Factors Associated With Full Implementation of Scope of Practice
Abstract
Purpose
To describe whether nurses fully implement their scope of practice; nurses’ perceptions of future practice implementation; and the association between scope of practice implementation with professional autonomy and self-efficacy.Design
A descriptive correlational study was conducted using a convenience sample of 145 registered nurses with post-basic certification from two Israeli university hospitals, from May 2012 to September 2013.Methods
Five questionnaires were distributed: (a) Demographic and Work Characteristics, (b) Implementation of Scope of Practice, (c) Attitudes Towards Future Practice, (d) Practice Behavior Scale, and (e) Practice Self-Efficacy. Descriptive statistics for all demographic and questionnaire data were analyzed. Two regression models were developed, where current and future implementations were the criterion variables and demographic and work characteristics, professional autonomy, and self-efficacy were the predictors.Findings
High levels of professional autonomy, self-efficacy, and attitudes towards future practice were found in contrast to low or moderate levels of current implementation of the full extent of scope of practice. Primary reasons associated with low implementation were lack of relevance to practice and permission to perform the practice. Significant associations were found between professional autonomy, self-efficacy, and attitudes towards future practice, but not with current implementation.Conclusions
Nurses wanted to practice to the full extent of their scope of practice and felt able to do so but were hindered by administrative and not personal barriers.Clinical Relevance
Even though staff nurses with post-basic certification had high levels of professional autonomy and self-efficacy, many were not implementing the full extent of their scope of practice. Similar to findings from around the world, external factors, such as administrative and policy barriers, were found to thwart the full implementation of nurses' full scope of practice. Therefore, practicing nurses should be aware of these barriers and work towards reducing them.The need to provide increasingly complex healthcare services at decreased costs induced countries from around the world to develop their own human resource solutions. For example, the English National Health Service instituted a national initiative changing the roles and scope of practice of physicians and nurses (Bohmer & Imison, 2013). Australia implemented initiatives further redefining and expanding the roles of enrolled and registered nurses. The Congress of the United States passed the Patient Protection and Affordable Care Act, thereby presenting a unique opportunity to improve healthcare by reforming scope of practice policies (Villegas & Allen, 2012) and encouraging nurses to practice to the full extent of their authority, especially in advanced nursing and primary care (Institute of Medicine [IOM], 2011; Kunic & Jackson, 2013).
Israel, a country in the Middle-East with socialized medicine, has also developed a solution. Over 30 years ago, the Israel Ministry of Health authorized advanced practices and procedures within the framework of post-basic certification. Certification is obtained by registered nurses who complete a course that is approximately 1 year in length and includes both theoretical and clinical content. Nurses must also pass a theoretical and clinical examination in order have post-basic certification. These courses are not given within an academic framework and initially did not require an academic degree. Areas of post-basic certification include midwifery, intensive care (neonatal, pediatric, and adult), emergency, oncology, geriatrics, and others. The scope of practice of nurses with post-basic certification is expanded from that of the registered nurse and includes a specific set of practices based on the type of certification (Ben Natan & Oren, 2011; Israel Ministry of Health, 2015; Table 1).
| Type of certification | |||||
|---|---|---|---|---|---|
| Neonatal/pediatric | |||||
| Practice | Adult ICU | ICU | Emergency | Oncology | Midwifery |
Note
| |||||
| Handheld defibrillation | √ | √ | |||
| Attach pacemaker electrodes and set heart rate | √ | √ | |||
| Set ventilator settings for weaning | √ | √ | √ | ||
| Connect and disconnect patient to ventilator | √ | √ | √ | √ | |
| Insertion of arterial line | √ | ||||
| Removal of arterial line | √ | √ | √ | √ | √ |
| Draw blood from an arterial line | √ | √ | √ | √ | √ |
| Administer drugs IV push | √ | √ | √ | √ | √ |
| Administer drugs IV push to central line | √ | √ | √ | √ | √ |
| Draw blood for type and cross-matching | √ | √ | √ | √ | √ |
| Care of a Swan-Ganz catheter | √ | √ | |||
| Blood drawing for laboratory tests, including arterial blood gases | √ | ||||
| Drawing of mixed-venous blood from a Swan-Ganz catheter | √ | ||||
| Draw peripheral arterial blood from a newborn | √ | √ (up to 1 year old) | |||
| Insert peripheral IV to newborn | √ | √ (up to 1 year old) | |||
| Draw venous blood from newborn peripheral vein | √ | √ | |||
| Insert peripheral venous line on the scalp and legs of newborn | √ | ||||
There are reports of nurses not working to the full extent of their education and training or scope of practice (IOM, 2011; D'Amour, Dubois, Dery, Clarke, Tchouaket, Blais, & Rivard, 2012). Previous studies have shown that lack of full implementation of the scope of practice might be due to internal as well as external factors. Internal factors include feelings of incompetence (McConnell, Slevin, & McIlfatrick, 2013) or personal characteristics, while external factors include organizational support (Shiu, Lee, & Chau, 2012), work environment (Oelke, White, Besner, Doran, Hall, & Giovannetti, 2008), institutional policies (McConnell et al., 2013), and local and national health policy (IOM, 2011).
