Protecting Your Nursing License When Staffing Is Suboptimal

The majority of nurses don’t often think about nursing regulatory bodies (NRBs), commonly referred to as boards of nursing, other than at license renewal time. In reality, every licensed nurse in the country is in partnership with nursing regulators through a shared commitment to keeping patients safe. We may approach it differently – critical care nurses through high-quality, evidence-based care and regulators through statute and regulation – but we are aligned in this goal.

The ability to provide care safely, as well as nursing licenses, may be at risk when barriers to appropriate staffing exist. A 2021 survey by AACN revealed that of the 9,335 respondents, only 24% reported that they have appropriate staffing 75% or more of the time (Ulrich et al, 2021). As nurses leave the profession, the staffing shortage may become even more problematic.

Patient outcomes are impacted by staffing levels. For example, rates of infection and pressure injury decrease with higher staffing levels in intensive care units. Additional research shows that surgical site and urinary tract infections increase with the addition of one patient to a nurse’s assignment. In a separate study, Aiken and colleagues report staffing deficits pre-dated the pandemic, and note that a large body of observational data demonstrates the association between nurse staffing, work environments and patient outcomes.

Addressing the Nursing Shortage

Efforts to address the nursing shortage and improve staffing have been the focus of a variety of stakeholders. Lawmakers around the country are seeking solutions to address nursing workforce issues. Legislators at the state and federal levels have introduced bills to establish alternative staffing models, increase funding for nursing education, provide tax credits for preceptors and offer tuition reimbursement for practice in areas of need.

The American Association of Critical-Care Nurses (AACN) in collaboration with American Nurses Association (ANA), American Organization for Nursing Leadership (AONL), Healthcare Financial Management Association (HFMA) and Institute for Healthcare Improvement (IHI) spearheaded an ambitious project, the Partners for Nurse Staffing Think Tank, to address nurse staffing through actionable recommendations, which address a variety of forces affecting the nursing workforce. More recently, a diverse group of organizations continued the work of the Think Tank as members of the Nurse Staffing Task Force, a forum for sharing innovative solutions to achieve and sustain appropriate staffing levels and optimize patient care.

The ethical and legal obligations to provide safe care do not change under any circumstances, but a nurse’s ability to fulfill those obligations may be challenged due to barriers such as suboptimal staffing. Situations that inhibit a nurse practicing safely and in compliance with professional standards and regulatory requirements can impact their license and livelihood.

So how does a nurse protect their license in the current practice environment of staffing shortfalls? This question is important, since it is through licensure that nurses are granted the authority to practice nursing in each jurisdiction in the U.S.

Regulation of Nursing

Nursing regulatory bodies are responsible for determining that an applicant for a license has attained the necessary competency to perform a unique nursing scope of practice. Formal regulation of the nursing profession is essential to ensure that nurses have the required skills to practice safely. The primary role of the NRB is to ensure public protection.

A license issued by the NRB assures the public that the nurse has met well-established standards that qualify them to provide care to the people in their communities. The evolution of nursing regulation began in the early 1900s when North Carolina granted the first registration for nurses. It wasn’t until many years later, during the 1970s, that licensure became the accepted means for ensuring safe nursing practice in the U.S. For APRNs, this standard became broadly accepted after the release of the APRN Consensus Model in 2008.

The authority for NRBs to regulate the practice of nursing and enforcement of laws is granted through the Nurse Practice Act (NPA). Each state has a unique NPA that defines the scope of nursing practice. The NRB maintains a balance between its mission of protecting the safety, health and welfare of the citizens of the state and the rights of the individual nurse to practice nursing.

The NPA does not provide complete guidance for the nursing profession, as it is broader in nature. Therefore, each state develops rules and regulations that are consistent with the statute to provide clarification and specificity for the NPA. For example, the NPA may require a nurse to complete 30 continuing education hours for license renewal, and the rules then define which continuing education or equivalent activities have been approved to fulfill the requirement. Both the NPA and the accompanying administrative rules have the force of law and are used to regulate the profession of nursing and should always be considered complementary regulatory provisions.

Nursing regulatory bodies have the legal authority, in keeping with the mission of public protection, to discipline a nursing licensee who violates the NPA or the administrative rules. Although the NRB must adhere to the law, each complaint about a licensee is considered individually on its own merits. Based on their evaluation of a complaint against a nurse, the board may render a wide range of decisions from no discipline to licensure revocation.

The language in NPAs and rules varies across states, but generally you will find a reference to standards of professional accountability. Every nurse is responsible for knowing and understanding these regulations.

Protecting Your License

Critical care nurses and NRBs share a commitment to patient safety. It is incumbent on every nurse to understand both the NPA and the rules in the state(s) in which they are licensed and providing care, including electronically. Since this is the regulatory standard to which you are being held, you must know your scope of practice and the state’s expectations of your professional behavior in order to be in compliance and protect your license.

If you are called before a board of nursing, you will not be able to cite a lack of knowledge of state practice regulation to justify your actions. It is your license to protect. Each NRB has a website with links to the NPA, rules/regulations and other information, such as position statements and FAQs, including those related to patient safety. For example, the North Carolina Board has a position statement that provides guidance for their licensees on staffing and patient/client safety: North Carolina BON position statement. The Texas Board of Nursing states in its FAQ that “the duty of every nurse is to provide safe patient care, and this duty supersedes any employment related requirements. Once a nurse assumes duty of a patient, the nurse has a regulatory responsibility to provide safe patient care in accordance with all applicable laws, rules and regulations.” (Texas BON, 2022)

Use a process or algorithm to guide your safe actions while caring for patients in all circumstances. This process can be particularly important when staffing is short. Here is an example of a tool to help determine if your actions are within the scope of practice.

Note that the first consideration in this tool is whether an activity is prohibited by nursing regulation. Understanding regulatory provisions in the state where the care is being provided is essential to using this framework tool and benefiting from its direction. The tool includes a question that considers how a reasonable and prudent nurse would act. In understaffed shifts, that question may help you prioritize competing elements of patient care.

The NRB will inquire about your decision-making process if a complaint is made against your license. So, using a framework is essential for deliberate consideration of what care to deliver and when. Integrating this process into the way you make decisions about the care you provide serves to formalize your thought processes, improve your decision-making and protect your license.

Nursing regulatory bodies have no authority over employers. However, it is appropriate for a licensed nurse to seek guidance from the NRB to provide interpretation of the NPA and rules, which may aid in individual decision-making. Depending on the setting, employers may be regulated by state and federal statute and insurers, such as CMS. The prioritization of patient safety applies to nurses, NRBs, hospital executives and healthcare leaders.

Nurses in understaffed situations demonstrate their commitment to patient safety when they advocate for safe patient care with employers. Find out how staffing determinations are made on the unit. Engage with colleagues, as well as unit and organizational leadership, to improve staffing. Investigate if the hospital has a staffing committee; if not, consider establishing one. Understand your employer’s policies related to patient assignments. Some staffing decisions may be outside your control. It is still appropriate to seek opportunities to contribute your expertise and learn from others. Critical care nurses are strong and resourceful; believe in your ability to be an agent of change. For ideas on ways to contribute to better staffing, consider reviewing an AACN blog on staffing.

The work to improve staffing continues and, as always, nurses must be diligent in protecting their license. Understanding and adhering to nursing regulation is an essential component of maintaining a license in good standing.