Scope of Nursing

Practice and Decision-

Making Framework
TOOLKIT

ICN Regulation Series

ICN Regulation Series

Scope of Nursing Practice and

Decision-Making Framework
TOOLKIT

Developed by Anne Morrison

Consultant Nursing and Health Policy
International Council of Nurses
All rights, including translation into other languages, reserved. No part of this
publication may be reproduced in print, by photostatic means or in any other manner, or
stored in a retrieval system, or transmitted in any form, or sold without the express
written permission of the International Council of Nurses. Short excerpts (under 300
words) may be reproduced without authorisation, on condition that the source is
indicated.

Copyright © 2010 by ICN - International Council of Nurses,

3, place Jean-Marteau, 1201 Geneva, Switzerland

ISBN : 978-92-95094-33-8

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Table of Contents

About the author 4

Introduction 5

CHAPTER 1
From legislation to regulation 7

CHAPTER 2
Scope of practice: approaches, definitions & key concepts 13

CHAPTER 3
Factors which influence scope of practice 19

CHAPTER 4
Decision-making frameworks 23

CHAPTER 5
Delegation & supervision, & enhancing the use of decision-making frameworks. 29

CHAPTER 6
Analytical tools 35

CHAPTER 7
Managing change & conflict 43

CHAPTER 8
Implementation 49

CHAPTER 9
Conclusion 51

Additional reading 53

References 55

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About the author

Anne Morrison RN, RM, BSc, BEdSt, MBA, FRCNA, MAICD

Anne Morrison is an ICN Consultant in Nursing and Health Policy whose prime
responsibilities relate to the development and management of ICN’s Regulation Programme.
Anne specialises in regulation, licensing and education, women and children’s health. Anne
also manages ICN’s international continuing education credits (ICNECS) and the ICN
partnerships database (ICNP) and coordinates a number of ICN Networks.

Anne has experience in nursing and midwifery clinical practice, education and professional
regulation in both Scotland and Australia.

Anne has held a number of senior roles including the Executive Officer of the Queensland
Nursing Council and Chairperson of the Australian Nursing and Midwifery Council.

In 2010, Anne will take up the position as the inaugural Executive Officer, Nursing and
Midwifery Board of Australia.

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Introduction
Since its inception, the International Council of Nurses (ICN) has held a clear position about
the importance of regulation in assuring safe and competent nursing practice in order to
protect the public. The way in which the scope of nursing practice is defined, outlines the
very parameters and boundaries within which nurses practice. It is vital that the profession
is able to clearly articulate its practice parameters in order to ensure that nursing practice
can accommodate and respond to the current needs of society. Otherwise there is a risk
that practice may become restricted and constrained, thereby leaving needs unmet or care
delivery fragmented.

Nurses today work in a dynamic health care environment. Their roles and functions are
constantly evolving and changing to meet patient needs as well as incorporating service
needs such as workforce shortages, skill mix issues and budget constraints. If nurses are
not supported in making scope of practice decisions, this has the potential to impact
negatively on both the quality of patient care and the profession of nursing.

This Toolkit is part of a learning package that describes the policy framework, relevant
concepts, key stakeholders and processes fundamental to any discussion, development and
implementation of the scope of nursing practice in any country or jurisdiction.

Within any nurse regulatory system it should be evident that the nurse is both responsible
and accountable for their breadth of nursing practice. The move globally to acknowledging
an individual nurse’s professional accountability to determine their own scope of practice is
reflected in the increasing development and use of decision-making tools to assist in the
process.

The Toolkit therefore also describes the key components of decision-making frameworks1
and tools and provides examples currently in use around the world.

Questions or exercises appear next to the symbol:

Key points to consider are shown with the following symbol:

1
The term decision-making framework used in this document refers to any framework, tool, trees or
flowchart used to inform nurses’ decision-making.

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Structure of the Toolkit
There are two parts to the Toolkit: 1) this workbook; and 2) an accompanying power point
presentation.

The module content

There are nine chapters covering the following:

1. From legislation to regulation
2. Scope of practice: approaches, definitions and key concepts
3. Factors which influence scope of practice
4. Decision-making frameworks
5. Delegation and supervision, and enhancing the use of decision-making frameworks
6. Analytical tools
7. Managing change and conflict
8. Implementation
9. Conclusion

Providing feedback
ICN believes that regulation is extremely important; both in terms of the care and services
that are delivered to the public and the way we practise. Health systems are constantly
changing and, as a result, regulation must also change. ICN welcomes feedback on how
useful you find this material and any suggestions you may have for improvement.

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Chapter 1
From legislation to regulation

Government role in health care

Health is a basic human need and a social right, not simply a market commodity. This
commitment places significant obligations and responsibilities on governments, who around
the world, through their ministries of health and related agencies, have an important role to
play in health care. Their role is in strengthening the health systems as well as the
generation of human, financial, physical, technical and other resources. These efforts
support health systems to achieve their goals of improving health, addressing access to
health care, securing adequate financing and responding to their population needs.

However, over the past few decades, changes in the global and health care environment
have impacted significantly and led to a repositioning of the government’s role in both health
and social care. As market forces have been inadequate in addressing the health needs of
populations, some governments are assuming more responsibility in improving both equity
and efficiency in terms of health service delivery (WHO-EMRO 2006).

In addition, the health professions are dealing with better informed patients and public.
Patients are demanding improved access to services, many of which are expensive and
whether in the high income or low income countries, governments are finding it difficult to
meet these ever-increasing demands. Health professionals are constantly being asked to
find more efficient and effective ways to deliver their services.

Such economic pressures are leading to excessive workloads, inadequate supervision, lack
of supplies and other resources. These can place the patient at risk and place nurses in
situations where their ability to deliver care in accordance with their scope of practice and
code of conduct may be compromised.

Governments have a central role in providing for the health of their citizens. They are
responsible for the planning and development of the health care workforce to ensure its
capability and capacity to meet both current and future needs. Governments are also
responsible for public policy in relation to health care priorities and resources. On that basis,
governments should be encouraged to guarantee the nursing profession’s access to and
engagement in policy development processes. These obligations can be met in part through
the creation of independent regulatory bodies free from government interference and
facilitating public participation in regulation.

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Nursing legislation
Government’s primary role in professional nursing regulation is in establishing appropriate
legislation. Statutory regulation should be designed such that it promotes nursing’s ability to
respond to societal needs and supports nursing’s role in health care services and in meeting
national and international health-related objectives.

Legislation may be used as a means to empower or constrain nursing practice. An

understanding of the processes involved in the preparation of legislation is vital in order to
have real influence over its outcome. Although it may be the lawyers representing the
government health department who will be responsible for turning the policy objective into
the necessary legislation, it is essential, however, that identified representatives from the
nursing profession work with the legal drafters to ensure that the end result actually meets its
original policy objectives (ICN 2007).

All activity relating to the preparation of legislation should start with a very clear sense of
purpose of the role of nursing and nurses within the health care framework. The contribution
that nurses and nursing can bring to the organisation and delivery of health care in the
society concerned must be clearly articulated. Any legislation supporting nursing and its
activities needs to be preceded and underpinned by a philosophical and conceptual
discussion about the nature of nursing practice and the role of the nurse in the
country/jurisdiction in question.

The nursing profession may be regulated through a number of different mechanisms.

Statutes, laws, decrees or ordinances constitute the highest level (for consistency the word
‘legislation’ will be used). Having established the legislation, secondary legislation in the
form of rules and/or regulations can be issued. This is followed by the interpretation and
implementation of both the law and the rules and regulations.

So, while primary and secondary nursing legislation generally establish the highest levels of
regulation within a country, it is the administration of these laws that is the responsibility of
the nursing council (or board). The council through its interpretation and implementation of
the legislation establishes policies and procedures which inform both the profession and the
public of expected education, practice, conduct and registration standards.

The following table summarises the purpose of the various levels as well as the body with
the relevant authority.

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 Type of Regulation Purpose Authority
One Trans-national agreements To provide common Regional Parliament
legal approach across National Parliaments
countries
Two Statute To provide statutory Parliament
Law authority for the President
Ordnance profession Minister
Decree Emir
Three Rules and regulations To further amplify the Minister Nursing
law Council
Four Interpretation and To put the content into Nursing Council
implementation specific guidelines Other delegated
To apply the law, rules authority
and regulations
Five Voluntary codes, position To give direction and Professional
statements, standards and provide a peer agreed associations
competency frameworks bench mark against Specialist interest
which the profession groups
can be judged
(ICN 2007)

It is important to note that each of these five levels of regulation offers differing degrees of
flexibility. Level one requires the existence of global or regional trade agreements. Level
two requires an act of parliament. Since the development and passage of the act into law
frequently requires considerable parliamentary time, achieving and amending this level of
regulation can be a challenging and lengthy activity. Rules and regulations are easier to
pass but do not afford the same level of authority and thus protection. The issuance of
guidance is the most flexible and the easiest to change. For professions at an early stage in
their development, the drafting of voluntary codes, position statements, standards and
competency frameworks can often provide an initial step towards bringing order to practice.

