1.3 Licensure, Regulations & Standards

Standards for nursing care are set by several organizations, including state Nurse Practice Acts, the American Nurses Association (ANA), agency policies and procedures, federal regulators, and other professional nursing organizations. These standards promote guidelines for safe, competent care to be provided to the public.

Nurse Practice Act

Nurses must legally follow regulations set by the Nurse Practice Act (NPA) in the state in which they work. The Nurse Practice Act is enacted by that state’s legislature, defines the scope of practice for nurses in that state, and establishes regulations for nursing practice. If nurses do not follow the standards and scope of practice set forth by the Nurse Practice Act, they can have their nursing license revoked by the state Board of Nursing. The Board of Nursing is a licensing and regulatory body that issues nursing licenses to qualified candidates and also provides discipline for nurses who do not follow standards and scope of practice established in the Nurse Practice Act.

Each state has their own Nurse Practice Act. To read more about the the Wisconsin Board of Nursing, Standards of Practice, and Rules of Conduct, use the information provided below.^[1]

Nursing students must understand their scope of practice as outlined in the Nurse Practice Act in the state in which they are completing their clinical courses. Nursing students are legally accountable for the quality of care they provide to clients just as nurses are accountable. Students are expected to recognize the limits of their knowledge and experience and appropriately alert faculty or other authority figures regarding situations that are beyond their competency. A violation of the standards of practice constitutes unprofessional conduct and can result in the Board of Nursing denying a license to a nursing graduate.

American Nurses Association (ANA)

The American Nurses Association (ANA) is a national, professional nursing organization that was established in 1896. The ANA represents the interests of nurses in all 50 states of America while also promoting improved health care for everyone. The mission of the ANA is to “lead the profession to shape the future of nursing and health care.”^[2] The ANA states that it exists to advance the nursing profession by doing the following:

• Fostering high standards of nursing practice
• Promoting a safe and ethical work environment
• Bolstering the health and wellness of nurses
• Advocating on health care issues that affect nurses and the public^[3]

ANA Scope and Standards of Practice

The American Nurses Association (ANA) publishes two resources that set standards and guide professional nursing practice in the United States: The Code of Ethics for Nurses and Nursing: Scope and Standards of Practice. The Code of Ethics for Nurses establishes an ethical framework for nursing practice across all roles, levels, and settings. It is discussed in greater detail in the “Legal and Ethical Considerations” section of this chapter. The Nursing: Scope and Standards of Practice describes a professional nurse’s scope of practice and defines the who, what, where, when, why, and how of nursing. It also sets 18 standards of professional practice that all registered nurses are expected to perform competently.^[5]

The “who” of nursing practice are the nurses who have been educated, titled, and maintain active licensure to practice nursing. The “what” of nursing is the recently revised definition of nursing: “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity.”^[6] Simply put, nurses treat human responses to health problems and life processes and advocate for the care of others.

Nursing practice occurs “when” there is a need for nursing knowledge, wisdom, caring, leadership, practice, or education, anytime, anywhere. Nursing practice occurs in any environment “where” there is a health care consumer in need of care, information, or advocacy. The “why” of nursing practice is described as nursing’s response to the changing needs of society to achieve positive health care consumer outcomes in keeping with nursing’s social contract and obligation to society. The “how” of nursing practice is defined as the ways, means, methods, and manners that nurses use to practice professionally.^[7] The “how” of nursing is further defined by the standards of practice set by the ANA. There are two sets of standards, the Standards of Professional Nursing Practice and the Standards of Professional Performance.

The ANA Standards of Professional Nursing Practice are “authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently.”^[8] These standards define a competent level of nursing practice based on the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.^[9] Each of these standards is further discussed in the “Nursing Process” chapter of this book.

The ANA Standards of Professional Performance are 12 additional standards that describe a nurse’s professional behavior, including activities related to ethics, advocacy, respectful and equitable practice, communication, collaboration, leadership, education, scholarly inquiry, quality of practice, professional practice evaluation, resource stewardship, and environmental health. All registered nurses are expected to engage in these professional role activities based on their level of education, position, and role. Registered nurses are accountable for their professional behaviors to themselves, health care consumers, peers, and ultimately to society.^[10] The 2021 Standards of Professional Performance are as follows:

• Ethics. The registered nurse integrates ethics in all aspects of practice.
• Advocacy. The registered nurse demonstrates advocacy in all roles and settings.
• Respectful and Equitable Practice. The registered nurse practices with cultural humility and inclusiveness.
• Communication. The registered nurse communicates effectively in all areas of professional practice.
• Collaboration. The registered nurse collaborates with the health care consumer and other key stakeholders.
• Leadership. The registered nurse leads within the profession and practice setting.
• Education. The registered nurse seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking.
• Scholarly Inquiry. The registered nurse integrates scholarship, evidence, and research findings into practice.
• Quality of Practice. The registered nurse contributes to quality nursing practice.
• Professional Practice Evaluation. The registered nurse evaluates one’s own and others’ nursing practice.
• Resource Stewardship. The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, financially responsible, and judiciously used.
• Environmental Health. The registered nurse practices in a manner that advances environmental safety and health.^[11]

Years ago, nurses were required to recite the Nightingale pledge to publicly confirm their commitment to maintain the profession’s high ethical and moral values: “I will do all in my power to maintain and elevate the standard of my profession and will hold in confidence all personal matters committed to my keeping and family affairs coming to my knowledge in the practice of my calling, with loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care.” Although some of the words are outdated, the meaning is clear: Nursing is a calling, not just a job; to answer that call, nurses must be dedicated to serve their community according to the ANA standards of care and code of ethics.^[12]

