Nurse Practice Act: RN Scope and Licensure

• The Nurse Practice Act (NPA) defines the scope of nursing practice and sets requirements for licensure
• It grants authority to Registered Nurses (RNs)
• Each state's NPA must align with federal provisions or statutes

NPA Basis for RN Scope and Licensure

• Each state has a Nurse Practice Act that mandates its Board of Registered Nursing (BRN) to establish rules
• These rules implement the scope of nursing practice
• Address methods for initial and continuing licensure
• And address nursing regulations within each state's jurisdiction
• Each state's NPA mandates the BRN to establish rules to implement these items:
• Scope of RN practice
• Methods of initial and continuing licensure
• RN regulations within each state's jurisdiction
• Advanced practice or public health RN roles
• Requirements for licensure and scope vary
• The Nurse Licensure Compact (NLC) allows one license to practice in multiple states but California is not part of the NLC

Board of Registered Nursing (BRN)

• The BRN's primary purpose is to protect consumers.
• It is contained within the California Business and Professions Code
• BRN information and rules can be found in the CA Code of Regulations – CCR Title
• The BRN evaluates the amount of nursing care needed for each patient category, validating unit and shift trends related to nursing care delivery
• They address RN care needs based on patient category, care delivery pattern, annual data, populations, skill mix, staff allocation, or patient care delivery model

CA Title 22- Nurse-Patient Ratios

• Hospitals must provide staffing by licensed RNs within the scope of licensure according to nurse-to-patient ratios
• Licensed RN includes registered nurses
• It also includes licensed vocational nurses, and licensed psychiatric technicians (only in psychiatric units)
• Hospitals cannot assign a licensed RN to a unit unless they have demonstrated competency and received sufficient orientation.
• Licensed RN-to-patient ratios represent the MAXIMUM number of patients assigned to one RN
• "Assigned" means the licensed RN is responsible for providing care to a particular patient within their scope of practice

CA Title 16 - Standards of Competency and Performance

• A Registered Nurse (RN) is considered competent when they can transfer scientific knowledge from social, biological, and physical sciences to the nursing process
• RNs act as patient advocates
• RNs may delegate tasks to Licensed Vocational Nurses (LVNs) or Unlicensed Assistive Personnel (UAPs)
• If an RN has an interim permit (IP), this requires them to practice under the direct supervision of an RN

How the BRN Protects Consumers

• The BRN provides RN licensing
• It monitors education standards
• The BRN also oversees continuing education
• A regulatory agency protects the public or consumer under the California Department of Consumer Affairs

Nurse Practice Act, 22

• Pt Classification Systems/RN-Pt Ratios
• CCR Title 16 covers standards of competent performance

CA Title 22 - Nurse Work Intensity

• (Pt Classification Systems/RN-Pt Ratios)
• Pt classification systems establish staffing requirements by unit, patient, and shift to predict RN care requirements
• The Board of Registered Nursing manages interventions
• It also maintains online license verification

BRN Mission Statement

• Protects the health/safety of consumers
• Accomplishes this by promoting quality RN care
• Licenses RNs
• Approves RN education programs
• Establishes and upholds competency standards
• Intervenes with discipline and rehabilitation
• Retains authority in the interpretation and enforcement of the RN Practice Act
• The BRN oversees RN licensing in California:
• Certified Nurse Anesthetist (CRNA)
• Certified Nurse Midwife (CNM)
• Clinical Nurse Specialist (CNS)
• Nurse Practitioner (NP)
• Public Health Nurse (PHN)

Initial Licensure

• To get initial licencure you must submit the application
• You must pay fees for the RN and Interim permits
• You must have the eligibility letter for testing
• Complete fingerprinting- LiveScan
• Pass National Council Licensure Exam (NCLEX-RN)
• May repeat after 45 days
• An Interim Permit is available after graduation
• It is not renewable and expires 6 months from the issue date or when NCLEX-RN results are available, at which point the interim permit is void
• The Board of Registered Nursing:
• Sets standards for RN education
• Approves RN programs in CA
• Issues and reviews licenses and certifications
• Investigates complaints and takes disciplinary action against RN licenses
• You must report any convictions and or discipline by a regulatory body & any name changes or changes in address to the BRN w/in 30 days of change to maintain your license
• Continuing Education must be completed with a board-approved provider such as (Concurrent Enrollment Programs, American Nurses Credentialing Center, other BRN providers)
• It must be relevant to nursing practice
• Should enhance knowledge above basic licensure requirements
• Cannot repeat the same content within the renewal cycle
• Must maintain proof of CE completion for at least 4 years