Review the ICN Model Act and Toolkit for information and guidance on
the development and implementation of legislation to regulate the
nursing profession.

Describe the current situation in your country.

Nursing Regulation
The purpose of statutory regulation is to ensure safe and competent care is provided by
practitioners who are accountable for their own practice. For best patient outcomes,
governments should ensure that any legislative development or review supports
achievement of the regulatory objectives.

In 1985, the ICN Report on the Regulation of Nursing noted:

What is nursing’s rightful scope of practice? How can the law be
reconciled with practicality? Too often...the law is at odds with practice.
The data from the studies revealed numerous examples of nurses being
legally constrained far short of their ability and the public need.

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Twenty five years later, these statements continue to be relevant. The drafting of new
legislation or the amendment of existing legislation often lags well behind the competencies
of nurses and the demands on practice resulting from the changing health care environment.
It is critical that nurses are supported and enabled to work within their capabilities.

Clearly defined boundaries which act to separate rather than define the practice of health
professions do not serve in the public interest. They are restrictive in that they impede the
nursing profession’s ability to evolve and respond to changing health care demands and
priorities. In today’s rapidly evolving health care environment, it is important to acknowledge
that nurses require an ability to incorporate new knowledge and skills into their practice. In
order to achieve this, they must be supported to continually renew and expand their
knowledge, skills and experiences (ICN 1998).

An example of how this flexibility and responsiveness can be achieved in legislation is found
in the Singapore Nurses and Midwives Act (2000). This sets out the functions of the Board.
In relation to scope of practice it states:

Functions of Board

8. The functions of the Board are —....

(e) to regulate the standards and scope of practice of registered nurses, enrolled
nurses and registered midwives;

This is a broad and flexible approach that empowers the Board to make changes in step with
patient need and health systems reform.

Regulatory frameworks should therefore allow for opportunities and innovations in practice
and not impose inappropriate practice restrictions or fail to acknowledge shared
competencies between differing health professional groups.

ICN’s position on regulation provides 12 principles which serve as a

fundamental guide to the development of professional regulation across
diverse legal, cultural and developmental settings.

The principles relate to purposefulness, relevance, definition, professional ultimacy, multiple

interests and responsibilities, representational balance, professional optimacy, flexibility,
efficiency and congruence, universality, fairness and inter-professional equality and
compatibility. For a detailed and contemporary explanation of the principles, please refer to
the ICN publication, Regulation 2020: Exploration of the present; vision for the future (ICN
2009a).

These principles offer an approach to regulation in very diverse legal, cultural and
developmental settings. Such a principle based approach is increasingly common in the
broader professional and economic environment as a number of governments throughout the

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world adopt this as a means to describe their own framework for wider regulation and its
reform. For example, the Better Regulation Taskforce of the United Kingdom, the
Productivity Commission in Australia, the Towards Better Regulation initiative in Ireland and
the Organisation for Economic and Co-operative Development (OECD) have all developed
principles for regulation. These initiatives endeavour to balance protection of the public
whilst seeking to reduce bureaucracy and stimulate efficiency and competition in dynamic
environments.

For further information and examples of these principles based approaches refer to
Chapter 8.

Consider how each of ICN’s 12 principles guiding the development of

professional regulation may be used to ensure a regulatory
framework supports opportunities and innovations in practice and at
the same time not imposing inappropriate practice restrictions.

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12
Chapter 2

Scope of practice: approaches, definitions and

key concepts

Permissive and restrictive approaches

Before exploring the key concepts and various definitions of scope of nursing practice used
around the world, it is important to note that these definitions are influenced by the approach
taken in describing scope of practice.

There are two main approaches to describing scope of practice:

permissive and restrictive.

• Restrictive approaches define and protect professional boundaries.

• Permissive or client/patient focused approaches are where client needs are considered
paramount (Chiarella 2002).

Restrictive approaches describe and impose limitations on aspects of practice (NNNET

2005). This approach provides clarity and protection for nurses, employers and the public by
defining the boundaries and limitations of practice. Restrictive approaches frequently list
those activities that may only be performed by nurses or which nurses must be credentialed
to perform. Such lists of approved activities risk becoming out of touch with contemporary
practice very quickly. In addition, this specificity raises the risk that the activities will be
viewed as the limit of a nurse’s capability and therefore opportunities for expansion of
practice are lost. For this reason, nurses often oppose any attempts to define the limits of
their work especially in the current climate of rapid change when new needs and situations
arise.

In Ontario, Canada, the scope of practice model is set out in the Regulated Health
Professions Act (1991) and consists of two elements: a scope of practice statement and a
series of authorized or controlled acts. In the following box is an extract from a reference
document titled Legislation and Regulation RHPA: Scope of Practice, Controlled Acts Model
(CNO 2009) which details the Controlled acts authorized to nursing.

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 Controlled acts authorised to nursing

Nursing is authorised to perform three of the 13 controlled acts. They are:

1. Performing a prescribed procedure below the dermis or a mucous membrane.

2. Administering a substance by injection or inhalation.
3. Putting an instrument, hand or finger
- beyond the external ear canal;
- beyond the point in the nasal passages where they normally narrow;
- beyond the larynx;
- beyond the opening of the urethra;
- beyond the labia majora;
- beyond the anal verge, or
- into an artificial opening into the body.

A registered nurse (RN) or registered practical nurse (RPN) may perform a

procedure within the controlled acts authorised to nursing:
• if it is ordered by a physician, dentist, chiropodist, midwife or nurse practitioner
(NP); or
• if it is initiated by an RN in accordance with conditions identified in regulation.
(CNO 2009)

Permissive approaches are less prescriptive and do not define boundaries around scope
of practice. This approach clearly transfers the responsibility and accountability for
professional practice from the regulatory body to the individual practitioner and also to the
employer (NNNET 2005). It facilitates the evolution of practice.

An example of this approach is provided by An Bord Altranais (2000) which describes the
scope of nursing/midwifery practice as:

...the range of roles, functions, responsibilities and activities, which a

registered nurse/midwife is educated, competent, and has authority to
perform in the context of a definition of nursing/midwifery.

In 1985, the ICN Report on the Regulation of Nursing noted:

The scope of practice regulations define nursing and outline the very
boundaries within which nurses operate. They may free them to act to the
limit of their judgement and ability, or restrict them to various procedures
prescribed and supervised by others.

However, even within permissive approaches there are sometimes restricted acts.

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 Review the legislation governing nursing practice within your
jurisdiction and try to identify: any restricted or controlled acts; or
approaches that provide flexibility and permissive powers.

Defining scope of nursing practice

Descriptions of scope of nursing practice are therefore influenced by whether the approach
taken is restrictive or permissive. However, a number of other factors can be seen to
influence the way in which scope of nursing practice evolves and is ultimately defined.
These factors, which are discussed in Chapter Three, may include amongst other things the
historical/traditional role of the nurse; workforce issues; the relationship between nursing and
other health care professions; public need, demand and expectation; as well as
organisational policies.

However, as with many other aspects of regulation, there are differing views and
understandings surrounding its terminology (e.g. expanded, advanced and specialist
practice). This lack of consistency in approaches to regulating scopes of practice is in part
due to different definitions and understanding of what constitutes scope of practice.

The ICN Position Statement on Scope of Nursing Practice states:

The scope of practice is not limited to specific tasks, functions or

responsibilities but includes direct care giving and evaluation of its impact,
advocating for patients and for health, supervising and delegating to others,
leading, managing, teaching, undertaking research and developing health
policy for health care systems. Furthermore, as the scope of practice is
dynamic and responsive to health needs, development of knowledge, and
technological advances, periodic review is required to ensure that it
continues to be consistent with current health needs and supports improved
health outcomes.
(ICN 1998, revised 2004)

This position statement also highlights the importance of establishing a scope of practice
definition as it communicates to all stakeholders the competencies and accountability of the
nurse while also accommodating change.

Scope of practice descriptions and definitions for the nursing profession generally address
the same elements. For example:

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 A profession’s scope of practice is the full spectrum of roles, functions,
responsibilities, activities and decision-making capacity which individuals within
the profession are educated, competent and authorised to perform. The scope of
professional practice is set by legislation; professional standards such as
competency standards, codes of ethics, conduct and practice; and public need,
demand and expectation. It may therefore be broader than that of any individual
within the profession.

The actual scope of an individual’s practice is influenced by the:

• context in which they practise;
• consumers’ health needs;
• level of competence, education, qualifications and experience of the individual
service provider’s policy, quality and risk, management framework and
organisational culture.
(ANMC 2007)

STANDARD ONE

Nurses/midwives work within their defined professional scope of practice.

RATIONALE
Nursing / midwifery practice aims to prevent illness, restore health and rehabilitate
the injured or infirm through health promotion activities and evidence-based
practice in primary, secondary and tertiary care. The activities include:

• monitoring and assessment of the health status and needs of clients;

• nursing interventions such as the administration of medication and treatment;
and
• counselling and health education of individuals or groups.

