Licensure, Scope of Practice, and Reporting

The National Council of State Boards of Nursing defines licensure as “the process by which boards of nursing grant permission to an individual (https://www.ncsbn.org/nursing-regulation/licensure.page) to engage in nursing practice after determining that the applicant has attained the competency necessary to perform a unique scope of practice.” States use licensure to establish minimum competencies for safe entry-level practice, thereby preventing public harm (https://www.ncsbn.org/public-files/Nursing_Licensure.pdf) from unqualified clinicians. Requirements for licensure can vary depending on a nurse’s level of education and state-specific practice acts (https://www.ncsbn.org/nursing-regulation/licensure/nurse-licensure-guidance.page).

“An RN license is an essential requirement for nurses to adhere to the acceptable and prevailing standards of safe nursing practice, which includes any applicable state and federal laws,” ONS member Susie Maloney, MS, APRN, AOCN®, AOCNS®, oncology advanced practice nurse at Oncology Nursing Advisors, LLC, in Dayton, OH, and member of the West Central Ohio ONS Chapter, said. “Many U.S. states participate in the Nurse Licensure Compact (https://www.ncsbn.org/compacts.page), which allows eligible nurses who meet established licensure requirements to be licensed in one state and practice in other compact states without obtaining a separate license in each state.”

“RN licensure represents a nurse’s responsibility to promote and champion safety and well-being in their communities,” ONS member Whitney Farowich, RN, BSN, BBA, BMTCN®, CLNC, oncology sales specialist at Janssen Biotech, Inc., in Seattle, WA, and member of the Puget Sound ONS Chapter, said. “I personally interpret this as upholding the highest standards of care, asking thoughtful questions in professional settings and with patients, encouraging independent insight and behavioral change, and staying up to date on current practice and research.”

What Licensure Means to Your Scope of Practice

Each nurse’s scope of practice varies according to their educational level and training, as determined in part by their state’s nurse practice act. Institutions may also have policies or procedures outlining structure and boundaries to ensure all nurses are practicing to the full extent of their licensure. An RN’s scope of practice helps outline their responsibilities and standardizes what they can and cannot do, ethically and legally (https://www.nursingworld.org/practice-policy/scope-of-practice/).

Although an RN’s scope of practice can vary, it centralizes on several key concepts (https://www.incrediblehealth.com/blog/nursing-scope-of-practice/), including administering and monitoring medications, developing care plans, obtaining vital signs, recognizing abnormalities, caring for wounds, and performing basic life support.

For example, the state of Washington’s nurse practice act (https://app.leg.wa.gov/RCW/default.aspx?cite=18.79), where Farowich practices, indicates that an RN’s scope of practice involves (https://app.leg.wa.gov/RCW/default.aspx?cite=18.79.260):

• Performing nursing care for individuals with illnesses, injuries, or disabilities
• Administering medications, treatments, tests, and inoculations, at or under the general direction of a licensed physician and surgeon, advanced practice RN (APRN), and other healthcare professionals acting within the scope of their licensure
• Delegating nursing care tasks to other individuals where the RN determines it is in the best interest of the patient

And section 4723.01(B) of Ohio’s nurse (https://ohionursing.wpenginepowered.com/wp-content/uploads/2020/02/RN-LPN-Scope-of-Practice-2019.pdf) practice act, where Maloney practices, signifies an RN’s scope of practice as:

• Identifying patterns of human responses to actual or potential health problems
• Executing a nursing regimen through selection, performance, management, and evaluation of nursing actions
• Assessing health status to deliver tailored nursing care
• Providing health counseling and teaching
• Administering medications, treatments, and regimens ordered by an individual authorized to practice in Ohio and acting within their professional practice
• Teaching, supervising, delegating, and evaluating nursing practice

Scope of practice can expand based on an RN’s specific education or training. For example, “an advanced level of nursing practice may be permitted if the nurse fulfills the requirements set forth by their state’s board of nursing, which may indicate that nurse obtains graduate education at a master’s, post-master’s, or doctoral level from an accredited college of nursing practice or specialized population foci. Some states grant distinct APRN licensure for practice or prescriptive authority,” Maloney said.

Maloney added that nurses in many states are advocating for full practice authority, in which APRNs can (https://www.aanp.org/advocacy/advocacy-resource/policy-briefs/issues-full-practice-brief) evaluate patients, diagnose, order and interpret diagnostic tests, and initiate and manage treatments—including prescribing medications—under the exclusive licensure authority of the state board of nursing” without physician involvement.

“Nurses can accelerate their careers by pursuing advanced nursing degrees and certifications (https://voice.ons.org/news-and-views/demonstrate-your-scope-of-practice-by-becoming-an-oncology-certified-nurse), which not only enhances their clinical credibility and improves their communication skills, but more importantly, it allows them to improve patient outcomes and work more effectively as members of interprofessional care teams,” Maloney said.

Farowich encouraged nurses to pursue degrees of interest even outside of the profession: For example, because of her degree in business economics, she has applied her nursing skills in the pharmaceutical industry and her legal nurse consulting (LNC) business.

