Healthcare professions that require specialized knowledge and skills such as nursing are regulated to ensure public safety and prevent inherent harm. As healthcare consumers, the trust that we place in our healthcare providers is based on the concept of competency; we often take it for granted that the nurse, dentist, or physician from whom we seek services is knowledgeable and qualified to provide those services.
Regulation of healthcare providers exists to protect the public. Healthcare outcomes are directly affected by nursing practice, how it is defined, and ultimately how it is regulated. Nursing regulation is designed to protect public safety; therefore, effective regulation is essential to promote better patient safety and improved health outcomes. Nursing practice is governed by state and territorial nurse practice acts and regulatory procedures. This chapter discusses the regulation of nursing practice, licensure, and certification and how they function to protect consumers of nursing services.
The Regulation of Nursing Practice
The American Nurses Association (ANA) defines nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in health care for individuals, families, communities, and populations”.
Nursing, like most other health professions that require specialized knowledge and independent critical thinking, is regulated because individuals can be harmed by the actions of an incompetent or unqualified practitioner. The public relies upon this regulatory oversight of healthcare providers because they themselves may not be able to identify whether specific healthcare providers are competent or incompetent. In order to regulate the practice of nursing, governmental oversight is provided on a state level by a regulatory authority known as a state board of nursing.
A state board of nursing (BON) is a state-specific licensing or regulatory body that sets standards for safe nursing care, decides the scope of practice for nurses within that state’s jurisdiction, and issues a license to a qualified nurse within the state that the board regulates. The structure for a BON is unique to each state along with its authority and decision-making powers.
In 2007, the National Council of State Boards of Nursing (NCSBN), which has member representatives from all state and territories, adopted guiding principles for nursing regulation. These guiding principles include protection of the public, competence of all practitioners regulated by a BON, due process and ethical decision making, shared accountability, strategic collaboration, evidence-based regulation, response to marketplace, and globalization of nursing. These guiding principles provide the foundation for nursing regulation.
Nursing practice is carefully defined within the profession’s scope of practice through the nurse practice acts (NPAs) of individual states and territories. Each state or territory has enacted an NPA, which is a piece of state regulatory legislation that is enforced by its state or territorial BON to promote competent and safe nursing care.
States and territories, through their police powers, enact laws to regulate nursing to protect persons from incompetent nursing care (NCBSN, 2016k). NPAs establish BONs that are authorized to define the scope of nursing practice, develop administrative rules to further define state law, create regulatory entities, empower delegated entities with regulatory authority, and ensure accountability for nurses.
Although each state and territory’s NPA differs, all NPAs include six critical elements. These include authority and composition of a BON, educational program standards, scope of nursing practice with accompanying standards, types of licenses and titles, licensure requirements, and grounds for disciplinary action. In summary, the NPA is the most authoritative and controlling piece of governing law that regulates nursing practice within a state’s jurisdiction.
Regulation is intended to guarantee that the public is protected from unscrupulous, incompetent and unethical practitioners; offer some assurance to the public that the person being regulated is competent to provide certain services in a safe and effective manner; and offer a means by which persons who fail to comply with the profession’s standards can be disciplined, including the withdrawal of their licenses. NCSBN holds that state/territory nurse practice acts provide the legal basis for the regulation of nursing activities and that the responsibility for interpreting the legal scope of nursing practice rests solely with the individual BONs.
Nurse practice acts vary among states; however, many of them are based on the model act that was originally published by the ANA in 1988. The NCSBN also maintains a model nurse practice act and model rules titled NCSBN Model Nursing Practice Act and Model Nursing Administrative Rules. The model act and administrative rules provide recommended or model language that individual states or territories may use in the development of their state/territory specific nurse practice acts.
The NCSBN Model Act and Rules contain exemplary legislation that can be used by any state or territorial BON. The current model act and rules were developed by NCSBN committees, approved by the Delegate Assembly in 2012, and then updated in 2014.
The NCSBN Model Act and Model Rules provide a resource that state legislators and members of individual state/territory BONs can use as a comparative guide to help write language for the existing nurse practice act of their respective state. This comparison can identify language that may be missing in a state/territory’s existing nurse practice act or provide language that can be used for new regulation.
Because each state/territory has its own unique version of an NPA, models provide examples and guidance for the use of standardized or uniform language that helps to facilitate a shared knowledge or understanding of what constitutes the practice of nursing. The challenge for many individual practicing nurses can be how to locate their own state or jurisdiction’s current NPA.