Kechi Iheduru-Anderson DNP-c, MSN, RN, CWCN.

December 2013

As a nurse in the united states you will encounter a variety of different types of caregivers.

You may work with unlicensed assistive personnel (UAPs), licensed practical nurses (LPNs), other registered nurses, and/or advanced practice registered nurses (APRNs).

Each of the licensed professions has its own legally defined scope of practice for nurses, as stated by the Board of Nursing in each state

The scope of practice are the range of roles, functions, responsibilities and activities, which a registered/licensed professional is educated for, competent in, and is legally authorized to perform.

It is important that you know your duties as a nurse, but the scope of practice of the others who make up a part of your nursing team providing patient care.

Remember that you are accountable for tasks you delegate to another caregiver.

Registered Nurses

Advanced Practice Registered Nurses and

Practical/Vocational Nurses

Unlicensed Assistive Personnel (UAP)

All registered (RN) and licensed practical or vocational (LPN/VN) nurses who work in the U.S. must have a nursing license in the state(s) where they will work.

In most states LPNs and UAPs are dependent members of the healthcare team who must be supervised by an RN or other authorized licensed professional.

A registered nurse (RN) is a nurse who has completed either a diploma in nursing, a bachelor’s degree in nursing (BSN) or Associate’s Degree in nursing (ADN), and who has also passed the nursing certification exam for Registered Nurses.

Registered nurses are independent practitioners and do not require supervision when they provide nursing care to individuals or groups of people.

RNs are prepared by education and clinical experience to assess, diagnose, plan, implement, and evaluate nursing care in all settings.

The nursing profession in the US recognizes three traditional routes to becoming an RN A diploma program most often administered in hospitals; Using an

apprenticeship model, hospital-based diploma programs prepare graduates to deliver direct patient care in a variety of settings.

An associate degree program usually offered at community colleges; Associate Degree in Nursing (ADN) programs provide an efficient, economical pathway to becoming a registered nurse.

A baccalaureate degree program offered at four year colleges and universities. the Bachelor of Science in Nursing (BSN) programs prepare new graduates to practice across all healthcare settings and assume the widest variety of RN roles.

Graduates of all three programs sit for the National Council Licensing Examination for RNs (NCLEX-RN) which measures minimum technical competency for entry-level nursing practice.

It is the responsibilities of the RN to supervise LPNs and unlicensed assist personnel (UAPs) with whom they work.

As a registered nurse, you should understand the scope of practice of the LPNs and UAPs in order to effectively and safely delegate tasks.

It is also important have a clear understanding of the differences between State scopes of practice and individual institutional policy with regards to the LPNs and UAPs.

Check your states nursing board website to review the nurse practice act.

As an RN, when you assign or delegate to others, you must clarify what the specific activity or task entails, and obtain any additional information that you may need, such as facility policies or procedures.

You must also conduct a self-assessment with regards to your own skills and abilities, and your documented competency to perform any task you have been assigned.

If you question your abilities, you must express this concern to the appropriate supervisor/staff person.

Once you accept an assignment, you are accountable for completing it in a safe and competent manner.

The LPN or NA may also refuse to accept the consequences of a delegated task from you, if they do not have the experience or documented competency in that skill .

The Registered Nurse within the scope of his/her practice is responsible for the nature and quality of all nursing care that a patient/client receives under his/her direction.

Assessment/ identification of the nursing needs of a patient/client, the plan of nursing actions, implementation of the plan, and evaluation of the plan are essential components of nursing practice and are the functions of the qualified licensed nurse.

What may be common practice in a facility may not be appropriate or legal in terms of the performance of activities or tasks by nurses or other caregivers and may be grounds for disciplinary action or medical malpractice claims.

RNs can delegate nursing tasks to other RNs or LPNs, and LPNs can delegate to other LPNs.

Delegation is the transfer of professional responsibilities to another person who is qualified by training, experience, and licensure to perform them.

Health-related activities and non-nursing tasks can be assigned to UAPs, but the UAPs’ training and competence to perform the tasks must be made known to the supervising RN.

It is unprofessional conduct to delegate a nursing task to an unlicensed person.

These are RNs who have met advanced educational and clinical requirements beyond those required for all RNs and are experts in specialized areas of practice.

APRNs are registered nurses educated at Masters or post Masters level and in a specific role and patient population.

APRNs are prepared by education and certification to assess, diagnose, and manage patient problems, order tests, and prescribe medications.

Their scope of practice include “the diagnosis of illness and physical conditions and the performance of therapeutic and corrective measures within a specialty area of practice, in collaboration with a licensed physician qualified to collaborate in the specialty provided” (NYSNA, 2007).

Each state independently determines the APRN legal scope of practice, the roles that are recognized, the criteria for entry-into advanced practice and the certification examinations accepted for entry-level competence assessment.

