Enabling Registered Nurses, Licensed Practical and Vocational Nurses, and Assistive Personnel to Practice to Their Fullest Extent

Q How do we ensure that all staff members— including registered nurses, licensed practical and vocational nurses, and assistive technical personnel—are able to practice to the full extent of their license or certification?A Rebecca L. Johnson, MS, RN, CCRN, PCCN, NPD-BC, replies:The concept of practicing to the full extent of one's ability is far from new, but achieving this goal is challenging. The Institute of Medicine's 2011 Future of Nursing report emphasized the need for nurses to "practice to the full extent of their education and training."1 The most recent Future of Nursing report, published in 2021, also cites "practice to the full extent of their education and training" as a goal.2 Several factors affect what this means: the workplace (location and type of institution), patient acuity levels, the workforce (education levels, training, experience, motivation), scope of practice, and federal regulations.3 Although there are many benefits to practicing to the greatest extent of one's ability, including improved patient care and outcomes and improved nursing outcomes such as staff satisfaction and reduced turnover,3 current nursing and other staff shortages highlight the need for everyone to practice to their maximum potential.The path to practicing to the full extent of one's ability starts with understanding the many influences on nursing practice. Each state has a board of nursing (BON) that advises the state legislators who write the Nurse Practice Act (NPA), the law governing the practice of registered nurses (RNs) and practical and vocational nurses (LPNs/LVNs).4 LPNs and LVNs play the same role, with the title depending on the terminology used by each state.5 The NPA, which varies by state, provides definitions, sets nursing school standards, establishes the scope of practice, determines licensing requirements, ensures title protection, and serves as the basis for disciplinary actions.4 The BON regulates and enforces the NPA.4 Each state BON belongs to the National Council of State Boards of Nursing, an independent organization that provides evidence-based guidance regarding nursing regulations and ultimately the NPA.4The Scope and Standards of Practice of the American Nurses Association (ANA) identifies the "who, what, where, when, why, and how" of nursing practice.6 Similarly, the ANA's Code of Ethics for Nurses identifies the ideals, ethical values, duties, and obligations of the nursing profession, setting the ethical standard for nurses and serving as a template for decision-making.7 As a result, the ANA guides the individual nurse but also helps guide the BON and NPA.4 Nursing practice is further influenced by federal regulations and each employer's policies.3 The Figure illustrates these major influences, but there are also others, such as additional state regulations and even certification status.3There are more than 2 million staff members constituting assistive personnel (AP) in the hospital setting8; unfortunately, regulation of the AP role is lacking, and they do not have a scope of practice.9 This lack of role regulation and scope of practice is a barrier to achieving the aim of practicing to the full extent of their ability for RNs, LPNs/LVNs, and APs. The goal of this article is not to clarify the NPA or provide a breakdown of the scope of practice for each state but rather to identify useful tools and suggest actions to help staff members in each role work to their maximum potential.Clear delineation of role expectations starts with understanding the difference between taking an assignment and delegation, the job expectations, and the scope of practice for each team member.10 Lack of clarity regarding roles leads to confusion and dissatisfaction among team members and negatively affects patient outcomes.9 Tension arises between RNs and LPNs/LVNs when there is a lack of knowledge regarding differences in scope of practice, leading to mistaken assumptions about an individual's abilities.11 Misunderstanding of AP roles leads to poor delegation and unrealistic expectations.11 This situation can lead to further role confusion, conflict, the perception of a power struggle, and bullying,9 impairing the ability of each staff member to practice to their fullest extent. Employers need to develop policies and guidelines for each role and integrate them into their organizational culture. In addition, nursing educators can provide high-quality education and role modeling to help teach role differentiation.Delegation is the process of distributing tasks to other employees. It is an integral part of nursing practice, relying on mutual trust, respect, and communication.12 Delegation is a learned skill and therefore needs to be taught12 and integrated into educational programs.13 It also needs to be incorporated into the employer's policies12,13 and organizational culture to avoid ambiguity and ensure that it is performed safely and correctly for each role.Skilled communication also depends on respect and trust.13 It enables individuals to speak up, ask for help, and guide others.10 Like delegation, communication skills need to be taught and prac-ticed.14 TeamSTEPPS (Team Strategies & Tools to Enhance Performance & Patient Safety) is a free program offered by the Agency for Healthcare Research and Quality to improve communication skills and teamwork.15 Role playing, simulation, and virtual training are other tools that can improve communication skills and should include all staff categories, not just nurses. Including AP in shift reports and providing job aids promotes feelings of inclusivity and improves communication among staff members in different roles.14 Communication is necessary for safe and full role implementation.When employers enculturate team models, each role is embraced and collaboration among team members increases.16 Strong, well-developed policies for staffing and skills mix, assignments, delegation, workload, and role clarification are essential to promote collaboration.16 Other key elements of teamwork include skilled communication, shared decision-making, and forming positive professional relationships.16 Poor collaboration leads to increased conflict and perceived workload inequity related to misunderstanding of scope of practice and lack of role clarification.16 The American Association of Critical-Care Nurses provides standards and guidance for true collaboration, skilled communication, effective decision-making (delegation), and appropriate staffing (clear roles) through its healthy work environment standards.17Regardless of how your state defines scope of practice, there are several opportunities to affect staff members' ability to practice to their fullest potential. Clear roles and expectations, safe and proper delegation, skilled communication, and developing a strong team with deliberate collaboration are achievable goals that require awareness of the concept of full extent of practice. Use the free evidence-based tools and practices that already exist to achieve these goals. The Table summarizes these points and provides resources. If an employer's policies for RNs, LPNs/LVNs, and AP are more limiting than the state's NPA, then advocate for policy changes. Work with peers, leaders, local representatives, the BON, and nursing organizations to advocate for changes in your state's NPA. Practicing to the full extent of one's ability depends on all staff members' working together and ultimately respecting each person for their individual contributions to health care.