“I have worked in several industries, and clinicians are the smartest and most compassionate. However, we are also humble, and sometimes can lose to someone who has a louder voice,” Farowich said. “Degrees and certification (https://voice.ons.org/news-and-views/demonstrate-your-scope-of-practice-by-becoming-an-oncology-certified-nurse) can give you gravitas and confidence to promote yourself in an increasingly competitive work environment.”

Advocate for Your Ability to Practice to Your Full Extent

Advocacy for nursing roles can take many shapes and forms, but no matter the avenue, the goal is the same: to ensure nurses’ ability to fully provide high-quality, safe patient care and contribute to the interprofessional team. An American Nurses Association panel identified that to achieve their full scope of RN practice, nurses must challenge their institutions or organizations to champion (https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-21-2016/No3-Sept-2016/Registered-Nurses-Executive-Summ.html) nurses’ actively engagement in decisions regarding nursing care.

“Speak up, know your worth, and know that your voice matters!” Farowich said.

Use Your Voice to Report Medical Errors in Practice

In addition to advocacy, nurses have an innate responsibility to report medical errors (https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-21-2016/No3-Sept-2016/Enhancing-Patient-Safety.html) as part of their commitment to protect patient safety. Maloney and Farowich said that nurses should not only report errors but also establish a culture of safety to encourage nurses to do so more often without fear of punishment. A culture of safety is an organization’s shared perceptions, beliefs, values, and attitudes that combine to create a commitment to safety and an effort to minimize harm (https://www.acpjournals.org/doi/10.7326/0003-4819-158-5-201303051-00002), and healthcare leaders can showcase their commitment (https://www.ecri.org/components/HRC/Pages/RiskQual21.aspx) by supporting training about errors and near misses, investigating errors to understand their causes, developing strategies to prevent error recurrence, and sharing the value of reporting through lessons learned.

Maloney presented at the 47th Annual ONS Congress® in 2022 about safe practices in oncology settings (https://ons.confex.com/ons/2022/meetingapp.cgi/Session/4293), and her session included content about medical error reporting and culture of safety. Maloney used RaDonda Vought’s case (https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient) as an example of the impact of medication errors and outcomes on health care.  Vought was criminally convicted for a fatal medication error after the jury returned a guilty verdict.

“We need to ensure that nurses feel safe reporting medical errors (https://voice.ons.org/news-and-views/become-a-champion-of-safety-through-error-recognition-and-reporting),” Maloney said. “Otherwise, errors have the potential to be ‘covered up,’ where nurses may not admit to making a mistake for fear of being prosecuted.”

To report a medical error, Maloney explained that typically, the nurse who made the mistake files an incident report for the nurse manager to analyze. The nurse manager may educate the nurse, or they may involve the quality department for additional reporting. The manager also examines the medical process that was followed, or not followed, to determine whether changes are needed to prevent a repeated mistake in the future.

“Always report an error and without blame,” Farowich emphasized. The aim of reporting is to improve practice, not punish mistakes.

The RN also has a duty to speak up if a provider’s treatment orders do not match established guidelines. Farowich and Maloney encouraged nurses to begin a conversation with the provider, voice their concerns, refer to their state’s laws and rules, and take action to ensure patient safety.

“Explain to the provider that the order does not meet the acceptable standard of care and ask if there is a rationale for the discrepancy,” Maloney instructed.

“I have been in this position before, and it was scary to say something. And even at first, the physician pushed back and wanted me to move forward anyway,” Farowich said. She explained to the provider that the intended patient care was sound judgement, but the orders did not match the verbalized plan. “I stuck to what I thought was right and eventually the physician did rewrite the order to match the guidelines.”

Be clear about what you want, Farowich advised. Use logic to explain that your job is to follow the guidelines, what the guidelines are, and what should change. “A physician or advanced practice provider will respect you for asking that,” she said.

Legal Nurse Consultants Bring a Nursing Perspective to Medical Error Analyses

Farowich said that medical error reporting initiates a legal analysis to determine whether what happened either failed to meet national or institutional standards or did not represent sound judgement. LNCs are involved in that process at the discretion of an attorney or legal team. Farowich said that an LNC can assist with:

• Screening and investigating cases for merit
• Defining applicable standards of care
• Assessing alleged damage or injuries
• Identifying factors that caused or contributed to alleged damages or injuries
• Organizing medical records
• Summarizing, translating, and interpreting medical records
• Identifying and recommending potential defendants
• Conducting literature searches and integrating standards and guidelines into case analysis
• Identifying and locating expert witnesses
• Preparing interrogatories
• Coordinating and attending independent medical exams
• Locating life care plan experts
• Preparing deposition and trial (cross or direct) questions

An LNC typically has minimal contact with any RNs involved in errors because they must be unbiased when deciphering a case. In her work as a clinical LNC, Farowich said she tries to look at the whole situation and understand system problems in addition to individual errors.

“Being a nurse amidst a legal battle involving attorneys, corporations, and insurance companies, I have the opportunity to maintain high ethical standards and hold all parties to this,” Farowich said. “Most people interpret legal battles to be about money, and while I am not in a position to dispute that, my role also involves reminding everyone that these are issues about health and safety and that these principles are universally valuable.”