The scope of nursing/midwifery practice refers to the range of activities and

clinical decisions in nursing / midwifery practice that each nurse/midwife is trained
and authorised by licence to perform independently and the performance of which
the nurse/midwife is accountable for. It is determined by the nurse/midwife's
professional qualifications, competencies, and clinical role. It may be expanded to
include new skills and responsibilities to keep abreast of advances in medical
science and technology, innovations in treatment modalities and changes in the
health needs of the population.
(Singapore Nursing Board 1999)

Key concepts
The scope of nursing practice therefore communicates the roles, competencies, professional
accountabilities and responsibilities of the nurse. It provides the foundation for establishing
standards of nursing practice, nursing education, nursing roles and responsibilities and also
communicates to the public the characteristics of who is qualified to provide particular
nursing services.

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However, we need to clarify some of the concepts referred to in the definitions above. This
is important because the often inconsistent use of terms associated with regulatory concepts
means that we cannot assume the terms referred to in this document are used in the same
way in all jurisdictions.

These inconsistencies have frequently arisen through differing legal traditions and historical
experiences which have led to both subtle and distinct differences. It is essential that across
jurisdictions, all stakeholders have a common understanding of regulatory terminology. For
further clarification on regulatory terminology, ICN’s Lexicon of key regulatory terms (ICN
2009b) seeks to provide a common language when describing regulation.

The terms competence, accountability and responsibility are often referred to when
discussing professional nursing practice and are defined as follows:

Competence refers to the effective application of a combination of knowledge, skill and

judgement demonstrated by an individual in daily practice or job performance. In nursing
definitions, there is wide-ranging agreement that, in the performance of nursing roles to the
standards required in employment, competence reflects the following:
• knowledge, understanding and judgement;
• a range of skills ― cognitive, technical or psychomotor and interpersonal; and a range of
personal attributes and attitudes.

Accountability refers to the individual nurse being responsible and answerable for their own
or others’ actions or inactions. This acknowledges a nurse's legal liability for his/her actions.
It therefore implies that the outcomes of the nurse’s actions will be judged against some
criteria.

Responsibility refers to a nurse’s obligation to perform competently at an acceptable level,

the level to which the person has been educated. Responsibility means that a person has
an obligation or duty to perform a role or function to an expected standard.

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18
Chapter 3
Factors which influence scope of practice
There are many factors constantly shaping and influencing nursing’s scope of practice.
These factors can be described in terms of political, social and environmental issues,
economics and trade, legal traditions, the health care system and cultural norms.

Contextual factors such as the increasing specialisation and diversity of practice settings,
increasing patient acuity in all health and social care facilities (particularly aged care
settings) have also advanced and expanded nursing practice. In addition, the expected
competencies both across and within health professions have also blurred understandings of
traditional roles (NNNET 2005).

A number of these factors are discussed below.

Health workforce shortages

What differentiates the current shortage from the temporary and fixable shortages of the past
is the increasing demand occurring at the same time as an ever decreasing supply of
nurses. The demand is driven by an ageing population with complex care needs and an
escalating incidence of chronic disease. On the other hand, the supply of nurses is affected
by an ageing workforce, inadequate funding for nurse education and a falling birth rate in
many parts of the world. Not only is there a global shortage of nurses but to meet the
growing demand for care requires recruitment into health care professions which are
experiencing significant competition from other workforce sectors. This means that there is
a danger of fewer people choosing to work in the health sector and more specifically in
nursing.

Workforce planning
Governments in all countries have an important role to play in the planning and provision of
health care, including the development of the health workforce. However, the ability to
achieve this is constrained by an increasingly complex, fragmented and technologically
driven environment in which competition and cost containment must be balanced against
access, acceptable standards of care and patient safety.

In many countries, workforce shortages mean that nurses are undertaking tasks and
activities which they have not been educated to perform nor assessed as competent against
any agreed standard. In addition, these activities often lie outside the nursing and other
legislation and are therefore unlawful. In some situations these activities are being
undertaking at the direction of the employer and / or government. Whilst the nurse may be
practising at an advanced level, the ability to assure the public that they are receiving safe
and competent care demands significant attention.

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Task shifting
As a result of this fast changing and high cost health care environment, there is much
overlap of health and social care roles as well as increased demand for value for money
services. This demand is set to continue and increase given the ageing population and
increasing incidence of chronic disease. The response, seen already in the midst of the
global health human resources crisis, is the use of less skilled workers and task shifting from
the more educated to the less educated, and from specialists to generalists.

New cadres
However, this increase in task shifting and introduction of new cadres of worker are serving
to increase the casualization of the regulated nursing workforce and the number of
unregulated health care workers. Regulations for these health workers and for task-shifting
need to be set with the professions involved and it should be clearly identified who is
responsible for their supervision. Curriculum development, teaching, supervision and
assessment should always involve the health professionals from whom the task is being
shifted (WHPA 2008). This is particularly important if the most vulnerable and needy in our
society are to receive holistic rather than fragmented and partial care.

Technology and health care delivery

Information and communication technological advances are creating new opportunities for
local, national and international health care delivery. This is associated with new models of
interviewing, diagnosing, prescribing and facilitating treatment and care as well as evaluating
and offering follow-up. Telehealth and telenursing represent a new age in health care
delivery. Through the power of technology and interdisciplinary health professional
collaboration, telenursing is positioned to address current and emerging health system
challenges such as those related to ageing populations and chronic illnesses; community
and home based care; access problems related to geographical, social and financial
circumstances; increasing costs and reduced funding; and nursing shortages.

Consider how the following may influence nursing’s scope of

practice within your country:
• historical/traditional role of the nurse
• role of women in society
• relationship between nursing and other health care professions
• organisational policies
• technology
• disease burden and health needs
• finance

Summary
In Chapters 1 to 3, we have examined how legislation shapes regulation, the two main
approaches to describing scope of nursing practice, various definitions and key concepts as
well as influencing factors.

20
Therefore, describing and defining the scope of nursing practice:
• provides guidance to all stakeholders about role expectations of the nurse;
• is central to the regulatory framework governing nursing practice;
• informs the education and professional competency standards;
• may identify restricted or controlled acts; and
• informs health workforce policy planning and development processes.

However, how does the individual nurse, in the variety of contexts and settings in which
nurses practise, apply such a broad definition to their day to day practice? If nurses are self
regulating, what assistance is there to inform decisions about what activities, skills or tasks
lie within their own scope of practice?

The remainder of this Toolkit will address these questions. In the meantime consider the
following exercise.

Reflect on how the professions scope of nursing practice may have

changed recently within your country.
• What were the drivers for this change?
• What was the impact on nurses’ scope of practice?
• How did nurses determine whether they were competent to
include new activities within their scope of practice?

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22
Chapter 4
Decision-making frameworks
We have described scope of practice as occurring within a legislative framework and
communicating to others the roles, standards and accountability of the profession. A
number of factors which influence and shape scope of practice have also been described.
However, the scope of practice of the profession is generally described in much broader
terms than the scope of practice of an individual nurse. Nursing practice is dynamic and
subject to constant influence by the health care environment.

Decision-making frameworks are increasingly being used to assist the individual nurse to
make decisions about their own scope of practice.

What are decision-making frameworks?

Frameworks for decision-making about scopes of practice are tools that:

• support nurses to make informed decisions about the provision of safe and high quality
care in their everyday practice;

• facilitate the development of new practice roles;

• support professionalism in nursing, assisting nurses to manage change, regulate their

practice and clearly identify the parameters of their own practice;

• assist nurse regulatory authorities to achieve their obligation of protecting the public by
providing a consistent approach to informed decision-making by nurses in relation to
their practice; and

• assist service providers and policy makers to acknowledge the contribution of nurses in
the provision of current and future health services, and to work with nurses to effect
change.
(Adapted from ANMC 2006)

Who benefits?

Decision-making frameworks can assist nurses, employers,

consumers and government understand and navigate the maze of
complex and interdependent factors which influence the scope of
nursing practice.

In any discussion about regulation and scope of practice, we need to acknowledge that there
are a variety of stakeholders with a role to play in assuring high quality patient outcomes.

23
The complementarity and interdependent nature of each stakeholder group must be
recognised in what is an increasingly complex and adaptive system.

Nurses
Because legislation cannot possibly define every possible duty or function that a nurse is or
is not permitted to perform, professional decision-making frameworks provide guidance to
nurses when faced with new procedures, protocols and activities in their daily practice.

As well as assisting the individual nurse to make decisions about what activities fall within
their own scope of practice, decision-making frameworks also assist in making decisions
when delegating tasks to other nurses or unlicensed health care workers. These tools can
ensure that the person who is given the task to carry out is able to provide the care in a safe
and competent manner.

Patients/ Populations
Increasingly, nurses and other health professionals are dealing with better informed patients
and public. Patients and their families need to be assured that decisions nurses make about
their care will be of the highest standard. Any changes in a nurse’s scope of practice must
be primarily focused on meeting the patient’s and/or population’s needs.