Two internal factors that might be related to the full implementation of scope of practice are professional autonomy and self-efficacy. Professional autonomy can be defined as control over one's professional practice (Bahadori & Fitzpatrick, 2009). Dempster (1990) described four aspects of professional autonomy: readiness (ability, skill, and mastery), empowerment (perception of the legitimacy to practice), actualization (decision making, authority, and responsibility), and valuation (an evaluation of professional worth and quality). Kilpatrick et al. (2012) found that increased levels of professional autonomy were associated with increased implementation of scope of practice among a sample of Canadian nurse practitioners. Goldberg, Kertzman, Van Dijk, & Eisenberg (2012) also found a positive relationship between professional autonomy and attitudes towards expanding the scope of practice among a sample of Israeli nurses.
Self-efficacy in this context can be defined as the assessment that a nurse is able to perform the roles and practices within the scope of practice. Efficacy expectations are defined as the belief that one is able to successfully perform a specific task for a specific purpose. These expectations influence whether one will attempt to perform the specific tasks as well as the amount of effort that will be expended to complete them (Bandura, 1977). No study was found that investigated the relationship between self-efficacy and implementation of scope of practice. However, it would seem logical that nurses who felt that they were not able to perform a practice successfully would neither attempt to perform it nor expend a lot of effort to do so. This information might be important to policymakers when they are deciding whether to endorse the expansion of certain practices into nursing.
Significance
Nurses are expected to deliver safe, high-quality, and cost-effective care (Kunic & Jackson, 2013). However, nurses working below the full extent of their scope of practice may have lower job satisfaction and increased turnover, leading to increased costs and decreased quality of care (D'Amour et al., 2012). While one of the major conclusions of the American IOM report on the future of nursing (2011) was to promote nurses to work to the full extent of their education and training, few studies have investigated whether nurses, especially staff nurses, from other countries are having similar problems. Even fewer have determined what factors are associated with nurses implementing the full scope of their practice.Aims
The aims of this study were to describe whether nurses worked to the full extent of their scope of practice; whether these nurses wanted to expand their scope of practice in the future; and whether demographic and work characteristics, professional autonomy, or self-efficacy were predictors of working to the full extent of the scope of practice or attitudes towards expanding scope of practice in the future.Design
This study was a descriptive, correlational study.Methods
Sample
The target population was Israeli nurses who had completed post-basic certification courses. The accessible population was nurses from two university hospitals. Nurses were chosen using convenience sampling of units that are expected by the Israel Ministry of Health to hire nurses with post-basic certification. The units that were included were intensive care (adult, pediatric, and neonatal units), emergency, oncology, and maternity departments. A power analysis found that a minimum of 134 subjects were needed to achieve a power of .80, with an alpha level of .05 with a moderate effect size (Cohen, 1992).Instruments
Five instruments were used in this study: (a) Demographic and Work Characteristics Questionnaire, (b) Implementation of Scope of Practice Scale, (c) Attitudes Towards Future Practice Scale, (d) Practice Behavior Scale (Dempster, 1990), and (e) Practice Self-Efficacy Scale.Demographic and work characteristics scale
This scale included the variables of age, sex, family status, religion and religiosity (measures of ethnicity in Israel), unit, role, experience as a nurse and on the current unit, professional education, type of post-basic course, and date of course completion.Implementation of scope of practice scale
This scale was designed by the investigators in order to measure the level of current implementation of nursing practices that are included in the Israel Ministry of Health list of expanded practices (practices allowed only by registered nurses with post-basic certification; see Table 1). The scale consists of a list of the practices relevant to the type of post-basic certification (range: 5–13 practices). Participants are asked to describe on a Likert scale to what extent they perform each practice independently (i.e., not require a physician or other healthcare provider to perform the practice), from 1 (never) to 5 (always). Higher scores indicate a higher level of current implementation of the full extent of the nurse's scope of practice.In the event that the participant responded with an answer in the range of 1 to 3, the participant was asked (using a checklist) why they did not perform this practice. Possible responses were no time, not have relevant knowledge or training, not enough confidence, and lack of permission or prohibited by a superior.
