Practicing Nurses

Nursing Scope of Practice Decision Tree

Step	Considerations
Define the Activity	Problem or care need Clinical environment in which the task will be performed Stability and complexity of the patient care needs Equipment or supplies needed to safely complete the activity Requirement for directions or orders from an authorized health care practitioner¹ Independent or interdependent action based on nursing licensure
Legality	Explicitly permitted or prohibited by Washington State nursing law or rule Other state laws or rules apply (facility licensing, health care professionals, etc.) Federal regulations Supervision or professional licensure requirements
Practice Standards	Evidence to support the activity within current standards of safe nursing care (National nursing organizations, associations, evidence–based literature and research, position statements, or community standards) WABON advisory opinions, interpretive statements, policy statements, declaratory statements, or other guidance about the activity
Institutional Policy	Prohibited or permitted by institutional policies and procedures Reimbursement requirements
Safety & Competency	Consistent with training in a pre-licensure program, post-basic program, continuing education program, certification program, or self-structured study Documentation of appropriate education and competency assessment specific to the activity Safe to perform the activity for the specific patient, in a specific setting, and at a specific time Specific environment or special equipment or personnel needed in case of unexpected responses to assure patient safety and quality of care Potential outcome for the patient if the procedure is not performed
Accountability	Reasonable and prudent nurse would complete the activity for this patient in this circumstance Willingness to be accountable and responsible, and accept consequences

¹ Licensed physician and surgeon, dentist, osteopathic physician and surgeon, naturopathic physician, optometrist, podiatric physician and surgeon, physician assistant, osteopathic physician assistant, advanced registered nurse practitioner, or midwife acting under the scope of their licensure. (RCW 18.79.260 and RCW 18.79.270).

Registered Nurse (RN) and Licensed Practical Nurse (LPN) Components of Care Scope of Practice Comparison Chart

Function

Registered Nurse

Licensed Practical Nurse

Role

Initiate the nursing process, establishing the nursing care plan
Provide nursing care independently without supervision or assignment
Collaborate in an interdependent role as a health care team member
Provide medical care and therapies in an interdependent role
Act as patient advocate in health maintenance and clinical care
Accept patient assignment(s)

Provide nursing care using the nursing process interdependently under the direction and supervision of the RN
Collaborate in an interdependent role as a health care team member
Provide medical care and therapies in a dependent role
Act as patient advocate in health maintenance and clinical care
Accept patient assignment(s)

Nursing Process

Nursing Assessment	Perform comprehensive nursing assessment: Initiate the data collection process Collect data and information related to the health care consumer’s health or the situation Assimilate data gathered from LPNs and other health care team members
Diagnosis	Analyze assessment data to determine nursing diagnosis, problems, and issues Use scientific principles to develop nursing diagnosis
Outcomes Development	Identify expected outcomes for an individualized plan to the patient or situation
Planning	Develop a plan that prescribes strategies to attain expected measurable outcomes
Implementation	Implement the identified plan Delegate and supervise certain nursing tasks to assistive personnel (AP) in specific situations and settings Coordinate care with other team members Use strategies to promote health and a safe environment
Evaluation	Evaluate progress toward attainment of goals and outcomes Modify care plan as appropriate

Nursing Assessment	Assist in performing nursing assessment: Perform initial, admission, or event–focuses assessment Collect data and information Recognize relation to diagnosis Communicate outcomes of the data collection process in a timely manner Determine immediate need for intervention
Diagnosis	Provide data to assist in development of nursing diagnosis
Outcomes Development	Assist in developing expected outcomes
Planning	Contributes to the development of the nursing care plan
Implementation	Implement the identified nursing care plan under RN supervision Direct and supervise nursing activities to AP in specific situations and settings as allowed in laws and rules Assist in coordinating care with other team members Assist in patient teaching
Evaluation	Contribute to the evaluation process by reporting patient outcomes and assisting with modifying the care plan

Reporting and Recording

Document in the medical record
Communicate (verbally or in writing) with the LPN and other health care practitioners/health care team as appropriate

Document in the medical record
Communicate (verbally or in writing) with the RN and other health care practitioners/health care team as appropriate

Case Management

Identify case management needs
Refer patients to appropriate resources

Assist the RN in identifying case management needs
Refer patients to appropriate resources based on nursing care plan

Nursing Delegation

Delegate nursing tasks to AP as allowed in laws and rules

Direction and Supervision

Perform nursing care independently
Carry out medical regimens under the direction of an authorized health care practitioner
Supervise care given by LPNs, and AP
An Authorized health care practitioner is not required to be on the premises when RNs carry out medical regimens

Carry out medical regimens under the direction and supervision of an RN or other authorized health care practitioner
Perform nursing care under the direction and supervision of an RN
Direct and supervise activities to AP as allowed in laws and rules
An RN or other authorized health care practitioner is not required to be on the premises when carrying out medical regimens or nursing activities

Complexity

Perform nursing care and carry out medical regimens in complex situations for clinically and behaviorally stable and unstable patients

Perform basic nursing care in routine situations for clinically and behaviorally stable patients
Assists in giving nursing care and carries out medical regimens in complex nursing situations

Health Education, Promotion, and Prevention

Provide health education, health promotion and preventive activities to patients, families and groups
Identify learning needs
Develop and evaluate education plans

Participate in developing, providing, and evaluating health education, health promotion and preventive activities to patients, families, and groups under the direction and supervision of an RN or other authorized health care practitioner

Prescribing Medication and Therapies

Administer legend drugs/controlled substances and medical treatments under the direction of an authorized health care practitioner (whether piercing or puncturing of tissues is involved and whether a degree of independent judgment and skill is required)

Administer legend drugs/controlled substances and medical treatments under the direction of an authorized health care practitioner (whether piercing or puncturing of tissues is involved and whether a degree of independent judgment and skill is required)

Responsibility

Responsible and accountable for the quality of nursing care given
Responsible and accountable for delegated activities
Responsible and accountable for following standards of nursing conduct or practice
Accountable for delegation and supervision when delegating tasks to others
May only perform activities within the RN’s individual scope of practice

Responsible and accountable for the quality of nursing care given
Responsible and accountable for following standards of nursing conduct or practice
Accountable for delegation and supervision when delegating tasks to others
May only perform activities within the LPN’s individual scope of practice