Employers
A nurse’s scope of practice is defined under the nursing legislation. However, it may be that
the employer’s polices are more restrictive and do not allow a nurse to meet their full role
responsibilities in that health care facility or setting. An employer cannot expand a nurse’s
scope of practice outside the legislation.

As already noted, drafting and amending legislation is a costly, time-consuming process

which usually lags behind evolving scopes of practice. Decision-making frameworks can
therefore address the realities of evolving practice requirements and assist in reducing the
risk to patients of unsafe and unlawful practice.

Governments
While patients are demanding improved access to services, many governments are finding it
difficult to meet the ever-increasing needs of their public. Economic pressures on health
service delivery can lead to excessive workloads, inadequate supervision, lack of supplies
as well as low ratios of trained to untrained staff. These can place the patient at risk and
place nurses in situations where their ability to deliver care in accordance with their scope of
practice and code of conduct may be compromised.

Other health professionals

The nature of nursing practice continues to change with increasing recognition being given
to the existence of shared competencies across several health professions. When
individuals from different clinical backgrounds provide similar services, a challenging and
complex regulatory environment emerges. Decision-making frameworks can therefore
assist nurses in making a decision about whether to accept delegations from other health
professionals.

24
Elements of a decision-making framework
There are various decision-making frameworks in existence all of which share a number of
similarities. Generally they recognise that the scope of practice of an individual nurse is
influenced by the legal framework, their education and competence, experience and the
context in which they practise.

Another use of these tools is to assist in making decisions about delegating tasks and
activities to another nurse or to unregulated assistive personnel and the supervision of those
individuals. A more detailed explanation of the use decision-making frameworks when
delegating activities is provided in Chapter 5.

In the decision-making process, if all conditions outlined in the framework are met, then the
nursing activity is considered to be within the scope of practice and the nurse can proceed
and perform the activity. If any of the elements are not satisfied, the nurse should not
proceed with the activity.

Legal framework
As already noted, nursing legislation establishes the basis for the scope of practice in which
a registered nurse may engage. Every jurisdiction has its own method of regulating nursing
practice. Such authorisation generally includes the educational preparation for nurses, the
protection of titles and systems for registration. One of the first decisions that the nurse
must make is to determine whether an action is within the relevant legal framework.

Education and competence

Nurses hold a professional responsibility to practice safely and within

their scope of practice. In determining one’s scope of practice, the
nurse must make a judgement as to whether they are competent to
carry out a particular role or function. They must also take measures
to develop and maintain the competence necessary for professional
practice (ICN 2005).

The scope of an individual nurse’s practice is influenced by their levels of competence and
education. Competence and the maintenance of competence are key components of
decision-making frameworks, achieved by engaging in continuing professional development.
Nurses, in acknowledging any limitation in their competence, need to take appropriate action
which may include refusing to accept a delegated activity. If required, a nurse must
undertake relevant continuing education to gain competence in a particular area.
Specialized education and/or formal assessment may be required for the performance of
particular nursing activities in some jurisdictions.

Experience
Experience is not synonymous with competence. It is not simply a matter that more clinical
hours will by themselves increase the level of nursing expertise. The process which nurses
engage in when making clinical judgements about their patients’ health status is not clearly
understood. However, it is recognised that clinical knowledge, critical reflection, past
experience and intuition all play a role in making such judgements (Oliver and Butler 2004).

25
Context of practice
Context refers to the nursing practice environment and therefore has a significant influence
on every decision about scope of practice. It includes:
• patients and their specific care needs;
• the setting in which nursing care is being provided, e.g. home, acute care facility etc.;
• the amount of clinical support and/or supervision available from nurses; and
• the human, physical, technical resources available, skill mix and access to other health
professionals.

An example of a decision-making framework

Decision-making frameworks are generally based on a number of supporting principles
which set out to guide decisions about scope of practice through assessment of education,
experience and competence. As well as applying these principles to the situation, nurses
also use their professional judgement to inform their actions.

The concepts addressed by the principles have been discussed in this and previous
chapters.

Principles for determining scope of practice

The following principles may be considered as the basis for making decisions with regard to
the scope of practice for an individual nurse:

• The activity is consistent with the nursing legislation, board policy and guidelines.

• The primary motivation for undertaking the activity is to meet patient needs and improve
health outcomes.

• The activity is appropriately authorised by a valid order/protocol and in accordance with

established policies and procedures.

• The nurse has the appropriate education and makes a judgement that they are
competent to perform the activity.

• The activity is consistent with accepted standards.

• The activity to be undertaken by the nurse is appropriate for the context.

Decision-making frameworks should be used alongside other

professional practice guidelines and standards such as competency
standards, policies, regulations and legislation related to nursing in
order to make informed decisions about practice.

These principles are reflected in the following flowchart which illustrates the series of
decisions a nurse must make when considering whether to include an activity into his/her
own scope of practice.

26
Flowchart 1: When making decisions about individual scope of practice

Start Undertake
activity

Yes
Step 1
Is the activity Step 6
consistent with the Is the activity
No No appropriate for the
nurse practice act,
regulations, board context?
policy and
guidelines?

Do not
Yes

Yes
proceed

Step 2 Step 5
Is the primary Is the activity
motivation for No No consistent with
delegating the activity accepted standards
to meet patient needs
and improve health
outcomes?
Yes

Yes

Step 3
Is the activity Step 4
appropriately Are you competent to
authorised by a valid No No perform the activity?
order/ protocol and in
accordance with
established policies
and procedures?

Yes

27
28
Chapter 5
Delegation and supervision, and enhancing the
use of decision-making frameworks

Delegation

Delegation is the transferring of authority to another person a task, activity

or function that is normally within the responsibility of the delegator
(NCSBN 2005; QNC 2005).

As well as assisting the individual nurse to make decisions about what activities fall within
their own scope of practice, decision-making frameworks also assist in making decisions
about others’ scope of practice.

Decision-making frameworks can include principles for delegation between nurses,

accepting delegated activities from others, as well as delegating to unregulated assistive
personnel. When delegating tasks to others, these tools can ensure that the person who is
given the task to carry out is able to provide the care in a safe and competent manner.

It should be noted that some decision-making frameworks differentiate between the terms
delegating and assigning.

When assigning a task to a colleague a nurse or midwife is asking this

colleague to do something that is normally within their responsibility.
Delegation on the other hand is giving another a task that is normally
within the responsibility of the delegator.
(An Bord Altranais 2000)

Accountability and responsibility

Whilst the terms accountability and responsibility have been defined previously, it is
important to further explore the application of these concepts in relation to delegation.

Accountability refers to the individual being responsible and answerable for their own or
others actions or inactions. This acknowledges a nurse's legal liability for his/her actions. It
therefore implies that the outcomes of the nurse’s actions will be judged against some
criteria. It was not uncommon in the past for nurses to regularly accept responsibility for
activities that did not fall within their scope of practice.

When delegating activities to another individual, both the delegator and the person receiving
the delegated role or function are accountable for their actions. Accountability cannot be
delegated. The delegator is accountable for ensuring that the delegated activity is
appropriate and that support and resources are available to the person to whom it is

29
delegated. The person to whom the activity is being delegated is also accountable and must
inform the delegator if he/she is not competent to perform the delegated task.

Responsibility refers to a nurse’s obligation to perform competently at an acceptable level,

the level to which the person has been educated. Responsibility means that a person has
an obligation or duty to perform a role or function to an expected standard.

Responsibility can be delegated, as long as it is delegated to someone who is competent to

carry out the activity. The nurse who is delegating the responsibility shares accountability for
the role or activity with the individual who accepts the delegation.

Supervision
The nurse who has delegated a task or activity to another nurse or to an unregulated
assistive personnel must monitor the performance of the task or function and ensure
compliance with standards of practice, policies and procedures.

The nurse must also determine the level of supervision, monitoring and accessibility they
need to provide. It is likely that there will be a difference in the level of supervision required
depending upon whether the activity is delegated to a licensed nurse or an unregulated
assistive personnel. In addition, the supervision requirement will differ depending on the
nature of the task as well as the proximity of the supervising nurse. The nurse continues to
have responsibility for the overall nursing care.

The nurse therefore determines frequency of supervision and assessment based on the
needs of the client, the complexity of the delegated activity, the competence and experience
of the person undertaking the task and the proximity of the location. The supervision may be
direct with the nurse present to observe and work with the person under supervision.
However, the circumstances of the activity may allow the supervision to be indirect so that
the supervisor is accessible but not actually observing the activity.

The nurse or unregulated assistive personnel who has been delegated the tasks remains
individually responsible for their own actions as well as being accountable to the delegator
for the delegated activities.

Principles for delegating tasks or activities to another nurse or unregulated

assistive personnel

The following principles may be considered as the basis for making decisions when
delegating tasks to others:
• The activity is consistent with the nursing legislation, board policy and guidelines.
• The primary motivation for delegating the activity is to meet patient needs and improve
health outcomes.
• The activity is appropriately authorised by a valid order/protocol and in accordance with
established policies and procedures.
• The person to whom the activity is being delegated has the appropriate education and is
competent to perform the activity.
• The activity is consistent with accepted standards.

