By Kathy Baldridge, DNP, FNP-BC, FAANP

Organized medicine is actively campaigning to “stop scope creep.” Try saying that 3 times really fast! It’s a tongue twister, but it is often a brain twister as well. Defining scope of practice can be confusing to nurses, nurse practitioners, physicians, the public, and certainly legislators. Understanding scope of practice can seem mind-boggling. Let’s make it simple by breaking it down.

Defining scope of practice

Multiple healthcare organizations have published definitions of scope of practice (SOP). The Federation of State Medical Boards (FSMB) defines scope of practice as:

“The activities that an individual healthcare practitioner is permitted to perform within a specific profession. Those activities should be based on appropriate education, training, and experience. Scope of practice is established by the practice act of the specific practitioner’s board, and the rules adopted pursuant to that act.”

The FSMB published this definition in a 2005 policy statement, and it began the first section of the document by noting that scopes of practice sometimes overlap among healthcare professions, reflecting shared competencies (Federation of State Medical Boards, 2005).

The federation’s definition of SOP is not much different from that of the American Nurses Association (ANA), which defines it as:

“The services that a qualified health professional is deemed competent to perform and permitted to undertake – in keeping with the terms of their professional license.” (American Nurses Association, n.d.).

The Centers for Disease Control and Prevention and U.S. Department of Health and Human Services has defined SOP similarly:

“Scope of practice describes the services that qualified health professionals are considered able and allowed to perform based on their professional licenses.” (CDC, 2019).

Note that the ANA and CDC specifically use the word “qualified,” which is closely linked to one of the components of access to care: the assurance that qualified health professionals are available to serve the community.

We cannot leave out the definition of scope of practice by the American Association of Nurse Practitioners (AANP):

“An NP’s scope of practice includes, but is not limited to, assessment; ordering, performing, supervising and interpreting diagnostic and laboratory tests; making diagnoses; initiating and managing treatment, including prescribing medication and nonpharmacologic treatments; coordinating care; counseling; and educating patients, their families and communities.”

Visualizing scope as the ‘lanes’ of professional practice

Consider the image of a highway. Essentially, each lane on a highway could represent a scope of practice for nurse practitioners. While physicians and NPs may perform some components of patient management that are the same, a nurse practitioner’s scope of practice is more limited than that of a physician.

The scope of practice for every profession, including advanced practice registered nurses (APRNs), the umbrella term for NPs, nurse anesthetists, clinical nurse specialists, and nurse midwives, is determined by four factors:

• education role and population
• individual knowledge and skills
• laws and regulations in the state where they practice
• policies and bylaws in their practice setting.

The physician can utilize the entire highway because their education is broader, and because uniformity exists in state regulations for physician practice. Practice authority for APRNs, however, varies from state to state.

So, organized medicine’s “stop scope creep” messaging is incorrect! Even with removal of state regulatory barriers (i.e., requirement of a collaborative practice agreement), an APRN does not have the freedom to “change lanes” because their scope is not expanded to that of a physician.

Scope-of-practice component 1: Education and population role

The first and foundational component of defining an APRN’s scope of practice is their education. When a bachelor’s-prepared registered nurse decides to go back for an advanced degree (master’s, post-master’s, or doctorate), they must select their role and population. As defined by advanced practice credentialing bodies, APRN roles and populations include:

Family nurse practitioner (FNP): Treats patients of all ages across the lifespan, managing acute and chronic conditions that fall under primary care. FNPs practice in community health centers, private practices, healthcare systems, and universities (AANP, 2019).

Adult-gerontology acute care nurse practitioner (AGACNP): Treats adult and gerontologic patients with complex, acute conditions. Many AGACNPs practice in intensive care, trauma, or acute care units. They also work in specialty clinics and long-term care facilities (AANP, Jan 2020).

Adult-gerontology primary care nurse practitioner (AGPCNP): Meets the health needs and provides care for patients from adolescence through older adulthood. They may work in long-term care settings, urgent care settings, hospital-based clinics, and private practices (AANP, June 2020).

Psychiatric-mental health nurse practitioner (PMHNP): Provides healthcare to patients across the lifespan with mental and emotional needs and/or disorders. PMHNPs work in acute/inpatient and outpatient settings, manage acute and chronic phases of illness, admit patients to hospitals, home health, hospice, long-term care and substance use treatment facilities (American Psychiatric Nurses Association, 2022).

Pediatric nurse practitioner (PNP): PNPs are educated and earn certification in pediatric acute care (PACNP) or pediatric primary care (PPCNP) and treat children from birth through transition to adult care. They also provide care to the families and caregivers of pediatric patients (NAPNAP, 2020).