Employer Policies, Procedures, and Protocols

In addition to professional nursing standards set by the American Nurses Association and the state Nurse Practice Act where they work, nurses and nursing students must also practice according to agency policies, procedures, and protocols. For example, hospitals often set a policy that requires a thorough skin assessment must be completed and documented daily on every client. If a nurse did not follow this policy and a client developed a pressure injury, the nurse could be held liable. In addition, every agency has their own set of procedures and protocols that a nurse and nursing student must follow. For example, each agency has specific procedural steps for performing nursing skills, such as inserting urinary catheters. A protocol is defined by the Wisconsin Nurse Practice Act as a “precise and detailed written plan for a regimen of therapy.” For example, agencies typically have a hypoglycemia protocol that nurses automatically implement when a client’s blood sugar falls below a specific number. The hypoglycemia protocol includes actions such as providing orange juice and rechecking the blood sugar. These agency-specific policies, procedures, and protocols supersede the information taught in nursing school, and nurses and nursing students can be held legally liable if they don’t follow them. Therefore, it is vital for nurses and nursing students to always review and follow current agency-specific procedures, policies, and protocols when providing client care.

Nurses and nursing students must continue to follow their scope of practice as defined by the Nurse Practice Act in the state they are practicing when following agency policies, procedures, and protocols. Situations have occurred when a nurse or nursing student was asked by an agency to do something outside their defined scope of practice that impaired their nursing license. It is always up to you to protect your nursing license and follow the state’s Nurse Practice Act when providing client care.

Federal Regulations

In addition to nursing scope of practice and standards being defined by state Nurse Practice Acts, the American Nurses Association, and employer policies, procedures, and protocols, nursing practice is also influenced by federal regulations enacted by agencies such as The Joint Commission and the Centers for Medicare and Medicaid.

The Joint Commission

The Joint Commission is a national organization that accredits and certifies over 20,000 health care organizations in the United States. The mission of The Joint Commission (TJC) is to continuously improve health care for the public by inspiring health care organizations to excel in providing safe and effective care of the highest quality and value.^[13] The Joint Commission sets standards for providing safe, high-quality health care. Examples of standards include following National Patient Safety Goals and establishing a Safety Culture in health care agencies.

National Patient Safety Goals

The Joint Commission establishes annual National Patient Safety Goals for various types of agencies based on data regarding current national safety concerns.^[14] For example, National Patient Safety Goals for hospitals include the following:

• Identify Patients Correctly
• Improve Staff Communication
• Use Medicines Safely
• Use Alarms Safely
• Prevent Infection
• Identify Patient Safety Risks
• Prevent Mistakes in Surgery

Nurses, nursing students, and other staff members are expected to incorporate actions related to these safety goals into their daily client care. For example, SBAR (Situation, Background, Assessment, and Recommendation) handoff reporting techniques, barcode scanning equipment, and perioperative team “time-outs” prior to surgery are examples of actions incorporated at agencies based on National Patient Safety Goals. Nursing programs also use National Patient Safety Goals to guide their curriculum and clinical practice expectations. National Patient Safety Goals are further discussed in the “Safety” chapter of this book.

Use the information provided below to read more about The Joint Commission and National Patient Safety Goals.

Safety Culture

A safety culture empowers nurses, nursing students, and other staff members to speak up about their concerns about client risks and to report errors and near misses, all of which drive improvement in client care and reduce the incidences of client harm.^[15] Many health care agencies have implemented a safety culture in their workplace and successfully reduced incidences of client harm. An example of a safety culture action is a nurse or nursing student creating an incident report when an error occurs when administering medication. The incident report is used by the agency to investigate system factors that contribute to errors. To read more about how The Joint Commission encourages agencies create a safety culture, use the information provided in the following box.

Reimbursement for Health Services and Regulations

Although many individuals pursue nursing careers to help others, it is important to realize that health care is a business. Even non-profit organizations rely on funding to provide services, pay employees, and maintain the facility and equipment. There are several sources of funding for health care, including private health insurance or government-funded programs like Medicare and Medicaid. No matter what type of funding source, agencies must comply with state and federal regulations.

Private Health Insurance

The health insurance industry provides private health insurance that is sponsored by employers or purchased privately by individuals from the Health Insurance Marketplace. Private insurance programs must comply with state and federal regulations even though they are privately owned. Read more about the Affordable Care Act in the following box.

Federal and State-Funded Health Care

Medicare is federally funded health care coverage of individuals aged 65 or older, individuals younger than 65 with certain disabilities, or those at any age with end-stage renal disease. Medicaid is a combination of state and federally funded health care coverage of low-income adults, pregnant women, and children. Agencies receiving Medicare or Medicaid reimbursement must comply with state and federal regulations and meet established client outcomes, or their reimbursement rates are decreased or eliminated. Read more about Medicare in the following box.

Centers for Medicare & Medicaid Services

The Centers for Medicare & Medicaid Services (CMS) is a federal agency that establishes and enforces regulations to protect client safety in hospitals that receive Medicare and Medicaid funding. For example, one CMS regulation states that a hospital’s policies and procedures must require confirmation of specific information before medication is administered to clients. This CMS regulation is often referred to as “checking the rights of medication administration.” You can read more information about checking the rights of medication administration in the “Administration of Enteral Medications” chapter of the Open RN Nursing Skills, 2e textbook.^[22]

CMS also enforces quality standards in health care organizations that receive Medicare and Medicaid funding. These organizations are reimbursed based on the quality of their client outcomes. For example, organizations with high rates of healthcare-associated infections (HAI) receive less reimbursement for services they provide. As a result, many agencies have reexamined their policies, procedures, and protocols to promote optimal client outcomes and maximum reimbursement.

Now that we have discussed various agencies that affect a nurse’s scope and standards of practice, let’s review various types of health care settings where nurses work and members of the health care team.