available, supporting the performance of the new activity.
- Establish goals and methods for learning that encompass knowledge and skills acquisition through which competence is attained.
- Demonstrate competent performance of the procedure/activity.
- Maintain records that reflect the acquisition and maintenance of competency.
The Texas Board of Nursing recognizes that individual scopes of practice will vary and that what is within the individual scope of practice for one advanced practice nurse may not be within the individual scope of practice for another advanced practice nurse authorized to practice in the same role and specialty. However, it is important to keep in mind that the Board holds each advanced practice nurse accountable for knowing and practicing within his/her professional and individual scope of practice.
Adopted by the Texas Board of Nursing, 10/20/2005
Scope of Practice FAQs
Q: The physician I work with wants me to perform a specific procedure as part of the services I provide in my practice setting. I did not learn how to do this procedure in my advanced practice program, but the physician is willing to teach me. Is it ok if the physician shows me how to perform the procedure?
A: The Standards of Nursing Practice in Rule 217.11 require nurses to accept only those assignments that take into consideration patient safety and that are commensurate with their own educational preparation, experience, knowledge, and physical and emotional ability [(1)(T)]. However, all nurses frequently find themselves in the position of needing to learn new procedures. Nurses at all levels of licensure are obligated to make a reasonable effort to obtain orientation/training for competency when encountering new equipment, technology, or unfamiliar patient care situations [Rule 217.11(1)(H)]. The BON also holds all nurses, including advanced practice nurses, accountable for their own continuing competence in nursing practice and individual professional growth [Rule 217.11(1)(R)]. The most appropriate mechanism for learning the new procedure and documenting competence will depend on the nature of the procedure. It is imperative that you and the physician work together to find an existing educational activity or develop a program that will prepare you appropriately to perform the procedure and provide the concomitant advanced practice nursing care to the patient.
It is important to remember that there is more to this issue than simply learning how to perform a particular procedure. Patient selection criteria, underlying physiology and/or pathophysiology (depending on the nature of the procedure) as well as indications for and contraindications to the procedure are among the many concepts that are fundamental to learning a new procedure. You must also learn to respond to and manage (as appropriate) untoward events/adverse reactions/complications that may occur as a result of the procedure. In many cases, on-the-job training will not include this type of content. If you are ever required to defend your practice for any reason (whether to the BON or any other entity), you will likely be required to provide evidence of education/training and documentation of competence related to the specific service you provided. As an advanced practice nurse, you retain professional accountability for any advanced practice nursing services you provide [Rule 221.13(e)].
Q: I am authorized to practice in a particular specialty area. I want to expand my scope of practice to include a second specialty area. (Examples of this situation include but are not limited to: adult health expanding to include pediatrics, family practice expanding to include care of patients with complex psychiatric pathologies, and primary care expanding to include acute/critical care). Can I do this by completing continuing education activities specific to the specialty and working with another advanced practice nurse authorized in that specialty or a physician?
A: There are finite limits to expanding one's scope of practice without completing additional formal education and obtaining the requisite authorization to practice in the additional role and/or specialty from the BON. When incorporating a new patient care activity or procedure into one's individual scope of practice, the board expects the advanced practice nurse to verify that the activity or procedure is consistent with the professional scope of practice for the authorized role and specialty and permitted by laws and regulations in effect at the time. For example, a women's health nurse practitioner or nurse-midwife who wishes to incorporate performance of colposcopies in his/her practice may do so without obtaining an additional authorization to practice from the BON because this activity is consistent with the professional scope of practice for those roles.
If the activity is not consistent with the professional scope of practice for the authorized role and specialty, additional formal education and authorization from the BON in the second role and/or specialty is required. For example, an advanced practice nurse who is authorized to practice in gerontological nursing wishes to provide advanced practice nursing care to all adult patients. In order to do so, he/she must complete education that will prepare him/her in an advanced practice role and specialty that encompasses advanced practice nursing care of adults of all ages. Rule 221.4(c) requires that this additional education meet the curricular requirements outlined in Rule 221.3, relating to advanced practice nursing education. After completing the additional formal education, you must obtain national certification in the additional role and specialty as well as authorization to practice in the particular role and specialty from the BON before you begin practicing in the additional specialty or role.
Q: An advanced practice nurse has recently joined my practice. I have requested that this advanced practice nurse provide certain services that he/she says are not within his/her scope of practice. As a registered nurse, his/her scope of practice encompasses nursing care of patients across the lifespan in all settings—from critical care to home health and everything in between. Why isn't his/her advanced practice scope of practice the same? As a physician, I can see any patient.
A: The RN scope of practice is extremely broad without limitation as to setting or patient population because the education the nurse completed to prepare him/her to practice as a RN was broad. His/Her RN education provided him/her with didactic (classroom) and clinical learning experiences that provided him/her with the knowledge, skills, and competence to provide nursing care to patients regardless of age, diagnosis or practice setting. Therefore, RN licensure is not limited based on practice setting or specific patient population.
Similarly, physicians complete broad education that encompasses the provision of medical care to patients across the lifespan, regardless of diagnosis or practice setting. Physicians do not specialize or sub-specialize in medical school; rather, they do so after completing their initial medical education.
In order to be authorized to practice as an advanced practice nurse, this individual completed additional educational preparation to expand his/her scope of practice beyond that of the RN. His/Her advanced practice nursing education, however, focused on expanding his/her nursing scope of practice in a particular advanced practice role and specialty (e.g. anesthesia, women's health, gerontology). Although he/she may have gained experience in a particular area in the RN role, experiences gained as a RN are not equivalent to and cannot replace formal education in the particular advanced practice role and specialty.