30
• The activity to be undertaken by the person is appropriate for the context.
• The nurse delegating a particular activity (the delegator) is accountable for the decision
to delegate. The person agrees to accept the activity and acknowledges their
accountability.
• Processes exist for ensuring appropriate supervision.

These principles are reflected in the following flowchart which illustrates the series of
decisions a nurse must make when considering whether to delegate an activity.

31
Flowchart 2: When delegating an activity

Start Undertake delegated

activity

Yes
Step 1 Step 8
Is the activity Are there processes
No No in place to ensure
consistent with the
nurse practice act, appropriate
regulations, Board supervision?
policy and guidelines?
Yes

Yes
Do not
proceed

Step 2 Step 7
Is the primary Does the person
No No accept the
motivation for
delegating the activity delegation?
to meet patient needs
and improve health
outcomes?
Yes

Yes

Step 3
Is the activity Step 6
appropriately Is the activity
authorised by a valid No No appropriate for the
order/protocol and in context?
accordance with
established policies
and procedures?
Yes
Yes

Step 4 Step 5
Is the person you Is the activity
are delegating the No No consistent with
activity to, accepted
competent to standards?
perform the activity?

Yes

32
Summary

It is now clear that delegation decisions cannot be made solely on the basis of the nature of
the task. The following must also be considered before a task or activity is delegated:

• Decisions related to delegation of nursing tasks must be based on the fundamental

principle of protection of the public.
• There may be activities which cannot be delegated based on legislative restrictions on
practice.
• Appropriate delegation is a two way communication process. The person being
delegated to must ensure that they are fit to carry out the role or function, and if not,
should inform the delegator.
• The delegator must be assured that the task is within the educational preparation, the
scope of practice, competence and the job description of the person to whom it is being
delegated and provide them with the necessary support.
• Each task or activity delegated must be considered in the light of the patient needs.
• Each decision about delegation must be made based on the individual merits of the
situation and the people involved.
• If an individual receives a delegated function beyond their current scope of practice, the
appropriateness of this delegation must be questioned.
• The delegator must be available to help and support the person to whom the task is
delegated.
• It must be clear to both the delegator and the person to whom the task is delegated why
the task or role is being delegated and the activity or task clarified.
• It must be clear who maintains responsibility and accountability.

Enhancing the use of decision-making frameworks

Notwithstanding the benefits associated with the development and implementation of a
decision-making framework, there are a number of cautions which need to be acknowledged
(Mosel Williams, Barnes and Hingst 2009).

Primary focus
The primary purpose of a decision-making framework is to focus the nurse on the needs of
the patient/ client. Whilst employer, facility and other local policies must be taken into
account, they should not become the principal focus of decisions in relation to scope of
practice and increase any compromise to patient safety.

Expansion of practice
While recognising that organisational and external imperatives are important, they must not
become the primary reasons for changes in practice over a professional nursing decision
based on patient need. Decision-making frameworks should not be used to pressure nurses
and unlicensed health care workers to act outside their scope of practice. Neither should
local policy place artificial boundaries around a nurse’s scope of practice which might
constrain their ability to meet their full role responsibility.

Institutional factors
Whilst the current environment is a key driver to changes in scope of practice, it is imperative
that the main motivations for such changes are communicated clearly and explicitly.
Workforce shortages, task shifting, inappropriate skill mix and economic imperatives should

33
not override the principles which inform decisions about practice nor lead them to be
inconsistent with the role of the nurse.

Resolving issues or disagreements about decisions

As well as providing direction to support decision-making about practice, assistance should
be available for those situations when despite using a decision-making framework, the nurse
is unable to make a clear decision or when there are disagreements about decisions.

Patient safety is paramount and so the patient(s) must not be placed in a situation where
their life and safety is at risk.

As well as documenting the issue, the delegator and the person to whom the task is being
delegated should refer to organisational policies and communicate their concerns to the
institution, agency or health care provider nurse practice committee or nursing director. The
documentation should include information about the practice issue addressed in each step of
the framework.

A nurse should not be directed or pressured by a supervisor,

employer or other person to engage in any practice that breaches or
has the potential to breach any professional standard, including
codes of conduct, ethics or practice for their profession. Nursing
legislation may contain provisions for penalties to be applied when a
nurse assists or coerces a nurse or other worker to engage in
unprofessional conduct.

Documentation and evaluation

Whether a nurse uses a decision-making framework to inform their own scope of practice or
delegate an activity or task to another, the decision and its outcome should be documented
and evaluated.

Further assistance in managing the change process as well as dealing with any conflict
which may arise in relation to scope of practice issues may be found in Chapter 7.

34
Chapter 6
Analytical tools
Being able to articulate the profession’s scope of practice and make informed decisions
using a robust decision-making framework can contribute significantly not only to patient
safety and quality care but also to an educated and competent profession, well prepared to
meet the changing needs of society.

Achieving the benefits that a decision-making framework can offer requires a fully developed
and detailed project plan as well as a comprehensive implementation plan to ensure the
profession embraces every aspect of the framework into every day practice.

A large part of the project work when developing a scope of practice and a decision-making
framework will involve consultation with the profession and other stakeholders, analysis of
the data, negotiating a final product and educating the profession during its implementation.

The following analytical techniques such as Delphi methodology, focus groups,

consequence mapping, force field analysis and flowcharting may be of assistance in these
various phases of the project.

Delphi technique or method

The Delphi technique is a method of collecting opinion on a particular research question.
This technique is becoming a popular strategy spanning both quantitative and qualitative
research methodologies.

The conventional Delphi uses a series of questionnaires to generate expert opinion from a
panel taking place over a series of rounds. Information is collected from the panel members,
analysed and then fed back to them as the basis for subsequent rounds.

The group interaction in Delphi is anonymous, in the sense that individual comments and
responses are not identifiable. The interactions among panel members are controlled by a
panel monitor who filters out material not related to the purpose of the group. The intention
of this technique is to overcome the disadvantages of conventional committee deliberations
and so the usual problems of group dynamics are avoided.

The basic method includes the following steps:

1. Establish a team to conduct and monitor a Delphi on a particular topic.

2. Select the panel to participate in the exercise. Panellists are usually experts in the area
to be investigated.
3. Develop initial or first round questionnaire.
4. Test the questionnaire for grammar, clarity, etc.
5. Distribute the first round questionnaire to the panellists.

35
6. Panellists independently generate their ideas in answer to the questionnaire which is
then returned.
7. The moderator analyses the first round responses and develops a feedback report.
8. Develop second round questionnaire (and possible testing).
9. Distribute the second round questionnaire to the panellists.
10. Panellists consider the feedback report and independently evaluate earlier responses
and independently vote on the second questionnaire.
11. Analysis of the second round responses (steps 8 to 10 are repeated as long as desired
or necessary to achieve consensus).
12. Preparation of a report by the moderator and analysis team to present the conclusions
of the exercise.

Conduct an exercise using the Delphi technique to achieve consensus on

a definition of scope of nursing practice in your country or jurisdiction.

Focus groups
A focus group is a small group of six to ten people led through an open discussion by a
skilled moderator. The group needs to be large enough to generate rich discussion but not
so large that some participants are left out.

Redmond and Curtis (2009) recommend focus groups for:

• collecting general background information on a topic of interest;
• purposes of stimulating new ideas and creative concepts;
• identifying potential problems with a new programme or service;
• generating impressions of services, programmes or products;
• learning how participants talk about the topic of interest which can assist with the
design and construction of other research tools such as questionnaires; and
• assisting with the interpretation of previously obtained quantitative results.

Four broad criteria are recommended for conducting the effective focus group interview.
The interview should:
1. address a maximum range of issues relevant to the topic;
2. provide data specific to the topic;
3. promote interaction that examines participants' feelings in some depth; and
4. take note of the personal context that participants describe when giving their
responses to the topic.

Interview guide
You will need to develop an interview guide to serve as a map for the focus group. The
format of the guide will depend upon whether you use a structured or semi-structured
approach. For an unstructured interview, two generally constructed questions or topics
might be sufficient, while for a more structured interview, four or five questions or topics, with
pre-planned probing questions for each, would be appropriate. A good interview guide
should facilitate a progression from general to more specific questions. The following
sequence might be useful to include in an interview guide: introduction; warm-up;

36
clarification of terms; easy and non-threatening questions; more difficult questions; wrap-up;
member check; and closing statements.

Participants
The characteristics of focus group members will be determined by the purpose of the study
and address biographical factors such as age, sex, educational background and knowledge
or experience with the topic. You will need to select individuals who will be willing and able
to contribute the required information. Participants for focus groups are frequently selected
based on their knowledge and expertise of the subject under investigation. The interaction
between participants is a key aspect of a focus group; therefore composition of the group
must be given careful attention. In selecting group participants, you should ensure that each
member of the group is not only able to contribute, but feels comfortable talking to other
group members.