The questionnaire was sent to five content experts (five nurses with expertise in policy and administrative issues related to scope of practice and advanced practice) to evaluate its content validity. Only minor changes were requested in the questionnaire. Cronbach's α reliability scores ranged from .31 (for midwives) to .67 (for the emergency and pediatric intensive care groups). Test-retest reliability (data collection with a difference of three weeks) was r = .92.
Attitudes towards future practice scale
This questionnaire was also designed by the investigators and describes attitudes towards the expansion of the scope of practice in the future. The questionnaire is based on that of Brodsky and Van Dijk (2008). The original questionnaire was distributed to nurses and physicians and described attitudes towards the introduction of the advanced practice role. The current questionnaire is addressed only to nurses with post-basic certification, and several additional items were added that were relevant to the current population. The questionnaire asks respondents to describe on a Likert scale from 1 (strongly disagree) to 6 (strongly agree) their level of agreement with 15 items. The questionnaire includes items such as what is the nurse's agreement with expanding their scope of practice to include prescriptive authority or whether they agree that further expansion of their scope of practice will improve their quality of patient care. Scores can range from 15 to 90, with higher scores indicating more positive attitudes towards increasing the extent of scope of practice in the future. The questionnaire was sent to five content experts (five nurses with expertise in policy and administrative issues related to scope of practice and advanced practice) to evaluate its content validity. Only minor changes were requested in the questionnaire. Cronbach's α reliability was .92 and test-retest reliability (data collection with a difference of three weeks) was r = .99.Practice behavior scale
This tool is a 30-item, Likert type questionnaire designed to measure professional autonomy (Dempster, 1990). The questionnaire is divided into four sections: readiness (11 items), empowerment (7 items), actualization (9 items), and valuation (3 items). Items are rated on a scale from 1 (not at all) to 5 (strongly agree). Final scores range from 30 to 150, with higher scores demonstrating higher levels of autonomy.Written permission was granted by the author of the questionnaire for its use and translation into Hebrew. The Brislin method (1970) was used for forward and back translation. Cronbach's α for the entire scale was found to be .90, with subscale scores ranging from .69 to .85.
Practice self-efficacy scale
Self-efficacy is a concept that must be measured within a specific context; therefore, this scale was designed by the authors for this study. The scale consists of nine items that measure efficacy expectations, a type of self-efficacy. Each item measures the level to which the respondent feels he or she is able to perform a specific nursing practice. For example, “I think that I am able to interpret x-ray reports (after instruction) in an acceptable, safe and efficient manner.” Items are measured on a Likert scale from 1 (strongly disagree) to 4 (strongly agree). Higher scores indicate higher levels of efficacy expectations for the specific practice.The questionnaire was sent to five content experts (five nurses with expertise in policy and administrative issues related to scope of practice and advanced practice) to evaluate its content validity. Cronbach's α reliability was found to be .89, while test-retest reliability (3 weeks apart) was r = .99.
