Every state and territory in the US set laws to govern the practice of nursing. These laws are defined in the Nursing Practice Act (NPA). The NPA is then interpreted into regulations by each state and territorial nursing board with the authority to regulate the practice of nursing care and the power to enforce the laws. Fifty states, District of Columbia and 4 United States (US) territories, have state boards of nursing (BON) that are responsible for regulating their individual NPA. The boards enforce these laws as defined by their respective state or territorial legislative bodies. The legislative body gives the board of nursing the power to discipline nurses who violate the nursing laws and regulations. Only the BON has the power to discipline a nurse who may pose a danger to the public.
Most states and territories have one nursing board regulating all levels of nursing, including PN/VN (practical nurse /vocational nurse), RN (Registered Nurse), and APN (Advanced Practice Nurse) practice (www.ncsbn.org). Some states, such as California, Nebraska, West Virginia, and Louisiana, have separate state boards for PN/VN, RN, or APN practice. These boards are all members of the National Council State Boards of Nursing (www.ncsbn.org). The National Council of State Boards of Nursing (NCSBN) promotes evidence-based regulatory excellence for patient safety in nursing care and public protection. The NCSBN has supported the Nurse Licensure Compact with 34 state boards of nursing, recognizing a single nursing license to practice in multiple states. However, nurses are held accountable to the specific state NPA at the location of nursing practice.
Issues of Concern
According to the NCSBN, public health, welfare, and safety of the public are protected by nursing regulation, which is found in the NPA. The NPA is the enacted regulations with full force and effect of law. Each state or territory has its own version of NPA, and they vary geographically at state lines. In general, the NPA provides guiding principles for the scope of nursing regulation to include: defining phrases and terms for the intent of the law, defining the composition of the board members, defining nursing school educational program standards, defining the scope of nursing practice, overseeing licensure processes, protecting titles and providing grounds for disciplinary actions for violations.[Russel KA]
The NPA is the law for governing nursing practice in each state and is used for guidance to action. Therefore, the NPA has terms and phrases clearly defined for the state boards of nursing to use for enforcement. There are terms that are established for understanding among legislators and citizens.[Russel KA] For example, the California Board of Registered Nursing defines “Nurse Practitioner” as an individual with a registered nurse license that has advanced nursing education, has acquired additional educational preparation and skills, meets the certification requirements to manage health-illness needs.
Authority of the BON
The BON has the authority and power to regulate nursing practice utilizing the language stipulated in the NPA. It is also the responsibility of the BON to protect the US citizens’ health, safety, and welfare against substandard nursing care. Memberships in the BON are generally appointed by the governor or senators with the recommendations from various professional organizations within the state or territory.[Russel KA] The BON members may include nurses, doctors, attorneys, and public members. The BON office may include nurses, attorneys, and administrative staff, who have investigative duties, and are not members of the BON. The BON’s duties generally include:
- Making, amending and enforcing regulations
- Setting standards in nursing education
- Setting licensure fees
- Ensuring criminal background check
- Providing license to applicants
- Ensuring nurses are updated with continuing education
- Collecting and analyzing nursing workforce data
- Carrying out disciplinary processes
Educational Program Standards
Nursing regulation requires agencies, such as hospitals, health clinics, and nursing schools, to work together to ensure patient safety and education of nurses is accomplished, which serves the best interests of the principle of public protection. Standards on prelicensure nursing education and clinical learning experiences are defined in the NPA and used for accreditation purposes to evaluate the nursing educational programs. Language may include curriculum specifics, faculty qualifications, and data collection of success in the nursing board examination.
Standards and Scope of Nursing Practice
Nursing regulation through NPA is a state-initiated effort. The regulations are to provide standardization for laws regulating the nursing practice. NPAs emphasizes the accountability of all nurses for not only providing but improving safe client care. NPA provides nursing practice standards and a code of conduct for the continued privilege to practice nursing. Clear definitions of nursing scope of practice are detailed in the NPA and aligned with the nursing process of developing a plan of care for patient advocacy. Furthermore, the scope of practice is inclusive of safe nursing practice appropriate for the level of training and orientation.