Duration of the focus group interview

To encourage in-depth discussion of a topic, generally focus groups will last from 45 minutes
to two hours. Beyond that most groups are not productive as it impacts on their physical and
psychological limit and becomes an imposition on participant time.

Group size
There are a number of factors to consider when deciding on the size of the group, such as
the amount of information that each participant is able to contribute to the discussion. Small
groups are best used when the participants are expected to contribute meaningfully and
interact with each other. Larger groups also bring challenges which may be greater than
those of smaller groups particularly if many participants are knowledgeable and experienced
in the topic. If you are planning to use a large group, an experienced moderator will be able
to manage the discussion without having to constantly control the participants.

The moderator
The moderator plays a key role in collecting information from the group participants. The
moderator’s goal is to generate a maximum number of different ideas and opinions from the
group. An effective moderator is a good listener, responsive to non-verbal as well as verbal
comments and draws the group into the process. S/he encourages interaction, listens well,
allows the discussion to flow with minimal intervention and reflects back in a way which
distils and encourages more refined thoughts or explanations.

Questions
At the beginning of the focus group, the moderator can use some icebreaking techniques
such as providing an overview of the topic and explaining the purpose of the interview. The
ground rules can be outlined and then an introductory question asked as a warm-up before
putting more specific questions to the group.

The moderator then uses their interview guide and proceeds from the general to the specific
with sensitive questions left to the end. In addition to questioning techniques, moderators
need to have non-reflective and reflective listening skills. The moderator does not talk on
the subject matter rather uses prompts to encourage discussion and probing questions to
elicit more information and views. It is not necessary for the moderator to cover all
questions, rather the main topic area should be covered and everyone given the opportunity
to discuss it.

37
Conclusion
Prior to concluding, the moderators should reiterate the purpose of the focus group,
summarise briefly what was discussed and indicate any next steps.

Develop a consultation document on the introduction of a decision-making

framework. Conduct a series of focus groups to obtain feedback on the
proposal to introduce a decision-making framework within your country or
jurisdiction.

Consequence mapping
Influence or consequence mapping is particularly useful in assessing complex situations
where there are potentially a wide range of events that can flow from a single starting
assumption.

The following diagram was generated based on exploring the impact of introducing a flexible
approach to describing scope of practice.

38
Consequence diagram: Exploring the impact of introducing a flexible
approach to describing scope of practice.

39
The technique lends itself to those who prefer to consider issues visually rather than orally
as it clearly illustrates the connections between various ideas and concepts. To generate a
consequence or influence diagram, you need to start with an initial assumption or
intervention and ask people to quietly brainstorm what they see as the consequences of the
assumption / intervention. An alternative approach is to ask the group to brainstorm on the
basis of determining what the assumption will influence.

After five or ten minutes of generating ideas using small postcards or post-it notes, ask
people to place their ideas on a large piece of paper with the original assumption /
intervention located in the centre of the page. One by one, each person places an idea on
the table and, in doing so, describes to the group how they see their idea stemming from the
initial one. If other people at the table have the same or similar thoughts, place these on top
of the original card.

Draw an arrow from the initial assumption / intervention to the idea placed on the paper.
Then place other ideas on the page and if there are connections between ideas, add these
by drawing connecting lines. Once all the cards are placed on the table, ask the group to
use the new cards as starting points and describe what they see as the consequences that
flow from the original ideas. After several rounds a comprehensive map will be generated.

Some ideas will have lots of arrows going into and out of them. These are considered as
potential pivotal points. If there are ideas that have few arrows going in but a lot going out
these are considered as drivers. Ideas where there are one or more arrows going in and no
arrows coming out are end points or potential outcomes. If these outcomes are desirable
you can back track to the antecedent events and think about how you might encourage
these to happen. If the outcome is undesirable, back track and think about how you can
block the antecedent events.

Generate a consequence map based on the one of the following

assumptions:

• Decision-making frameworks raise the profession’s awareness of

scope of practice.
• Decision-making frameworks contribute to safety and quality in
nursing practice.

Force field analysis

Force field analysis is a technique that can be used to assist you in moving forward your
plans to describe the scope of nursing practice or to develop a decision-making framework.
This technique enables you to identify forces that will assist you in reaching your goal and
also those that may impede progress. It is important to begin the analysis with a well-
defined proposal for change. You should then brainstorm forces for and against this change.

40
Ask the group to assign a score from one to five, with one being weak and five being strong,
for each of the forces identified. Place the scored forces in either the ‘for’ or ‘against’ change
column. Calculate a total score in each column and then discuss with the group how you
can strengthen the positive forces for change, weaken negative ones and also create some
new positive forces to support the desired initiative. These points can then be recorded in a
timed action plan where individual members of the group can take responsibility for
achieving the planned steps.

Conduct a force field analysis to identify the forces for and against the
development of a scope of practice decision-making framework in your
country.

Flowcharting
We are all aware of the concept of a flowchart: a simple diagram which graphically
represents a series of actions or flow of information in order to get to an end point or exit
along the way.

A flowchart helps to clarify how things can be improved and assists in finding key elements
of a process. It stimulates communication among participants and establishes a common
understanding about the process.

A flowchart can therefore be used to:

• define and analyse processes;
• build a step by step picture of the process for analysis, discussion or communication;
• define, standardise or find areas for improvement in a process

By setting out the information in a step by step flow, you are able to concentrate more
closely on each individual step, without being lost in the bigger picture.

Flowchart are often drawn according to defined rules

• Each decision box has exactly two exits, one YES or TRUE and one NO or FALSE.
• All control flows must end in a process box, a decision diamond, or a terminator.
• Control flows must always ensure that the process eventually stops.
• Typically, the flow of control goes from top to bottom on a flowchart.
• Every feedback loop must have an escape. For example, a loop may end when the end
of file is reached or a particular condition met.
• Typically, a process box has only one exit point. A process box with more than one exit
may require a decision diamond.

41
Standard flowchart symbols include:

• elongated circles, which signify the start or end of a process;

• rectangles, which show instructions or actions; and

• diamonds, which show decisions that must be made

Within each symbol, write down what the symbol represents. This could be the start or finish
of the process, the action to be taken, or the decision to be made. Symbols are connected
to each other by arrows which show the flow of the process. While many other symbols may
be used, it is important to remember that the purpose of flowcharts is to improve
communication. Using non standard symbols risks obscuring communication.

To draw the flow chart, brainstorm to identify the tasks and list them in the order they occur.
You should ask questions such as "What really happens next in the process?" and "Does a
decision need to be made before the next step?" or “What approvals are required before
moving on to the next task?"

Start the flow chart by drawing the elongated circle shape, and label it "Start". Then move to
the first question, and draw a rectangle or diamond as appropriate. Write the question
down, and draw an arrow from the start symbol to this shape.

Work through the whole process, showing actions and decisions appropriately in the order
they occur, and linking these together using arrows to show the flow of the process. Where
a decision needs to be made, draw arrows leaving the decision diamond for each possible
outcome, and label them with the outcome.

Remember to show the end of the process using an elongated circle labelled "Finish".

Test the flow chart by proceeding from step to step asking yourself if you have correctly
represented the sequence of actions and decisions involved in the process.
http://www.mindtools.com/pages/article/newTMC_97.htm.

Develop a flowchart of the process involved in developing a scope of

practice.

42
Chapter 7
Managing change and conflict
If you are embarking on the development and/or implementation of a scope of practice and /
or decision-making framework then you will also need to consider how you will manage the
change process and ensure that all stakeholders are involved. Their success and adoption
will require you to manage this change carefully through taking a systematic approach.

Managing change
Change management is a method for reducing and managing resistance to change when
implementing process, technology or organisational change.

It is important here to distinguish between change and transition.

Change is the process or "thing" that takes place, for example, when
organisations are restructured, new teams are created or policies are
developed and implemented.

Transition is the mental process individuals must progress through in

order to accept or reject the change. It is the process of internalising
what is happening.

You should not try to ‘sell’ change to people as a way of accelerating or improving the
likelihood that you will achieve agreement and adoption of the decision-making framework.
Selling change is not a sustainable strategy for success. Change needs to be understood
and managed in such a way that people can respond and cope with it effectively. Change is
usually unsettling and so the person driving the change needs to undertake this in an
informed and supportive manner.

John Kotter (1995) describes a useful model for understanding and managing change. He
developed an eight-step process which can be applied to any change process and is useful
when considering the change associated with the introduction of a decision-making
framework.

1. Increase urgency ― inspire people to move, make objectives real and relevant.
2. Build the guiding team ― get the right people in place with the right emotional
commitment, and the right mix of skills.
3. Get the vision right ― create a collective vision and strategy, focus on emotional and
creative aspects necessary to drive service and efficiency.

4. Communicate for buy-in ― involve as many people as possible, communicate the

essentials simply and to appeal and respond to people's needs.

43
5. Empower action ― remove obstacles, give constructive feedback and lots of support,
reward and recognise progress and achievements; provide adequate resources: time
and finance.
6. Create short-term wins ― set aims that are achievable and in small steps; finish
current stages before starting new ones.
7. Don't let up ― encourage determination and persistence in the face of continuous
change; provide frequent progress reports, highlighting achieved and future milestones.
8. Make change stick ― reinforce the value of successful change; weave change into
culture.

