2020 Sentara Scope of Practice Statement for Professional (RN) and Technical (LPN) Nursing

Purpose

To define the scope of practice for the Registered Nurse (RN) and Licensed Practical Nurse (LPN) within Sentara Healthcare. Provides description of the scope of nursing practice addressing actions for Sentara nurses. The profession of nursing defines the scope and standards of nursing practice and State Boards of Nursing define legal parameters for nursing practice in that setting. This document summarizes available information into succinct guidelines to guide nursing practice and delegation. Patient safety always is the priority; when questions remain lift up the situation in question to nurse leaders for resolution and guidance.  All nurses are responsible for adherence to Board of Nursing regulations and laws of the state in which they practice.

Definitions

Accountability: To be answerable to oneself and others for one’s own choices, decisions and actions as measured against a standard (ANA, 2015)

Assignment: The routine care, activities and procedures that are within the authorized scope of practice of the RN or LPN or part of the routine functions of the assigned person.

Delegated Responsibility: A nursing activity, skill or procedure that is transferred from a licensed nurse to a delegatee.

Delegation: Transfer of responsibility for the performance of a task from one individual to another while retaining accountability for the outcome (ANA, 2015).

Supervision: guidance or direction of a delegated nursing task or procedure by a qualified, registered nurse who provides periodic observation and evaluation of the performance of the task and who is accessible to the unlicensed person.

 


 The following delegation decision tree can assist the licensed nurse in determining appropriateness for delegation.

click to enlarge

Further guidance is specified in specific Sentara policies, procedures or job aids.

Only RN’s with validated competencies are authorized to perform the following (not an all-inclusive list):

  • Delivery and Documentation of Nursing Care: Be in charge of a unit (this does not preclude the LPN in long-term care from managing/leading care with a minimum of 8 hours/24 hour period of RN supervision per long-term care regulations). Perform the nursing admission, learning assessment, post-op and post procedural, skin integrity risk and restraint assessments (in long-term care the RN completes/or signs off on the Minimum Data Set (MDS)). Develop, review, evaluation and update the interdisciplinary plan of care (in long-term care the LPN may make modifications to reflect emergencies or support patient safety)
  • Emergency Departments: Initial arrival and ongoing reassessments including triage; Advanced Triage Protocols/Standing Orders
  • Competency validation sign offs on other nursing personnel
  • Maternal Infant Newborn and Pediatric Care: Magnesium Sulfate Infusion for Hypertensive Disorders of Pregnancy, Tocolysis, or Fetal Neuroprophylaxis; Invasive Blood Pressure Monitoring (Neonatal); Fetal Fibronectin Testing; Insulin Intravenous Infusion for the Obstetric Patient; Central Lines (Neonatal): Peripheral Arterial, Umbilical Arterial, Umbilical Venous and Central Venous.
  • Behavioral Health: perform Violence and Suicide Risk Assessment and Patient Management in non-psychiatric units; Utilize the Suicide/Violence Assessment Tool (CTRS) to determine risk level.
  • Patient Transport: accompany patient who has experienced unexpected acute intervention or is hemodynamically unstable to the appropriate level of care.
  • Infusion Therapy: external jugular vein insertion in trauma;  access, care or discontinue umbilical artery or vein  infusion device; insert PICC lines or midline catheters; access epidural and intraoral infusion devices to administer medication, Intraosseous Access; assess and document infiltration treatment and response
  • Handling and Administration of Hazardous Medications: Chemotherapy must be prepared by the RN (or physician, pharmacist, or pharmacy technician). All routes of Chemotherapy are administered only by the RN (or qualified physician, physician assistant or advanced practice RN).
  • Moderate sedation administration (under certain conditions)
  • Blood Administration: Initiate and hang blood and blood products to neonates; RN must be one of the two nurses to verify blood and blood products information prior to administration in adults
  • Glycemic Management with Glucommander: manage and deliver Glucommander computerized glycemic management software program predictive dosing algorithms for subcutaneous or IV insulin therapies
  • Central Line Care: Discontinue non-tunneled/non-cuffed CVAD, declot or repair or insert central lines.
  • Insert a small bowel feeding tube ( per the critical care procedural guidelines)

Scope of Practice

RN Scope of Practice: All RNs are responsible to perform a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process.  The standards of practice (assessment, diagnosis, outcomes identification, planning, implementation, coordination of care- teaching and health promotion and evaluation) along with the standards of professional performance (ethics, culturally congruent practice, communication, collaboration, leadership,  education, evidence- based practice and nursing research, quality of practice, professional practice evaluation, resource utilization, and environmental health) encompass the actions and foundation of professional nursing. The RN is held accountable for the quality and quantity of nursing care given by self or those under the RN’s supervision.

