APRN Policy and Regulation

Scope of Practice

Scope of practice describes the services that a qualified health professional is deemed competent to perform, and permitted to legally undertake – in keeping with the terms of their professional license. Currently, all health care licensure is state-based, and there is some variability between the qualifications for licensure and re-licensure for each state, particularly with regards to the four roles of advanced practice registered nurses (APRNs).

Each jurisdiction has laws, licensing bodies, and regulations that describe requirements for education and training, and define scope of practice.

Scope of practice describes the procedures, actions, and processes that a healthcare practitioner is permitted to undertake in keeping with the terms of their professional license. Defining scope of practice is generally a two-step process:

• Step 1: The state legislature passes a law, known as a "Nurse Practice Act."
• Step 2: Regulatory bodies then create and implement rules and regulations, intended to protect the public.

While APRN practice is typically defined by the Nurse Practice Act and governed by the Board of Nursing, other laws and regulations may impact practice, and other boards may play a role. For instance, in some states nurse-midwives are regulated by a Board of Midwifery or public health. In addition, the Clinical Nurse Specialist (CNS) role may not be distinctly identified in the Nurse Practice Act, which means the CNS is held to the same scope of practice as any registered nurse within the state. Although the practice of Certified Registered Nurses (CRNAs) is fairly standard, they again may not be recognized in the Nurse Practice Act or have limitations imposed.

In addition to scope, Boards of Nursing or other regulatory body may interpret specific activities, not evident conclusively in the Nurse Practice Act in the form of an opinion. For example: Who may perform micro-dermabrasion, and under what circumstances? What are the parameters for participation in a radiologic procedure? Can an APRN administer IV anesthetics for intractable pain?

Given the variation between APRNs and related state statutes, rules, and regulations, it is essential that APRNs have a clear understanding of how their scope of practice is defined by those laws and regulations, as well as any opinions promulgated by the state regulatory agency. The best place to begin is with the state Board of Nursing.

Cross border practice is an area that is also complex. There are Nurse Licensure & APRN Compacts. While telehealth has grown in popularity, laws, rules, and regulations have not kept pace. They vary between states as to the who, when, how and payment for services.

Advancing and protecting the scope of practice for nurses, particularly advanced practice registered nurses, is a major initiative at ANA. ANA is working together with our state/territorial affiliates (nurses associations) to remove barriers and secure full practice authority. Full Practice Authority for APRNs (members only) for APRNs is the ability to fully utilize the knowledge, skills, and judgment to practice consistent with education and training and thus reflected in statute (Nurse Practice Act). We continue working state by state to ensure that state laws affecting advanced practice registered nurses are both fair and consistent across the country, and that scope of practice is not unfairly limited based upon the APRN Consensus Model.

Supported by a growing body of evidence of the safe and cost-effective provision of care by APRNs, there is a national call to remove all barriers to full practice authority from organizations such as the Institute of Medicine (IOM), the National Governors Association (NGA), the Federal Trade Commission (FTC), the Bipartisan Policy Center, and the Veteran's Health Administration (VHA), among others. Removal of regulatory barriers is work in which the ANA and its' Constituent - State Nurses Associations have been engaged for many years. "Full practice authority" is generally defined as an APRN's ability to utilize knowledge, skills, and judgment to practice to the full extent of their education and training.

Passion, alone, won't garner legislative success. It takes years to advance legislation. The competition for policy makers’ attention is intense, so preparation, perseverance, flexibility and coordination are essential. Preparation includes Conducting a Political Environmental Scan (members only).

The importance of communication – styles and words should never be underestimated especially with regards to issues involving strong emotions. Remember our views and reactions to communication are based on the lens in which we see the world, stemming from our values and life experiences. Dialogue between the professions and with lawmakers can sometimes be hampered by terms with charged meanings, such as "scope of practice", "supervision", "independent", practice," "supervision," "independent" and "lead" that "often have us talking past each other".  Words Matter – Guide to Discussing APRN Practice (members only).

It is widely accepted that patient-centered team-based health care fosters efficient, equitable and economical health care. But debate has ensued about who should lead and supervise the team. Large physician groups have resisted acknowledging that other health professionals, such as nurses, are equipped to lead a team and launched a campaign focused on "team-based health care." ANA supports diverse health care teams with flexible leadership optimizing the unique abilities, training and expertise of each team member. There is evidence of success Team-based Care: A Case Study from Tennessee (members only).

Unlike legal scope of practice reflected in statute, professional nursing scope and standards are developed and published by ANA and other national specialty nursing organizations. The American Nurses Association has an established program for recognition of a nursing specialty, approval of a specialty nursing scope of practice statement, acknowledgment of specialty nursing standards of practice, and affirmation of focused practice competencies. Details about each component of this program, specialty characteristics, review criteria, and submission process are described here. Also see ANA’s Scope and Standards.

Team Based Care

• Issue Brief: Promoting Patient-Centered Team-Based Health Care (members only)
• Executive Summary: Promoting Patient-Centered Team-Based Health Care (members only)
• Team-based Care: A Case Study from Tennessee (members only)
• Coding and Billing

Advocacy

• Conducting a Political Environmental Scan (members only)
• Full Practice Authority for APRNs (members only)
• Words Matter – Guide to Discussing APRN Practice (members only)
• The ICAN Act

Research & Data

• Economic Case
  • The Free Market Case for Full Practice Authority (members only)
  • Compilation of Studies/Literature Review

Advanced Practice Registered Nurses (APRN)

• ANCC Digital Collateral Page
• ANA represents the interests of all APRNs, which include: Certified Nurse Practitioners (NPs), Certified Registered Nurse Anesthetists (CRNAs), Clinical Nurse Specialists (CNS), and Certified Nurse Midwives (CNMs). For more information visit the Advanced Practice Registered Nurses (APRN) page.