Data Collection
After institutional ethical approval, the investigators received approval from the nurse managers to collect data. Some nurse managers preferred that data be collected during a staff meeting. A brief explanation was given about the study, and then nurses were asked to complete the questionnaire while one of the investigators was present to answer any questions. On other units, questionnaires were individually distributed. Questionnaires were returned to a closed envelope.Ethical Issues
The study was approved by the ethics boards of both institutions. Questionnaires were anonymous and were distributed and stored according to the local ethics board regulations.Statistical Analysis
Descriptive statistics were used to describe the sample and results of the questionnaires. This included mean, standard deviation, and frequency data. Associations between variables were assessed using Pearson product moment correlations. Two regression models were designed. The predictor variables for both models were professional autonomy, self-efficacy, age, sex, years of experience as a nurse, years worked on the current unit, nursing education, role, and type of post-basic certification. The criterion variable for the first model was current implementation of scope of practice while future implementation of scope of practice was used for the second model.Results
Questionnaires were distributed to 207 nurses from 13 units in two institutions, and 145 were returned (70% response rate). The mean age of nurse participants was 43 years, with a mean of 16 years as a nurse and 10 years working on the current unit. Most nurses were women (n = 131, 90%) with an academic education (BA or MA; n = 88, 61%). For further demographic data, see Table 2.| Demographic characteristics | Work characteristics | ||||
|---|---|---|---|---|---|
| Variable | n | Result | Variable | n | Result |
Note
| |||||
| Age (years) | 141 | M = 42.7 | Experience as RN | 144 | M = 15.8 |
| SD = 9.7 | SD = 9.2 | ||||
| Range = 26–66 | Range = 2 – 43 | ||||
| Missing: 4 | Missing: 1 | ||||
| Sex | 145 | Female: 131 (90.3%) | Experience on current unit | 143 | M = 9.9 |
| Male: 14 (9.7%) | SD = 7.6 | ||||
| Range = 1–36 | |||||
| Missing: 2 | |||||
| Family status | 143 | Married: 109 (76.2%) | Years since post-basic | 140 | M = 10.6 |
| Single: 24 (16.8%) | certification | SD = 8.6 | |||
| Divorced: 9 (6.3%) | Range = 1–36 | ||||
| Other: 1 (0.7%) | |||||
| Missing: 2 | |||||
| Religion | 144 | Jewish: 131 (90.3%) | Type of certification | 145 | Neonatal/Pediatric ICU: 47 (32.4%) |
| Muslim: 9 (6.3%) | Midwifery: 37 (25.5%) | ||||
| Christian: 3 (2.7%) | Adult ICU: 30 (20.7%) | ||||
| Other: 1 (0.7%) | Emergency: 18 (12.4%) | ||||
| Missing: 1 | Oncology: 13 (9.0%) | ||||
| Place of birth | 140 | Israel: 87 (62.1%) | Nursing education | 144 | BA in nursing: 68 (46.9%) |
| Eastern Europe: 39 (27.9%) | MA in nursing: 20 (13.8%) | ||||
| Americas: 8 (5.7%) | MA in other field: 19 (13.1%) | ||||
| Western Europe: 4 (2.9%) | RN: 19 (13.1%) | ||||
| Africa: 2 (1.4%) | BA in other field: 18 (12.4%) | ||||
| Missing: 5 | |||||
| Role | 145 | Staff nurse: 38 (26.2%) | |||
| Senior nurse: 88 (60.7%) | |||||
| Nurse administratoror | |||||
| manager: 19 (13.1%) | |||||
| Type of certification, M (SD) | |||||
|---|---|---|---|---|---|
| Adult | Neonatal/pediatric | Emergency | Oncology | Labor and | |
| Practice | ICU (n = 30) | ICU (n = 47) | (n = 18) | (n = 13) | delivery (n = 37) |
Note
| |||||
| Handheld defibrillation | 2.5 (1.3) | 2.3(1.4) | |||
| Attach pacemaker electrodes and set heart rate | 2.5 (1.3) | 2.6(1.4) | |||
| Set ventilator settings for weaning | 4.0 (1.2) | 1.8(1.2) | 1.6(0.9) | ||
| Connect and disconnect patient to ventilator | 4.6 (0.6) | 4.0(1.5) | 3.6(1.1) | 1.0(0.0) | |
| Insertion of arterial line | 1.2(0.8) | ||||
| Removal of arterial line | 4.7 (0.6) | 3.9(1.5) | 1.5(1.2) | 1.0(0.0) | 1.1(0.7) |
| Draw blood from an arterial line | 4.6 (1.0) | 4.7(0.5) | 1.4(1.0) | 1.3(1.1) | 1.0(1.3) |
| Administer drugs IV push | 4.6 (1.0) | 4.6(0.8) | 3.0(1.6) | 3.8(1.3) | 2.0(1.3) |
| Administer drugs IV push to central line | 4.4 (1.2) | 4.3(1.0) | 1.8(1.4) | 3.7(1.4) | 1.1(0.7) |
| Draw blood for type and cross-matching | 3.5 (1.7) | 3.0(1.7) | 1.6(1.3) | 4.4(1.2) | 4.8(0.9) |
| Care of a Swan-Ganz catheter | 2.7 (1.6) | 1.1(0.5) | |||
| Blood drawing for laboratory tests, including arterial blood gases | 4.7 (0.8) | ||||
| Drawing of mixed-venous blood from a Swan-Ganz catheter | 1.8 (1.2) | ||||
| Draw peripheral arterial blood from a newborn | √ (up to 1 year old) | ||||
| Insert peripheral IV to newborn | 3.4(1.6) | √ (up to 1 year old) | |||
| Draw venous blood from newborn peripheral vein | 2.6(1.6) | √ | |||
| Insert peripheral venous line on the scalp and legs of newborn | 3.0(1.6) | ||||
The mean score for future implementation of extended scope of practice was 4.4 (SD = 1.0) (possible range 1–6). Highest scores were for referral to laboratory tests and their interpretation (M = 4.9, SD = 1.0) and prescriptive authority based on standardized protocols (M = 4.7, SD = 1.3). Nurses thought that extending the scope of practice was important (M = 4.8, SD = 1.4), would improve nursing care (M = 4.7, SD = 1.4), and would improve the overall quality of care (M = 4.6, SD = 1.2).
