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Nursing Practice

Nursing is a licensed profession with the same types of laws, licenses, and regulations as the medical profession. Physicians who supervise nurses directly or who authorize nurse practice should be familiar with the state's nursing practice act and its attendant regulations. Beyond the personal risks of improperly delegating authority to nurses, a physician who does not comply with the state's nursing laws will endanger the licenses of the nursing staff. Unlike boards of medical examiners, boards of nursing examiners have enforced rules against the unauthorized practice of medicine.

All nurses providing medical care must do so on either the independent authority of a nursing license or on the delegated authority of a properly licensed physician. All parties to the care--the nurse, the patient, and the physician--must understand and agree on who is responsible for what. If a physician writes an order for, say, 250 mg of amoxicillin by mouth three times a day, the nurse administers the medicine on the authority of the physician. The nurse has an independent responsibility to ensure that the drug, the dose, and the schedule for administration are consistent with established nursing practice.

When nurses are working from standing orders or protocols, their authority is derived from the physician's authority, but the lines of responsibility are less obvious. Intensive care nurses may be authorized to look at a cardiac monitor and to give a bolus of lidocaine when the monitor shows premature ventricular contractions. The nurses may not realize that they are not doing this on their own judgment or responsibility. The protocols are authorized by the physician in charge of the intensive care unit. If no physician has authorized the protocols, the nurse is practicing medicine without a license.

Nursing training recognizes many different specialties and practice styles. Some states recognize these additional certifications beyond the basic registered nurse license, but many do not. Nurses and physicians should know the laws of their state concerning specialty nursing. A nurse midwife or a board-certified nurse-practitioner may be able to get a license that permits a more advanced level of care than is permitted for a simple registered nurse. It is important to know, however, that the board of nursing examiners may recognize nurse specialists without the state law's granting them any extraordinary privileges over other registered nurses. A nurse-practitioner may simply be recognized as one of a class of nurses who are skilled at working independently under protocol. Physicians cannot assume that specially certified nurses may be delegated more responsibility than other registered nurses.

Nurse-practitioners may have unrealistic expectations, fostered by their academic training programs, about independent practice. They may have been taught to diagnose many common ailments without realizing that making these diagnoses is likely to be outside the scope of practice allowed to nurses. The shelves of the medical bookstores are filled with books of nurse-practitioner protocols with differential diagnoses. These are teaching protocols, however; they are not suitable for delegation of authority for medical practice from a physician to a nurse.

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