ADVANCED PRACTICE REGISTERED NURSES SCOPE OF PRACTICE: IN-PATIENT versus OUT-PATIENT
Many advanced practice registered nurses (APRNs) may question what, if any, restrictions there are in their practice. In most states it depends upon many factors. These include federal/state rules and regulations, Board of Nursing rules and regulations, and practice/group/facility by-laws and regulations. So, each practice site may present unique challenges. It is your professional responsibility to learn and understand each of these circumstances and how they apply to your site and your scope of practice.
WHAT ARE THE FEDERAL RULES AND REGULATIONS FOR ADVANCE PRACTICE NURSES SCOPE OF PRACTICE?
In many cases, the Centers for Medicare and Medicaid Services (aka CMS) as well as the Joint Commission on Hospital Accreditation may restrict the scope of practice for advanced practice nurses. One example is admitting privileges. Another is documentation that requires a physician’s signature. Many of these may only apply to hospitals and/or clinics that are on a hospital license.
WHAT ARE THE STATE RULES AND REGULATIONS FOR ADVANCE PRACTICE NURSES SCOPE OF PRACTICE?
While many believe that the state Board of Nursing determines the scope of practice for an APRN, it is most often the elected state legislators that ultimately decide what an APRN may or may not do in their practice. This is often influenced by special interests that may attempt to restrict or limit an APRN’s scope of practice.
WHERE DOES THE NC BOARD OF NURSING GETS IT'S AUTHORITY TO REGULATE THE PRACTICE OF NURSING?
A state Board of Nursing derives its authority from legislation and typically is charged with regulating the practice of nursing and protecting the public in regards to nursing and advanced nursing practice. In North Carolina, the Board of Nursing Rules and Regulations are found in the Nursing Practice Act, North Carolina Administrative Code (NCAC) Article 9. Nurse Practice Act. §§ 90-158 through 90-171.18: Recodified as §§ 90-171.19 through 90-171.47.
In some states there are separate regulations that apply to APRNs. In North Carolina, Advanced Practice Registered Nurse (APRN) is an umbrella title for Registered Nurses who are, as defined in the North Carolina Administrative Code (21 NCAC 36 ), as Nurse Practitioner, Nurse Anesthetist, Nurse-Midwife or Clinical Nurse Specialist.
WHAT IS AN IN-PATIENT SETTING?
This most often refers to a hospital or clinic that is affiliated with and under the license of the hospital. It may also refer to a long-term care facility, nursing home facility or federally funded critical access facility. Most hospitals have a governance structure that includes a medical executive committee that often determines the content of a document named Delineation of Privileges or DOPs. The DOP will list the procedures and interventions that an APRN may perform independently or under various levels of supervision. In many facilities, each privilege must be accompanied by a competency statement. There must also be approvals to practice by the supervising physician, Department Chair or Service Line leader and facility Chief of Staff. Typically, the Board of Directors will then be the final approving body. In NC, all Nurse Practitioners and Certified Nurse Midwives must also have a Collaborative Practice Agreement. This agreement must include specific components that are available on the NC Board of Nursing website. All of these must be completed before an APRN begins to practice in a facility.
WHAT IS AN OUT-PATIENT SETTING?
This location is most often considered a private provider’s office. It could be owned by the provider or group of providers or by a healthcare or business system or corporation. If the advanced practice registered nurse has met all of the national, state and any practice specific regulations, the APRN practice is, by-in-large, determined by an agreement between the APRN and the supervising physician – as defined in the Collaborative Practice Agreement.
KEEP UP WITH YOUR EDUCATION and COMPETENCY
In both settings it is most important to consider the age range and experience, education, additional training and competency in the specific population of patients one is delivering care for and to. Nurse Practitioners are educated in a variety of these areas and as a professional responsibility, must assure that they are competent in their respective areas of practice.
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