Enforcement Program by Department of Consumer Affairs

• Includes complaints about Patient care, Fraud, Criminal conviction, Sexual misconduct, Substance abuse
• Includes investigation, legal action and probation monitoring

Discipline/Revocation

• Discipline or revocation may happen if a nurse violates the Nursing Practice Act:
  • Revoke or suspend the license
  • Accept the surrender of the license
  • Place the nurse on probation
• When using “I.P.” designation you must Practice with direct supervision
• You must be present at all times during the care
• You may delegate duties that the permittee is capable of performing
• Maintaining Licensure:
• Renewed after 2 birth yrs (last day of mo. following birth mo.) then every 2 years
• Complete 30 hrs of approved continuing education
• You may gain exemption for first renewal & may apply ongoing college RN units
• Intervention Program Costs/Time Requirements:
• RNs pay $25/mo during the program and all other rehab related costs
• The program takes ~ 3-5 yrs to finish a concurrent work per BRN clinical safety assessment and approval:
• Ineligible nurses are:
• Previously disciplined by BRN for chemical dependency or mental illness
• Been terminated from the program/other state’s diversion program d/t non-compliance or sold drugs or caused pt harm
• No person may engage in the practice of nursing without holding a license w/ an active status, and the RN may cite and fine

California BRN Intervention program

• Alternative to traditional disciplinary process.
• This is intended for all RN’s licensed and living in CA
• Self-Referral: RNs who would like assistance may contact the program directly
• Board-Referral: RNs are referred to the Intervention Program by the BRN as a result of a complaint indicating the RN may be impaired d/t substance use disorder or mental illness.
• If the the RN rejects entering the program, that RN may referred to the Enforcement Program for investigation and possible disciplinary action
• Must be in writing, signed, and dated, with the following requirements to be followed:
• Must Specify experience, education, or training required
• Must Describe initial and ongoing competency & Maintain written record of all actions authorized to perform
• Setting: Provide required supervision, communication, limitations and periodic reviews

Community Health Standardized Procedure

• Examples include: Allowing qualified RNs to refill designated RX per protocol with the RN's functions of e-prescribing, insurance authorization, lab work, setting, and supervision
• Every licensee may be known as a RN may place the letters "R.N." after his or her name
• To set standards the following must be established:
  • Nurse Practice Act, ANA Scope and Standards of Practice, ANA Code of Ethics, professional specialty organizations & EBP sources

RN Scope

• Assessment and interpretation of clinical findings, disease prevention & restorative measures
• Administration of medications (w/ valid order), and skin tests, immunizations, Implementation of standardized procedures.
• Standardized Procedures: Used when RNs are not common w/in the standards of practice (usually medical practice, i.e., conscious sedation, intubations)
• Standardized Procedures are resources that can be offered through professional organizations in complex or high-risk issues & provide resources & continuing education, with the ANA Scope and Standards of Practice
• RN Delegating to Nursing Assistive Personnel (NAP) - POTENTIAL RISKS are liability for negligence
• Potential issues are for task delegation based on job description, knowledge base, & demonstrated skills along with Pt. Conditions such as HTN or DM

Abandonment Defined By CA BRN

• Happens when someone is accepted the pt assignment and they severed the the RN-pt relationship w/o giving reasonable notice where supervisor and the RN are using good judgement
• Refusal to work additional hours would NOT be considered abandonment, where the BRN has no jurisdiction in this situation
• When the RN is practicing with another health care partner, the RN must know the limits
• May not delegate any medical administrations, Venipuncture or IV therapy as well as parenteral or tube feedings, invasive procedures, assessing the patient, education of the patient
• If the RN delegates tasks and the NAP lacks the competency to do the task the RN may face discipline

Delegation 5 Rights of Delegation

1. Right task
2. Right circumstances
3. Right person
4. Right direction/communication
5. Right supervision provided

Patient abandonment occurs when

• CA RNs must meet the requirements for reporting any known or suspected ABUSE
• Certain injuries and/or domestic violence, sexual abusend abuse

All Advanced Practice Nurses (APNs) must

• They must have strict professional liabilityinsurance d/t risk assoc. and must have clinical experience as a Clinical Nurse Specialist, Certified Nurse Midwife, or Anesthetist