Q: Does the BON consider the scope of practice for a clinical nurse specialist equivalent to the nurse practitioner scope of practice?
A: The BON has been regulating advanced practice nurses since 1980. It has always viewed the clinical nurse specialist and nurse practitioner roles as separate and distinct roles. The Board acknowledges that there may be some overlap in the scopes of practice of these two categories of advanced practice nurses. The amount of overlap will vary based on the individual's advanced practice educational preparation.
Q: What requirements need to be met for advanced practice nurses who want to first assist and be reimbursed for their services?
A: HB 1718, passed in the 79th Regular Legislative Session (2005), amended the Nursing Practice Act to include Section 301.353. This section defines a nurse first assist as an individual who:
- Is licensed to practice as a RN,
- Has completed a nurse first assistant educational program approved or recognized by an organization recognized by the board, and
- Is either (1) certified in perioperative nursing (CNOR) OR (2) recognized by the board as an advanced practice nurse and qualified by education, training or experience to perform the tasks involved in perioperative nursing.
Therefore, if you are recognized by the board as an advanced practice nurse and qualified by education, training or experience to perform the tasks involved in perioperative nursing, you will only need to complete a nurse first assistant educational program. The nurse first assistant educational programs recognized by the Texas Board of Nursing are the nurse first assistant educational programs that are included on the Competency and Credentialing Institute's (CCI's) list of acceptable RNFA programs. You may access that list of programs on-line at the following URL: http://www.cc-institute.org/cert_crnf_prep_rnfa.aspx.
Please note: Advanced practice nurses who are recognized by the BON as nursemidwives may complete the American College of Nurse-Midwives' (ACNM's) process for incorporating first assistant responsibilities for obstetrical and/or gynecological procedures into their scopes of practice in lieu of a course accepted by CCI.
Q: Is it within the advanced practice nurse's scope of practice to provide services such as ordering home health services or performing FAA medical examinations for pilots?
A: Although many categories of advanced practice nurses may have been educated to provide these and many other patient care services, other laws and regulations [such as federal laws, other state laws (e.g., Texas Health and Safety Code), or JCAHO requirements] significantly impact an advanced practice nurse's ability to provide a specific service. Although the BON may state that the performance of a particular procedure or provision of a specific patient care activity is within an advanced practice nurse's professional scope of practice, the advanced practice nurse may not perform the procedure or provide the particular service if other laws and regulations prohibit this.
The Standards of Nursing Practice in Rule 217.11 remind nurses at all levels of licensure that they are obligated to know and conform to the Nursing Practice Act and BON rules in addition to all federal, state and local laws, rules or regulations affecting their current area of nursing practice [(1)(A)]. BON staff cannot speak as experts on other agencies' laws and regulations. Therefore, it is important for advanced practice nurses to investigate whether other laws or regulations prohibit the performance of a procedure or patient care activity before they perform it.
Q: My office practice employs two advanced practice nurses who are approved in different specialties. I understand that there is overlap in their scopes of practice. [An example of such a situation is an OB/GYN setting in which both a family nurse practitioner (FNP) and a women's health nurse practitioner (WHNP) practice]. Does this mean both advanced practice nurses have the same scope of practice in this setting?
A: BON Rule 221.12 defines the advanced practice nurse's scope of practice. It is important to understand that scope of practice for the advanced practice nurse is founded first and foremost upon his/her advanced educational preparation. The patient population, individual advanced educational program content and competencies attained in the advanced practice nursing educational program always serve as the foundation for advanced nursing practice. Rule 221.13(b), relating to the core standards for advanced practice, further states that advanced practice nurses must practice within the role and specialty appropriate to their educational preparation.
Although both programs included content related to a particular specialty or sub-specialty, the depth of the content included in each program varies significantly. As in the example of OB/GYN specialty content for the FNP and WHNP, the FNP educational program provided some content related to OB/GYN. It did not, however, include OB/GYN specialty content to the same depth that the WHNP's program did. Therefore, although there will be overlap in the scope of the services each advanced practice nurse provides in this setting, there may be procedures or patient care activities that are within the WHNP's scope of practice that are not within the FNP's scope of practice in this particular setting. Each advanced practice nurse is responsible for practicing within the role and specialty authorized by the board and appropriate to his/her educational preparation. Additionally, each advanced practice nurse is responsible for recognizing when he/she is in danger of exceeding his/her personal and professional scope of practice.
Q: May an Advanced Practice Nurse (APN) delegate tasks to other nurses or unlicensed assistive personnel using the same rules a physician uses?
A: No. Advanced practice nurses are regulated solely by the Texas Board of Nursing. As RNs, advanced practice nurses may only delegate tasks to unlicensed staff or assistive personnel utilizing the applicable RN Delegation rules 224 or 225 as appropriate and in compliance with rule 217.11(3)(B). Advanced practice nurses are not authorized to exceed the delegation criteria in Rules 224 and 225.
With regard to other nurses, it is important to note that an advanced practice nurse may make an assignment to another nurse that takes into account his/her scope of practice and level of licensure [Rule 217.11(1)(S)]. An advanced practice nurse may not assign tasks to RNs or LVNs that exceed the RN or LVN scope of practice, even if the advanced practice nurse agrees to co-sign the RN's or LVN's documentation. An advanced practice nurse’s co-signature for something that is beyond the RN's or LVN's scope of practice does not legitimize the RN's or LVN's actions. A nurse never functions "under the license" of another nurse nor does a nurse "delegate" to another licensed nurse. Board rules are accessible in their entirety on the BON web page under the link for Nursing Laws and Rules www.bon.state.tx.us/nursinglaw/rr.html.