The mean level of professional autonomy was 118.8 (SD = 12.5; range: 81–145). Highest scores were the in the subscale of actualization (M = 4.4, SD = 0.5), followed by valuation (M = 4.2, SD = 0.6), readiness (M = 4.0, SD = 0.5), and empowerment (M = 3.4, SD = 0.6). No statistically significant differences were found between the different types of post-basic certification on professional autonomy or its subscales.
The mean level of self-efficacy was 3.1 (SD = 0.7; possible range: 1–4). Most nurses felt able to extend their current scope of practice (n = 86, 59%), prescribe medications (n = 103, 71%), or refer patients for laboratory tests and interpret them (n = 85, 59%). No statistically significant differences were found between the different types of post-basic certification on levels of self-efficacy.
No statistically significant associations were found between the current level of implementation of scope of practice and future levels of implementation of extended scope of practice, self-efficacy, or professional autonomy for the entire sample. However, statistically significant associations were found between current implementation of scope of practice and professional autonomy among nurses with ICU post-basic certification (r = .37, p ≤ .05) and pediatric ICU certification (r = .36, p ≤ .05). Statistically significant associations were found between future implementation of extended scope of practice and professional autonomy (r = .36, p ≤ .01) and self-efficacy (r = .75, p ≤ .01).
The majority of the shared variance in the scores for current implementation of the scope of practice (68%) was found to be significantly predicted by a model including future levels of implementation, professional autonomy, self-efficacy, and demographic variables, F(17,120) = 18.3, p ≤ .01. Only current role and type of post-basic certification were found to be significant predictors, where those in administrative roles and nurses with pediatric and ICU post-basic certifications were found to have higher levels of implementation. Other demographic and work characteristics were not found to be statistically significant predictors in the model. A similar model was built with future implementation of scope of practice as the criterion variable. This model was also found to be statistically significant, F(17,120) = 11.0, p ≤ .01, explaining 56% of the shared variance, with the variables of self-efficacy and actualization of professional autonomy statistically significant predictors. Increased levels of self-efficacy and actualization predicted higher levels of future implementation. Demographic and work characteristics were not found to be statistically significant predictors in the model.
Discussion
The nurses in this study demonstrated a wide range of implementation of the extent of their scope of practice. However, the overall mean was low to moderate, where those in the adult ICUs had a moderate-high level, pediatric ICU and oncology a moderate level, and emergency and labor and delivery a low level of implementation of the full extent of the scope of practice. It was also found that nurses had positive attitudes towards increased scope of practice expansion. Participants demonstrated a high level of self-efficacy, indicating a high ability and readiness to take on expanded practices. In addition, the participants had high levels of professional autonomy that were positively associated with attitudes towards scope of practice expansion. These results point to the readiness of nurses to expand their scope of practice.Two primary reasons were given as to why nurses do not implement the full extent of their scope of practice. The first was lack of relevance of many of the practices to the work environment. For example, nurses working in labor and delivery or oncology have little or no reason to remove an arterial line, while almost all nurses take blood for type and cross-match. Similar results were reported by Kilpatrick et al. (2012), who found a low level of implementation among nurse practitioners for those practices that were uncommon (e.g., using defibrillators).
The second reason was the lack of permission to perform the practice by supervisors or institutional policy, where approximately one quarter of the sample described this as the reason they did not practice to the full extent of their authority. Few nurses cited lack of knowledge or time.
