Scope of Nursing Practice in Acute Care Hospital Settings

KBN has published Advisory Opinion Statement (AOS) #27 entitled “Components of Licensed Practical Nursing Practice.”  This AOS references the statutory definitions of “nursing process,” “registered nursing practice,” and “licensed practical nursing practice,” and contains guidelines for safe practice.  Based upon the Kentucky Nursing Laws, the LPN practices under the direction of a RN, physician, or dentist.  It is the advisory opinion of the Board that “direction” means communicating a plan of care to a LPN.  The RN directs/assigns the LPN in the performance of nursing care for individuals or a group of individuals within the legal scope of LPN practice.  It is the responsibility of the RN to know that the LPN has the appropriate education and training and has demonstrated competency in all aspects of nursing that the LPN is directed/assigned to perform.  In addition, the LPN is individually accountable and responsible for his/her own knowledge and skill.  It is the RN’s responsibility to provide appropriate supervision of the LPN’s provision of care.  This supervision includes initial and ongoing direction, procedural guidance, observation, and evaluation of the provision of care.

Consistent with the Kentucky Nursing Laws and AOS #27, the Cabinet for Health and Family Services (CHFS), Office of the Inspector General, has promulgated a Kentucky administrative regulation governing hospital operations and services (902 KAR 20:016).  This regulation contains requirements for the provision of nursing services that state in part:

• …There shall be registered nurse supervision and staff nursing personnel for each service or nursing unit to insure the immediate availability of a RN for all patients on a twenty-four hour basis.
• …Patient care shall be carried out in accordance with…nursing process, and nursing care procedures….
• A RN shall assign staff and evaluate the nursing care of each patient in accordance with the patient’s need and the nursing staff available.
• Nursing notes shall be written and signed on each shift by persons rendering care to patients…

In Kentucky, the scope of LPN practice is defined by content taught within approved Kentucky practical nursing educational programs.  The core curriculum includes essential content for basic health assessment.  The practical nursing student is  taught to collect objective and subjective data; identify normal from abnormal in each of the body systems; and to identify changes in the patient’s condition that are then reported to the RN or physician/ARNP.  The analysis of the data and formulation of the plan of nursing care is the RN’s responsibility.  The LPN contributes to the established plan of care through systematic basic health assessment and data collection.  In Kentucky, LPNs practice under the direction of a RN, physician or dentist, and the scope of practice does include patient/client basic assessment/data collection within their knowledge, abilities and skills.

The information on the degree of supervision required for LPN practice is provided in AOS #27, Page 4, C, 2.  The Board has not specified time intervals for onsite supervision in various health care settings/agencies; however, it is within the purview of the agency to establish written approved policies and procedures that define time intervals, and that are consistent with established standards of practice and evidence based practice.