Types of Licenses and Titles
The NPA exists to regulate and protect the public from practitioners who are a risk to the health, safety, and welfare of the citizens within its state board jurisdiction. This protection principle is accomplished by assessing competence at initial licensure and throughout the career of the nurse. Licensure requirements are set at initial licensure as well as for licensure renewal. Licenses and titles are defined and protected by the NPA for usage in the public. They are privileged and granted by the BON after meeting the requirements of graduating from accredited nursing educational programs, passing professional board examinations, background checks, and paying applicable fees.
Grounds for Disciplinary Action
Within the NPA, the boards set standards to which they hold practitioners accountable for providing safe client care. These standards are based on professional, ethical, and legal standards for nursing. The NPA also ensures that any practitioner who has a complaint brought against their practice has the right to due process. Due process ensures the rights of the nurse are maintained throughout the discipline process.
When a patient/family sues a nurse for substandard care (malpractice), there are elements that must be proved in a court of law: Duty (the nurse had a duty to the patient), breach of duty (the nurse breached that duty), harm or injury (some type of harm or injury must be demonstrated), and causation (that the harm or injury was caused by the nurse as a result of a failure to follow standards of care). Malpractice cases in a court of law may set compensatory and punitive damages against a nurse, but only the board of nursing may discipline a nurse for substandard practice.
The BON receives complaints regarding substandard care from a variety of sources (patients, healthcare professionals, including other nurses, and healthcare agencies). These complaints are investigated to determine if a nurse did provide care below the standard set by the NPA or other standards of care, such as in professional organizations or in the community. For the BON investigations, the actual injury does not need to be determined. Only that the nurse violated the standard of care. The BON determinations against the nurse for violating the standard of care result in disciplinary action (called stipulations against the license), which can include fines, supervised practice, mandatory remedial education, or suspending/revoking of license.
Nurse Licensure Compact
The NPA also includes laws and rules relating to the Nurse Licensure Compact. Currently, there are 34 states that have passed legislation joining the compact. This is a mechanism for nurses to practice, usually online or over telephone connections across state lines. There are specific laws and rules govern this practice. A nurse whose home state, a state in which he/she holds licensure, is a member of the compact may practice in another state who is a member of the compact, but the nurse must follow the laws and rules in the practice act in the state in which they practice. “Multistate licensure privilege” is the term used by the BON to denote the nurse licensure compact status of the nurse. If a nurse is practicing in a particular state and violates a law or rule of that state’s nursing practice act, that particular state may take action to discipline that nurse. Once a state’s board has determined if a practice violation occurred and has determined the disciplinary action to be implemented, the nurse’s home state may then decide to also discipline the nurse for the practice violation. In most circumstances, nurses under any form of disciplinary action usually lose their multistate licensure privilege.
Nurses practicing in a state or territory should be familiar with the NPA. Nurses are responsible for knowing the laws affecting their practice as most boards maintain ignorance of the law is no excuse for non-compliance and substandard nursing practice. NPAs are laws and rules in the NPA designed to protect the public from unsafe practice, which may include standards of practice for all nursing levels (PN/VN, RN, or APN).
Nursing, Allied Health, and Interprofessional Team Monitoring
Public Access to BON and NPA
Since the BON is state-appointed and the NPA is the law, both the BON and NPA are available for public access. Licenses can be verified online through a state-sponsored verification system free of charge. Each state's BON has database tracking licensure as well as disciplinary actions against the nurse for public records. Federal law also requires states to report any adverse actions against a nurse to the National Practitioner Data Bank, established by Congress in 1986. This databank can be accessed by authorized entities, including hospitals, licensing boards, attorneys, licensees, and professional societies.[Russell KA]