LPN Scope of Practice: Licensed practical nursing is performed under the direction or supervision of a RN, licensed medical practitioner, or licensed dentist in observing and caring for the ill, injured, or infirm, in promoting preventive measures, in acting to safeguard life and health, in administering treatment and medication prescribed by a physician or dentist or in performing other acts not requiring the skill, judgment, and knowledge of a RN. The licensed practical nurse shall be held accountable for the quality and quantity of nursing care given to patients by self based upon educational preparation and experience.

 

Delegation

Delegation is a complex process involving licensed nurses responsibilities for understanding what can be delegated, to whom, when, in what circumstances, and with what supervision or evaluation. Delegation is determined by accepted professional nursing standards of practice, individual state statutes and nurse practice acts, state regulations and organizational policy statements. The delegating RN retains accountability for the patient outcomes associated with nurse delegation, provided the person to whom the task was delegated performed it as instructed.

The RN may delegate selected nursing tasks and procedures to unlicensed assistive personnel, if the following criteria are met. Unlicensed personnel shall not reassign delegated tasks and procedures. Nursing tasks shall only be delegated after an assessment is performed.

  1. In the judgement of the delegating nurse, the task or procedure can be properly and safely performed by the unlicensed person and the delegation does not jeopardize the health, safety and welfare of the patient.
  2. The delegating nurse retains responsibility and accountability for nursing care of the patient, including nursing assessment, planning, evaluation, documentation and supervision.
  3. Delegated tasks and procedures are within the knowledge, area of responsibility and skills of the delegating nurse.
  4. Delegated tasks and procedures are communicated on a patient specific basis to an unlicensed person with clear, specific instructions for performance of activities, potential complications, and expected results.
  5. The person to whom a nursing task has been delegated is clearly identified to the patient as an unlicensed person by a name tag worn while giving care to the patient and by personal communication by the delegating nurse when necessary.

Nursing tasks that shall not be delegated to any unlicensed person are (VA BON):

  • Nursing assessment, problem identification, and outcome evaluation which require independent nursing judgment
  • Counseling or teaching except for activities related to promoting independence in personal care and daily living
  • Coordination and management of care involving collaboration, consultation and referral
  • Emergency and nonemergency triage
  • Administration of medications except as specifically permitted by the Virginia Drug Control Act
  • Circulating duties in an operating room.

LPN Scope of Practice

LPN practice requires assignment or delegation by and performance under the supervision, orders, or directions of a RN, physician, dentist or other person authorized to provide supervision.  LPNs are responsible and accountable for their own actions and documentation. It is beyond LPN scope of practice to be responsible for: nursing unit management, nursing administration, performance appraisal, orientation and teaching of nursing staff, validation of competence, or nursing staff development.

LPNs may do the following actions with validated competencies:

  • Collection and comparison of data, documentation, and reporting
  • Observe and assist patients
  • Monitor restraint safety
  • Assist patients with therapeutic regimens
  • Implement established plans of care
  • Assist the patient with self-care and discharge techniques
  • Intravenous Therapy Care: perform venipuncture for blood sampling, insert and removal of peripheral catheters, perform maintenance of CVADs, access and de-access CVADs; may not remove central line catheters
  • Administer tasks, treatments, and medications in accordance with validated competencies
  • LPNs are not approved to administer the following medications per Sentara documents:
    • Hazardous medications (per Handling and Administration of Hazardous Medications procedure)
    • Antineoplastics and investigational medications (per Medication Administration Policy)
    • IV thrombolytic medications/ Alteplase reconstitution and administration
    • IV conscious sedation medications
    • IV Pitocin (during the labor/delivery phase)

References:

American Nurses Association (ANA). (2012). ANA’s Principles for Delegation. Silver Spring, MD: Author.American Nurses Association (ANA). (2015). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: Author. American Nurses Association (ANA). (2016). Nursing Scope and Standards of Practice 3rd Edition. Silver Spring, MD: Author. ANA/NCSBM (2010). Joint Statement on Delegation American Nurses Association and the National Council of State Boards of Nursing. Retrieved from https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdfNCSMB (2019). National Guidelines for Nursing Delegation. Retrieved from https://www.ncsbn.org/NGND-PosPaper_06.pdfNorth Carolina Board of Nursing. (June 2016). Infusion Therapy/Insertion/Access Procedures. Retrieved from https://www.ncbon.com/vdownloads/position-statements-decision-trees/infusion-therapy.pdfNorth Carolina Board of Nursing. (February 2019). Position Statements. Retrieved from https://www.ncbon.com/practice-position-statements-decisions-treesNeuss, M., Gilmore, R, Belderson, K., Billett, A., Conti-Kalchik, T., Harvey, B., Hendricks, C., LeFebvre, K., Manqu, P., McNiff, K., Olsen, M., Schulmeister, L., Von Gehr, A. & Polovich, M. (2016). 2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, Including Standards for Pediatric Oncology. Journal of Oncology Practice, 12(12): 1262-1271. Virginia Board of Nursing. (February 2019). Regulations Governing the Practice of Nursing. Retrieved from http://www.dhp.virginia.gov/nursing/nursing_laws_regs.ht