Nurses in this study had very positive attitudes towards expanded scope of practice, as was found in other studies (Brodsky & Van Dijk, 2008; Goldberg et al., 2012). Participants also had high levels of professional autonomy, irrespective of the type of certification. These results are also similar to findings in other studies (Cajulis & Fitzpatrick, 2007). Nurses showed high levels of self-efficacy, again without differences between types of certification. This demonstrated an across-the-board readiness and support of nurses in the field for the expansion of their scope of practice. According to Bandura (1982), this is related to a successful completion of these practices. For example, nurses in this study expressed a willingness and readiness to have prescriptive authority or referral of patients to laboratory tests, roles associated with advanced practice.
No statistically significant associations were found with current levels of implementation. These consistent results imply that predominantly external forces as opposed to internal forces seem to be related to a lack of implementation of the full extent of the scope of practice. Others have found a significant relationship between professional autonomy and implementation of scope of practice (Kilpatrick et al., 2012). One possible explanation is the differences in the healthcare systems, culture, and policies of the two countries where the research was conducted. Others have also found that as levels of professional autonomy increase, there are more positive attitudes towards expansion of scope of practice (Goldberg et al., 2012).
Two variables were found to predict the extent of implementation of the scope of practice: role and type of certification. Like Brodsky and Van Dijk (2008), those in administrative positions were more likely to have implemented their scope of practice. Such nurses are also more likely to have a higher level of commitment, levels of self-confidence, knowledge, and training. ICU nurses were also found to have higher levels of implementation. This result is consistent with the findings listed earlier that described an increased relevance of expanded practices to those who work in critical care as opposed to maternity or oncology.
Two other variables were found to positively predict future implementation: self-efficacy and actualization (a subscale of professional autonomy). While no study was found that can be related to these findings, they are consistent with Bandura's self-efficacy theory, where the higher the level of personal feelings of authority and responsibility, the higher the feeling that one is able to perform the practice and wants to perform it in the future.
It is recommended that further studies be conducted in other countries on registered nurses with different forms of education. Other factors and barriers to current and future implementation of full scope of practice such as peer and interprofessional relationships should also be investigated.
The results of this study demonstrate that nurses with post-basic certification feel willing and able to expand their scope of practice to areas associated with advanced practice. Therefore, policymakers should take advantage of this fact and promote the introduction of advanced practice in these clinical areas. Administrators and policymakers should also investigate what are the specific factors associated with administrative barriers to expanding nursing scope of practice as well as matching the expanded practices with the specific work environment.
Limitations
This study contains several limitations. First, it was conducted in only one country and in two institutions. Second, most of the questionnaires used in the study were designed by the authors. Almost all of the reliability and validity scores were within acceptable levels, except for the current level of implementation of scope of practice among labor and delivery nurses. It is possible that this score has a lower internal consistency because of the great variation in current practices across units or because most nurses did not implement most of the practices. In addition, one of the questionnaires was translated into Hebrew. While the translation was validated, there might be cultural and language differences between the two versions of the questionnaire. The response rate was 70%, which also might have led to a bias in the results. Results of this study were based on self-report, and there were no “objective” means of data collection to determine whether nurses practiced to the full extent of their scope of practice. It is also possible that other factors and barriers could be associated with implementation, such as interprofessional relationships, the work environment, or other personal characteristics, that were not investigated. Several comparisons between clinical areas were found to be statistically significant. However, it should be noted that some of the areas contained a small number of nurses, and so conclusions based on the data should be taken with caution.Conclusions
Nurses wanted to practice to the full extent of their scope of practice and felt able to do so but were hindered by administrative barriers. Therefore, it is recommended that efforts continue to expand the scope of practice for registered nurses, that factors associated with administrative barriers be investigated and eliminated, and that further research be conducted with other nurses and in other countries to determine what factors are associated with the implementation of the full scope of practice.Clinical Resources
- •American Nurses Association. Scope of practice: http://www.nursingworld.org/EspeciallyForYou/AdvancedPracticeNurses/Scope-of-Practice-2
- •Nursing Council of New Zealand. Scopes of practice: http://www.nursingcouncil.org.nz/Nurses/Scopes-of-practice
- •Nursing and Midwifery Board of Australia. Fact sheet: Contest of practice for registered nurses and midwives: http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/FAQ/Context-of-practice-for-registered-nurses-and-midwives.aspx
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