• PACNPs focus on health restoration and caring for children with acute and chronic illness or injuries in inpatient/hospital, ambulatory specialty care, pediatric intensive or critical care, emergency departments and urgent care settings.
• PPCNPs focus on the management of acute and chronic conditions and may work in pediatric primary care practices, public health settings, school-based clinics, subspecialty practices, medically underserved, and rural health practice settings.

Women’s health nurse practitioner (WHNP): Provides care to females from puberty through the adult lifespan. WHNPs focus on common and complex gynecologic, sexual, obstetric, reproductive health, and common nongynecologic primary health needs. They may also provide sexual and reproductive healthcare to males. The care provided by WHNPs is inclusive of all gender identities and sexual orientations. Care may be provided in private offices, community health centers, health departments, hospital-based care centers, family planning/fertility centers, rural health clinics, and inpatient settings (NPWH, 2020).

Regardless of education and population role, APRNs can work in administrative, teaching, and research capacities. They can also work in specialty settings. For example, the list above does not include dermatology NP, cardiology NP, neurology NP, etc.

When nurse practitioners are employed in a specialty area, they must still function within the scope of practice of their education role. Therefore, it is simply not true when opponents of full practice authority for NPs state that removal of collaborative practice agreements would allow nurse practitioners to function as a dermatologist, orthopedist, or cardiologist.

APRNs earn advanced education that is built on professional registered nurse preparation and follows the nursing model of assessment, diagnosis, planning/implementation, and evaluation. This advanced training educates bachelor’s-prepared nurses at the master’s, post-master’s, or doctoral levels, developing their knowledge in diagnosing and prescribing.

Advanced practice education is a competency-based model, and national nursing organizations have established nurse practitioner role competencies that must be met upon graduation.

Further, every nurse practitioner must adhere to the ANA Standards of Professional Performance, which include ethics, advocacy, respectful and equitable practice, communication, collaboration, leadership, education, scholarly inquiry, quality of practice, professional practice evaluation, resource stewardship, and environmental health.

Scope-of-practice component 2: Individual scope based on additional education or training

The second component of determining your scope of practice is based on completion of additional formal education. The APRN’s knowledge, skills, and competencies may further determine scope of practice.

The expansion of scope of practice through additional formal education is finite. The legally recognized title or designated role cannot be changed through experience. For example, you may have worked in the intensive care unit for years as a registered nurse but chose to be educated at the advanced level as a family nurse practitioner.

Despite having years of experience in the ICU, your scope is limited by the FNP role, which is appropriate for primary care.

Additionally, as mentioned above, despite years of working in a dermatology practice as an FNP, this does not qualify you as a dermatologist. This can only be achieved by completing the formal educational preparation to become a dermatologist. You should not refer to yourself as a dermatology NP. You should say that you are an FNP working in dermatology.

Individual scopes of practice vary. What may fall within one person’s scope of practice may not mean it falls within another’s scope of practice. Consider large joint injections. If you are an FNP who has attended workshops to learn how to perform large joint injections and have been checked off on that skill, you have “expanded” your scope of practice to that skill. But another FNP who does not have that skill would not include that in their scope of practice.

Each APRN must practice within their individual scope. Each state’s Board of Nursing holds APRNs accountable for knowing and practicing within their professional and individual scope of practice. You should always maintain verifiable evidence of additional education and competency.

Scope-of-practice component 3: State laws and regulations

State law and regulation is the third component of defining your scope of practice. Even though you may be educated to perform a task, state law and/or board licensure regulation can further restrict SOP.

For example, it is within an NP’s scope of practice to treat acute and chronic pain. However, state law may prohibit nurse practitioners from prescribing controlled substances in the management of chronic pain. So, although you may be educated to do it, state law restricts it.

It is important that you know and follow the nurse practice act in your state. This is one of the areas that is most confusing at the legislative level, which means NPs need to educate their state lawmakers about SOP.

Although removing regulatory barriers can expand NP scope of practice, it cannot expand it beyond what the NP was educated to do! When you work in a state that is deemed “full practice authority,” you have the authority to practice to the top of your license and the role you were educated in.

Scope-of-practice component 4: Institutional policies and bylaws

Lastly, it is important to know that the facility or institution that employs you can further restrict your scope of practice.

Consider an inpatient facility where you wish to be considered for medical staff membership. It is within your educational role scope of practice and there is no state law prohibiting it, yet the facility has an institutional policy or bylaw that prohibits NPs from being considered for medical staff membership. Therefore, the institutional policy further restricts scope of practice. Institutional polices are allowed to further restrict the scope of practice, but they cannot expand your scope beyond what you are educated to do.

Let’s go back to the skill of performing large joint injections. It is within your educational preparation, and you have proven competency, but it is a prohibited procedure for NPs in that acute care setting. Your scope of practice has been restricted by the institution’s policy. But if you have never been trained to do large joint injections and do not have proven competency, it should not be listed as a skill you are allowed to perform for the facility.