In some states the APRNs work independent of physicians supervision

APRNs include Certified nurse practitioners (CNP),

clinical nurse specialists(CNS),

certified registered nurse anesthetists (CRNA), or

Certified nurse midwives (CNM).

APRNs are educated in one of the four roles and in at least one of six population foci:

family/individual across the lifespan, adult-gerontology, pediatrics, neonatal, women’s health/gender-related or psych/mental health.

APRN sit for and pass the a certification examination to assess national competencies after completion of the educational program.

To learn more about APRN visit https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf

CNMs are licensed health care practitioners educated in the two disciplines of nursing and midwifery.

They provide primary health care to women of childbearing age, including prenatal care, labor and delivery care, care after birth, gynecological exams, newborn care, assistance with family planning decisions, preconception care, menopausal management, and counseling in health maintenance and disease prevention.

A CRNA is a registered nurse who is educationally prepared for and competent to engage in the practice of nurse anesthesia.

CRNAs administer approximately 27 million anesthetics in the United States each year, practice in every setting where anesthesia is available, and are the sole anesthesia providers in more than two-thirds of all rural hospitals.

CNRAs can also administer every type of anesthetic and provide care for every type of surgery or procedure.

The CNS is an expert clinician in a specialized area of nursing practice.

The specialty may be a population (e.g., pediatrics), a setting (e.g., critical care), a disease (e.g., cardiovascular or mental health), or a type of problem (e.g., wound or pain).

CNSs are engaged in direct clinical practice; function as consultants in their area of expertise; provide expert coaching and guidance; interpret, evaluate, and participate in research; provide clinical and professional leadership; collaborate; and employ ethical decisionmaking.

NPs are registered nurses who are prepared, through advanced education and clinical training, to provide a wide range of preventive and acute health care services to individuals of all ages.

NPs take health histories and provide complete physical examinations; diagnose and treat many common acute and chronic problems; interpret laboratory results and x-rays; prescribe and manage medications and other therapies; provide health teaching and supportive counseling, with an emphasis on prevention of illness and health maintenance; and refer patients to other health professionals as needed.

Licensed practical nurse (LPN) also known as Licensed Vocation Nurses (LVN) is the term you will hear about only in the United States and most Canadian provinces.

In the U.S. a person becomes and LPN after one year to 15 months of training in an accredited institution and passing the NCLEX-PN examination

Licensed Practical Nurses (LPN), also known as Licensed Vocation Nurses (LVN) in some states like Texas and California

LPN/LVN educational requirements vary among the States.

1-year and up to 15 months program at nursing schools.

LPNs and LVNs must complete an accredited program.

These programs are commonly in technical schools and community colleges.

To practice as LPN or LVN the must also pass the National Council Licensure Examination (NCLEX-PN examination) and get a license.

LPNs/LVNs can transition to an RN role through either an Associate Degree in Nursing (ADN), or a Bachelor of Science in Nursing (BSN) degree.

These programs enable people who are currently practicing as an LPN/LVN to obtain their ADN or BSN and take the NCLEX-RN exam to become a registered nurse

The duties that an LPN can legally perform are governed by state statute or regulation.

Each state’s “scope of practice” defines the parameters within which LPNs are legally authorized to work.

Duties of LPNs and LVNs vary, depending on the states regulation and work setting.

Bedside and basic nursing care is the primary scope of practice for a LPN/LVN.

They work under the direction of registered nurses and physicians (Bureau of Labor Statistics (BLS), 2013).

State regulations govern the extent to which LPNs and LVNs must be directly supervised; for example, an LPN may provide certain forms of care only with instructions from a registered nurse (BLS, 2013).

In most states, LPNs cannot independently develop or make changes to the plan of care, perform telephone triage or complete a patient’s admission assessment.

Experienced licensed practical and licensed vocational nurses may oversee and direct other LPNs or LVNs and unlicensed staff.

In some settings RNs and LPNs often fill the same role.

But ultimately the RNs supervises the LPN.

Where state law allows, the LPN can perform wound care, and, give medications, administer intravenous medications and perform venipuncture.

Despite what the states scope of practice may be, employers establish their own internal practice guidelines, which may be more restrictive than the legal scope of practice.

The LPN can delegate and supervise other LPNs in the delivery of care within the LPN’s legal scope of practice and level of competency.

The LPN can supervise unlicensed assistive personnel.

LPNs and LVNs work in many settings, including nursing homes and extended care facilities, some hospitals, physicians' offices, and private homes.

The LPN scope of practice is often too limited to allow for significant employment of LPNs in acute care settings.

Majority of them work in nursing homes and extended care facilities, 29% in 2010 (BLS, 2013).

LPNs and LVNs can advance to registered nurses, by getting more education through education programs.

Nurses’ aides (NA), Nursing assistants (NA), and Nursing attendants.

Operating room technicians, dialysis technicians, and nuclear medicine technicians, have been permitted in a limited manner to perform some activities that fall within the nursing scope of practice.