However, regardless of how attractive a particular change might appear, it is not usually
embraced easily. A degree of resistance is normal since change is often both disruptive and
stressful. People frequently feel threatened by change.

There are four basic reasons why change is resisted:

1. parochial self interest;

• individuals are often more concerned with the implications for themselves;
2. misunderstanding;
• poor communication;
• inadequate information;
3. low tolerance of change;
• sense of insecurity;
• different assessment of the situation;
4. disagreement over the need for change;
• disagreement over the advantages and disadvantages.

One of the biggest challenges facing anyone involved in delivering change is how to
overcome the resistance they find in people towards what they are trying to do.

Kotter and Schlesinger (1979) set out the following six change approaches to deal with this
resistance to change. You may need to use more than one. If you try to deliver change
without any plan of how to manage resistance, you may well be unsuccessful.

1. Education and communication ― One of the best ways to overcome resistance to

change is to educate people beforehand about the change effort. Up-front
communication and education helps people to see the logic and the need for change.
This reduces speculative rumours concerning the effects of change in the organisation.
A major drawback can be the inherent time delays and logistics when a lot of people are
involved. It also requires mutual trust.

2. Participation and involvement ― People will be more supportive of change and less
resistive if they are involved in the change effort. Again it can be time consuming; and if
groups are asked to deliberate and make decisions there is a risk that some decisions
will be compromises leading to sub-optimal change.

3. Facilitation and support ― People may resist change due to adjustment problems, so
you can address potential resistance by being supportive of staff during difficult times.
Providing support helps people deal with fear and anxiety during a transition period. The

44
 basis of resistance to change is likely to be the perception that there will be some form of
detrimental effect arising from the change in the organisation. This approach can involve
either training or counselling.

4. Negotiation and agreement – During any change process, it is likely that someone or
some group may feel they will lose out. When that individual or group has considerable
power to resist the change, you can overcome this resistance by offering incentives to
staff not to resist change. Negotiation and agreement are normally linked to incentives
and rewards and so when the resistance stems from a perceived loss as a result of the
proposed change, this can be useful, particularly where the resisting force is powerful.
However, offering rewards every time changes in behaviour are desired is likely to prove
impractical and it may be best if the individual is assisted to leave the company in order
to avoid having to experience the change effort. This approach will be appropriate when
those resisting change are in a position of power.

5. Manipulation and co-option - Where other tactics will not work or are too expensive,
specific manipulation and co-option techniques are suggested. A frequently used and
effective manipulation technique is to co-opt with those resisting change. This involves
bringing a person into a change management planning group for the sake of
appearances rather than their substantive contribution. This often involves selecting
those most resistant to participate in the change effort. These individuals can be given a
symbolic role in decision-making without threatening the change effort.

6. Explicit and implicit coercion - Where speed is essential and to be used only as last
resort, managers can explicitly or implicitly force employees into accepting change by
making clear that resisting change can lead to performance management actions. The
use of threats can work in the short term but is unlikely to result in long-term
commitment.

Managing conflict
Conflict is a reality of life. While we all require the skill of being able to work with others, it is
also a requirement that we effectively manage the inevitable differences which occur
between us. Improving our understanding of conflict can help us deal with it more
effectively.

At times there may be conflict or disagreement on the application of principles in relation to

scope of practice including delegation decisions. Whilst we touched on this in Chapter 4, the
following techniques will provide strategies to use in any situation where disagreement
arises.

Conflict can be positive or negative

Conflict is commonly viewed as a source of emotion, frustration, and negativity and
something to be avoided at all costs. Despite these views of conflict, some disagreements
within an organisation can be an opportunity for creative thinking, problem-solving, learning,
and growth.

45
 When conflict is managed well, it can improve the ability of individuals
within a group to accomplish their task, work together, and contribute to
personal growth.

Conflict can be used to provide a better understanding about an issue from others’
perspective, rather than to simply persuade people that it is a question of right and wrong.

In order to deal with conflict constructively we must:

• rationalise and internalise a commitment to resolving the issue;
• acknowledge that resolving conflict is often necessary to achieve a positive or desired
outcome;
• accept that a degree of conflict will strengthen the final outcome; and
• accept that a better solution may exist and be prepared to change our position.

Working within the context of these criteria will increase the likelihood of a successful
resolution to the conflict situation.

Strategies for resolving conflict

Having established the conditions to constructively address conflict there are five conflict
management styles which are generally used to reach resolution. You should choose the
style that is appropriate for the conflict situation. Your choice of style in a conflict situation
will vary depending on a variety of factors such as, the relationship between those in dispute
and the importance of the subject of the conflict to each individual.

1. Avoidance (no winners or losers) is a viable option when:

• the issue is insignificant;
• you need to gather more information in order to deal with the issue; or
• time is needed to avoid emotion becoming a barrier to a solution.

2. Accommodation (lose-win)
• should not be used for major issues;
• is appropriate for immediately addressing issues where re-evaluation of the
situation may be required later;
• can be an interim step towards building trust and a resolution through collaboration;
• can lead to escalation of a conflict if used inappropriately or if it is seen as an easy
alternative to avoidance.

3. Compromising (win some-lose some)

• is an acknowledgement that a resolution addressing both parties’ issues is
essential; and
• works where both parties are willing to accept a middle position and modify some
expectations.

4. Competition (win-lose)
• will have someone win and someone lose;
• requires one person to have the authority to follow through and be prepared to
have little or no co-operation from the other party; and

46
 • should only be used after you evaluate whether such a resolution is ultimately
beneficial to both parties.

5. Collaboration (win-win) takes the most time however it:

• generally provides the most sustainable resolution supported by all parties;
• promotes creative problem solving;
• requires trust and co-operation, but not necessarily compromise; and
• focuses on information and consideration of alternatives.

It is important to match the strategies to the situation. When deciding which strategy to use,
you will need to consider the time available to you to reach agreement, how important is the
issue, how important is your relationship with the other party and the relative power held by
both parties.

Consider a conflict situation you were involved in and reflect on which

of the above strategies you used. Did you use the same strategy as
the other party? Do you think it was the most appropriate strategy to
use for that situation?

Using these options can be very helpful in facilitating a balanced outcome to conflict when
supported by effective communication skills. There are two primary factors - assertiveness
and co-operation - inherent in these strategies. Your assessment of the issue itself and the
response of the party with whom you are dealing will determine the proportion of
assertiveness and co-operation that you choose to use in addressing the issue. You should
ensure you are involved in an intellectual, not an emotional resolution.

Position vs. interest based negotiation

The distinction between positional negotiation and interest-based negotiation is another way
to approach conflict resolution. A position is what you want and an interest is why you want
it.

Negotiations between parties in conflict traditionally occur through a process which is

position-based. That is, each party comes with pre-determined positions and conducts face-
to-face negotiations where they attempt to convince the other party that their personal
position is the proper position for the parties to agree upon.

Interest-based problem solving is a way of resolving issues based on the interests of the
parties rather than pre-established positions. This process results in a win-win outcome for
all participants and eliminates the sense of losing when meetings are position-based.

So by looking at interests a different perspective is provided. In addition, understanding

interests makes it possible to find a solution satisfactory for both parties.

47
48
Chapter 8
Implementation
A considerable amount of effort and time will be invested in consulting with stakeholders
when developing a scope of practice and / or decision-making framework. This consultation
process is critical to the development of a product which is designed to meet the needs of all
stakeholders involved in the delivery of nursing services.

It is the implementation phase, when the product is introduced into the

practice settings for use by the profession which will determine its
success and adoption by the profession.

When developing a scope of practice and / or decision-making framework, the overall plan
should also consider communication and implementation strategies to address the
information to be provided to the profession and the public. Consideration needs to be given
to the information and resources needed, who should be involved, and what information in
the form of guidelines and fact sheets should be developed.

In order to improve the successful implementation of a scope of practice and / or decision-

making framework the following strategies and associated activities are recommended
(adapted from ANMC 2007):

1. Develop a comprehensive and targeted education programme for all users.

• Education is required to provide guidance in how to use the tool and to ensure
consistent application of the principles.
• Education needs to include concepts such as change, conflict, leadership,
communication, regulation, competence, competence assessment, and professional
accountability.
• Education needs to be provided to everyone affected by the framework.
• Sufficient and appropriate resources need to be available for the implementation of
the decision-making framework, including educational resources, training and follow-
up.
• Those using the frameworks will need to understand the purposes and limits of the
tools as well as the consequences of not using them.

2. Design educational resources with a number of key elements to ensure consistent

and effective use and understanding.
• Educational resources should support the use of decision-making frameworks and
communicate these as tools which increase the potential for appropriate integration
of activities into professional practice, supervision and delegation.
• Including a lexicon of terminology in the resources will improve consistent
understanding and application.
• Adopting a principle based approach to the framework will guard against it being
used as a checklist of activities.
• All resources need to promote the advantages of the decision-making framework but
acknowledge any weaknesses.