How do you determine whether an activity is in your scope of practice?

In my roles as a state NP association president, APRN advocate, and nurse practitioner education specialist, I hear many questions about NP scope of practice. Can we do X, Y, and Z? One person will say yes, yet another will say no. Are they both right? Maybe.

It is crucial that you know your scope of practice. It is equally important that you understand where any scope-of-practice restriction originated. Are you restricted based on your role, individual competence, state law, or institutional policy?

Every NP is individually responsible for recognizing limits of knowledge and experience, and for resolving situations beyond their NP expertise by consulting with or referring patients to other healthcare providers.

Additionally, not adhering to the ANA Standards of Professional Practice can be considered a violation of scope of practice. Your State Board of Nursing can hold you accountable for scope-of-practice violations that may include improperly prescribing medication, performing a procedure you don’t have competency in, or failing to report another healthcare provider who is under the influence of drugs and alcohol.

To determine whether an activity or procedure is within your scope of practice, ask yourself these questions:

• Is it consistent with your education in the role and specialty? Does the activity/procedure/diagnosis cross lanes into another advanced practice role? (For example, an FNP diagnosing and treating a mental health disorder that is specific to the PMHNP role.

• Is it consistent with your professional practice standards?

• Is it consistent with statutory or regulatory laws?

• Is it consistent with your nursing board’s licensure rules and regulations?

• Is it consistent with your institution’s policies and bylaws?

• Is it consistent with evidenced-based care, clinical guidelines, or standards of care?

• Is it consistent with reasonable and prudent practice?

• Are you willing to accept accountability and liability for the activity and outcomes?

References

American Association of Nurse Practitioners. (2022). Scope of practice for nurse practitioners. American Association of Nurse Practitioners, Advocacy Resources. https://www.aanp.org/advocacy/advocacy-resource/position-statements/scope-of-practice-for-nurse-practitioners

American Association of Nurse Practitioners. (2019). Are you considering a career as a family nurse practitioner? American Association of Nurse Practitioners. https://www.aanp.org/news-feed/are-you-considering-a-career-as-a-family-nurse-practitioner#:~:text=FNPs%20maintain%20patient%20records%3B%20perform,that%20fall%20under%20primary%20care

American Association of Nurse Practitioners. (2020, Jan.). Are you considering a career as an adult-gerontology acute care nurse practitioner? American Association of Nurse Practitioners. https://www.aanp.org/news-feed/are-you-considering-a-career-as-an-acute-care-nurse-practitioner#:~:text=AGACNPs%20provide%20complex%20monitoring%20and,administrative%2C%20teaching%20and%20research%20components

American Association of Nurse Practitioners. (2020, June). Are you considering a career as an adult-gerontology primary care nurse practitioner? American Association of Nurse Practitioners. https://www.aanp.org/news-feed/are-you-considering-a-career-as-an-adult-gerontology-primary-care-nurse-practitioner

American Medical Association. AMA is leading the charge to stop scope creep.

https://www.ama-assn.org/amaone/ama-recovery-plan-america-s-physicians-fighting-scope-creep

American Nurses Association. (2023). Practice & Advocacy: Scope of practice. https://www.nursingworld.org/practice-policy/scope-of-practice/#:~:text=Scope%20of%20practice%20defined%20in%20nursing&text=Where%3A%20Wherever%20there%20is%20a,contract%20and%20obligation%20to%20society

American Nurses Association Committee on Nursing Practice Standards. (2021). Recognition of a nursing specialty, approval of a specialty nursing scope-of-practice statement, acknowledgement of specialty nursing standards of practice, and affirmation of focused practice competencies. https://www.nursingworld.org/~49d755/globalassets/practiceandpolicy/scope-of-practice/3sc-booklet-2021-june.pdf

American Psychiatric Nurses Association. (2022). Psychiatric-Mental Health Nursing: Scope & Standards of Practice. (3rd Ed.). (American Psychiatric Nurses Association).

Centers for Disease Control and Prevention. (2019). Nurse Practitioner Resources. https://www.cdc.gov/dhdsp/pubs/toolkits/np-resources.htm

Federation of State Medical Boards of the United States, Inc. (2005). Assessing scope of practice in healthcare delivery: critical questions in assuring public access and safety. (Page 8). https://www.fsmb.org/siteassets/advocacy/policies/assessing-scope-of-practice-in-health-care-delivery.pdf

National Association of Pediatric Nurse Practitioners. (2020). About Pediatric Nurse Practitioners. https://www.napnap.org/about-pediatric-nurse-practitioners/

Nurse Practitioners in Women’s Health. (2020). National Association of Nurse Practitioners in Women’s Health white paper: The essential role of women’s health nurse practitioners. https://www.nccwebsite.org/content/documents/cms/npwh_white_paper_the_essential_role_of_whnps_final_7.13.2020.pdf

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