Orderlies

Under most circumstances, a UAP is a specifically trained individual who to assist licensed nurses with non-nursing functions and health-related activities in delivering direct care to patients or clients.

Non-nursing functions are generally classified as housekeeping, clerical, transportation, and dietary tasks.

Health-related activities are direct patient care activities that are not within the legally protected scope of nursing practice and can be assigned to UAPs who have demonstrated competency.

A health-related activity is one that does not require professional judgment or critical thinking and can be completed using a standard procedure.

Nurses aides help provide basic care for patients in hospitals and residents of long-term care facilities, such as nursing homes.

Nursing assistants typically need a postsecondary certificate or award and must pass their state’s competency exam.

In 2010 55% of nursing assistants worked in nursing and residential care facilities.

Nursing assistants work under the supervision of a registered nurse (RN), licensed practical nurse (LPN) or other medical staff.

Like nurses , they nursing assistants , may work shifts; days, evening and nights, weekends, and holidays depending on setting of employment.

NA help provide basic care for patients in hospitals and residents of long-term care facilities, such as nursing homes.

There major function is assisting with activities of daily living (ADLs).

Qualified nursing assistants are relied upon to provide basic care, which frees up RNs and LPNs to perform more complex nursing tasks.

Nursing aides and attendants must earn a postsecondary certificate or award, in which they learn the basic principles of nursing and complete supervised clinical work.

These programs are found in community colleges, vocational and technical schools, and in hospitals and nursing homes.

Some high schools offer nursing aide programs.

At the completion of the state-required education, the nursing assistant will take a competency exam.

Passing this exam allows them to use state-specific titles.

In some states, a NA is called a Certified Nursing Assistant (CNA), but titles vary from state to state.

Nursing assistants who have passed the exam are placed on a state registry.

In many states, nursing aides and attendants must be on the state registry to work in a nursing home.

Assisting with activities of daily living (feeding, bathing, ambulating, turning and positioning,

grooming, toileting, etc.)

Measuring vital signs

Applying clean dressings

Performing basic intake and output

Providing oral suctioning and mouth care

Delivering care of nails, hair, and skin

Listen to and record patients’ health concerns and report that information to nurses (New York State Nurses Association

(NYSNA), 2007).

With additional training and demonstrated competency, UAPs may also be permitted to: Taking EKGs

Using a glucometer

Performing phlebotomy

Caring for external catheters

Assist with placement of braces and prostheses (NYSNA,

2007).

UAPS who can perform these tasks often have titles different from CNAs and NAs.

Assessing, evaluating, or problem solving

Developing a nursing care plan

Performing sterile or invasive procedures or techniques

Inserting urinary catheters

Delivering nasogastric or gastrostomy tube feedings

Administering oxygen

Performing tracheal suctioning, tracheostomy care, or respiratory care

Administering medications, immunizations, or blood or blood products

Some states have other requirements as well, such as continuing education and a criminal background check.

In some states, nursing aides and attendants can get additional credentials beyond a CNA, such as becoming a Certified Medication Assistant (CMA).

As a CMA, they can give medications (usually in the homecare setting, group homes etc.).

Bureau of Labor Statistics. (2013a). U.S. Department of Labor, Occupational Outlook Handbook, 2012-13 Edition, Licensed Practical and Licensed Vocational Nurses. Retrieved November 19, 2013 from http://www.bls.gov/ooh/healthcare/licensed-practical-and-licensed-vocational-nurses.htm

Bureau of Labor Statistics. (2013b). U.S. Department of Labor, Occupational Outlook Handbook, 2012-13 Edition, Nursing Aides, Orderlies, and Attendants. Retrieved November 19, 2013 from http://www.bls.gov/ooh/healthcare/nursing-assistants.htm

Anderson, L. (2013). Understanding the Different Scope of Nursing Practice. Retrieved November 20, 2013 from http://www.nursetogether.com/understanding-the-different-scope-of-nursin

New York State Nurses Association (2007). Guidelines Regarding Utilization of Licensed Nurses (RNs and LPNs) and Unlicensed Assistive Personnel (UAP) in the Delivery of Nursing Care. Retrieved November 20, 2013 from http://www.nysna.org/images/pdfs/practice/scope/rn_uap_guidelines04.pdf

National Council of State Boards of Nursing. (2008). Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. Retrieved December 1, 2013 from https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf

O’Grady, E. T. (nd). Advanced Practice Registered Nurses: The Impact on Patient Safety and Quality. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Retrieved December 1, 2013 from http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/OGradyE_APRN.pdf

Raines. C.F., Taglaireni, M.E., (Sept. 30, 2008) "Career Pathways in Nursing: Entry Points and Academic Progression" OJIN: The Online Journal of Issues in Nursing; Vol 13 No 3 Manuscript 1. DOI: 10.3912/OJIN.Vol13No03Man01