49
3. Clearly articulate the relationship between the framework and other relevant
standards and policies.
• The scope of practice and/or decision-making framework needs to be clearly linked
to other existing professional standards for example, code of ethics, code of conduct,
practice standards.
• Employer, facility and other local policies need to be consistent with the scope of
practice and/or decision-making framework in order for it to be effective.

4. Involve stakeholders, encourage champions and collaboration.

• Employer support and understanding is critical for effective implementation.
• Establish champions within employing organisations, professional groups and unions
/ associations to encourage a collaborative effort with implementation.
• Encourage collaboration and involvement of other health professions who will be
working with the nurses in implementing the framework.
• Leadership within the health care facility, particularly at the middle management
level, is critical for successful application in the clinical setting.

5. Develop supporting publications and resources.

• The framework needs to be concise, simple and easy to follow.
• Consider other resources such as posters, pocket guides, flow charts, standard
power point presentations, podcasts, FAQs etc.
• Educational guides are helped by exemplars to support the tools. Self-directed
learning guides may also be useful.
• Hold workshops where questions or examples are explored.

50
Chapter 9
Conclusion
Nurses around the world make a significant contribution to the health of the societies in
which they practise. These societies rightly have the expectation that they will receive safe
and competent care from those licensed by the relevant regulatory body.

However, in the our fast-paced and ever-changing health care environment it is unrealistic
and even dangerous to assume that nurses conceptualise their scope of practice as
something which is a constant. It must be acknowledged that each nurse has a different
scope of practice from another, based upon the diversity of nursing roles and the contexts in
which they practise.

In the face of resource restrictions and endeavouring to meet increasing needs and
demands, the evidence demonstrates that better health outcomes are achieved when
greater numbers of registered health professionals are engaged in direct care. However,
those involved in workforce planning have a keen interest in defining and describing the
particular scope of practice of not just nurses but other health professional groups. In doing
this they attempt to identify gaps and overlaps across the various practice disciplines. These
gaps and overlaps provide the opportunity for shifting responsibilities and adding new cadres
of workers which results in a fragmented and inefficient service through reductionist and
vertical approaches.

The World Health Professions Alliance Joint Health Professions Statement on Task Shifting
offers 12 guiding principles for task shifting (WHPA 2008). A number of these guiding
principles for task shifting are relevant to and aligned with decision-making frameworks.
These principles recommend that roles and job descriptions should be described on the
basis of the competencies required for service delivery and constitute part of a coherent,
competency-based career framework that encourages progression through lifelong learning
and recognition of existing and changing competence. In addition, there need to be
sufficient health professionals to provide the required selection, training, direction,
supervision, and continuing education of auxiliary workers.

51
 The benefits of a clearly articulated scope of practice and associated decision-
making frameworks are that they:

• accommodate existing regulatory structures and at the same time support a

flexible and innovative approach to practice;
• assist nurses to articulate their role, accountabilities and responsibilities as
well as the contribution they make to safe and competent nursing care;
• identify those decisions with the potential to harm others need to be made
by qualified and licensed nurses;
• facilitate the appropriate integration of activities into personal professional
practice;
• facilitate the appropriate delegation of activities to others;
• assist in the effective allocation of resources for the development and
sustainment of the health professional workforce;
• inform the public about the standard of care they should expect to receive
from the nursing profession.

Developing a contemporary scope of practice and supporting its implementation with a

decision-making framework is therefore an essential step in securing quality care and health
services provision.

52
Additional Reading
Australian Nursing and Midwifery Council (ANMC) Decision-Making Framework Documents
www.anmc.org.au/professional_standards

American Nurses Association (2005). Principles for Delegation. Safe Staffing Saves Lives
www.safestaffingsaveslives.org//WhatisSafeStaffing/SafeStaffingPrinciples/PrinciplesforDele
gationhtml.aspx

Regulatory Principles

Better Regulation Commission (2000).. Five Principles of Good Regulation.

http://archive.cabinetoffice.gov.uk/brc/publications/principlesentry.html accessed 16.10.09

Council of Australian Governments (1995, amended in 2004). Principles and Guidelines for
National Standard Setting and Regulatory Action by Ministerial Councils and Standard-
Setting Bodies. www.pc.gov.au/orr/external/nationalstandardsetting accessed 16.10.09

Government of Ireland (2004). Chart of Regulatory Principles and Actions. Better Regulation
www.betterregulation.ie/eng/Government_White_Paper_'Regulating_Better'/Chart_of_Princi
ples/Chart%20of%20Regulatory%20Principles%20and%20Actions%20Rich%20Text%20For
mat.rtf accessed 16.10.09

OECD (2005). Guiding Principles for Regulatory Quality and Performance

www.oecd.org/dataoecd/24/6/34976533.pdf accessed 16.10.09

Examples of decision-making frameworks, tools and trees

Maine State Board of Nursing (2003). Scope of Practice Decision Tree

www.maine.gov/boardofnursing/questions/scopeofpracticedecisiontree.doc

National Council of State Boards of Nursing (1997). Delegation Decision-Making Tree

www.ncsbn.org/Delegation_Decisions__Making_Tree_NEW.pdf

New Jersey Board of Nursing (1999). Seven Step Decision Making Model: Algorithm for
Determining Scope of Nursing Practice. www.state.nj.us/oag/ca/nursing/seven.htm

Ohio Board of Nursing (2004). Scope of Practice Decision-Making Model.

www.nursing.ohio.gov/pdfs/Decmodel.pdf

Oklahoma Board of Nursing. (2007). Decision-making model for scope of nursing practice
decisions: Determining RN/LPN scope of practice guidelines.
www.state.ok.us/nursing/prac-decmak.pdf

Queensland Nursing Council (2005). Scope of Practice Framework for Nurses and Midwives
www.qnc.qld.gov.au/assets/files/pdfs/policies/SOP_Framework_policy.pdf

Texas Board of Nursing (2006). Six-step decision-making model for determining nursing
scope of practice. www.bne.state.tx.us/practice/pdfs/dectree.pdf

53
Analytical tools

Day J & Bobeva M (2005). A Generic Toolkit for the Successful Management of Delphi
Studies, Electronic Journal of Business Research Methods Volume 3 Issue 2 2005 (103-
116). www.ejbrm.com/vol3/v3-i2/v3-i2-art2-day.pdf

Department of Sustainability and Environment, Australia. Delphi Study

www.dse.vic.gov.au/DSE/wcmn203.nsf/LinkView/D7B9E063A2B4FFAFCA25707E00248822
EBB2EB2F9035229BCA257091000BF7A6

Mind Tools Ltd. Flow Charts, Understanding and Communicating How a Process Works.
www.mindtools.com/pages/article/newTMC_97.htm

USAID Quality Assurance Project. Flow charts, Methods and Tools, QA Resources
www.qaproject.org/methods/resources.html

54
References
An Bord Altranais (2000). Scope of Nursing and Midwifery Practice Frameworky. Dublin,
Ireland.
www.lenus.ie/hse/bitstream/10147/45073/1/6798.pdf
(accessed 06.08.09)

Australian Nursing and Midwifery Council (2006). Demystifying Scopes of Practice and
Decision Making Frameworks. Australian Nursing and Midwifery Council, Canberra.

Australian Nursing and Midwifery Council (2007). Report to the Australian Nursing and
Midwifery Council. Project to produce a National Framework for the Development of
Decision-making Tools for Nursing and Midwifery Practice (National DMF). Australian
Nursing and Midwifery Council, Canberra.
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Chiarella M (2002). Selected Review of Nursing Regulation, in National Review of Nursing

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College of Nurses of Ontario (2009). Legislation and Regulation: RHPA: Scope of Practice,
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Government of Singapore (1999, revised 2000). Singapore Nurses and Midwives Act.
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209&doctitle=NURSES%20AND%20MIDWIVES%20ACT&date=latest&method=part&sl=1

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Mind Tools Ltd. Flow Charts, Understanding and Communicating How a Process Works.
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Mosel Williams L, Barnes M and Hingst M (2009). Scope of Practice Decision Making
Framework: a Picture. Final Report

National Council of State Boards of Nursing (2005). Working with Others: A Position Paper
www.ncsbn.org/Working_with_Others.pdf

National Nursing & Nurse Education Taskforce (2005). Scope of Practice Commentary
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Oliver M & Butler J (2004). Contextualising the trajectory of experience of expert, competent
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1, pp. 21-27).

Queensland Nursing Council (2005). Scope of Practice Framework for Nurses and Midwives
www.qnc.qld.gov.au/assets/files/pdfs/policies/SOP_Framework_policy.pdf

Redmond R & Curtis E (2009). Focus groups: principles and process. Nurse Researcher,
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Singapore Nursing Board (1999) Standards of Practice for Nurses and Midwives.
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World Health Organization - Easter Mediterranean Regional Office (WHO-EMRO) (2006)

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56
International Council of Nurses
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