Regulation of Nursing Practice in the USA: Ensuring Competency and Patient Safety

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Nursing is one of the most reputable and trusted professions in the United States of America, known for its dedication to patient care and safety. However, maintaining this trust requires a robust regulatory framework that governs not only the practice and standards of care but also the workplace behavior and responsibilities of nurses.

The regulatory framework governing the nursing in USA involves federal and state governments, licensing boards, and professional organizations. With over 4.7 million licensed nurses in the U.S., regulatory frameworks ensure public safety, set professional benchmarks, and guide nurses in their responsibilities, in addition to addressing the legal and licensing structures (Rosseter, 2024).

How the nursing practice is regulated in the USA?

Nursing regulation encompasses creating and enforcing legal, professional, and ethical standards that guide nursing practice. These regulations are essential for ensuring the quality and safety of care provided by nursing professionals. This regulatory framework ensures that nurses are competent, ethical, and can provide safe and effective care. The regulatory structure of nursing in USA involves:

  1. State Nurse Practice Acts (NPAs).
  2. State Boards of Nursing (BONs).
  3. Standards of Care
  4. Nurse Licensure Requirements.
  5. Oversight by professional organizations.
  6. Continuing Education and Competency Requirements.
  7. Ethical and Legal Accountability.
  8. Employee Guidelines.

1. Nurse Practice Acts (NPA):

A series of statutes to regulate the nursing practice in the United States of America was initially enacted in 1903 by the state legislature. The North Carolina Board of Nursing took a pioneering step by being the first to establish the Nurse Practice Act. Following this important development, New York, Virginia, and New Jersey also introduced registration laws, contributing to the advancement of nursing standards and practices. This collective effort reflects a commitment to enhancing the professionalism and regulation of the nursing field (California Board of Registered Nursing, 2023).

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Till 1947 all 50 states passed the legislations to regulate the nursing in USA. The core principle of the NPA is to distinguish between nursing practice and medical practice by defining the scope of nursing practice. Although the NPAs vary from state to state, the following are the collective functions of NPAs.

a. Establishing the definitions of nursing

The Nurse Practice Act operates as the law and guidance for every state in the US. The NPA has established a comprehensive framework of terms, definitions, and phrases to facilitate effective enforcement and enhance the clarity of understanding among state boards. They also established the terms for legislature and citizens.

For example, the APRN (Advanced Practical Registered Nurse) must own advanced nursing education and training accompanied with registered nurse degree and nurse licensure. They also pursue further certifications and enhance their skills to effectively address the health and wellness needs of the population (Boehning & Haddad, 2023).

b. Defining educational program standards

NPA defines the pre-licensure nursing education required for the accreditation process, specific curriculum language, and the faculty’s qualifications. NPA sets criteria for nursing education programs and nursing schools in United States, ensuring they meet required standards (ANA, 2020).

c. Defining the scope of nursing in USA

The Nurse Practice Act serves as an essential framework that delineates the core standards and criteria for professional nursing practice. It establishes the qualifications required for nurses, detailing the activities they are authorized to perform based on their licensure and clinical experience (Boehning & Haddad, 2023).

Additionally, the Act clearly defines the scope of practice for Licensed Practical Nurses (LPNs), Registered Nurses (RNs), and Advanced Practice Registered Nurses (APRNs), ensuring that each role is well-understood and appropriately utilized in the healthcare system. The NPA underscores the importance of accountability among all nursing professionals and establishes a comprehensive code of conduct to ensure the delivery of safe nursing practice.

d. Defining titles and licenses for nurses

NPA defines the titles for nurses and types of licenses to protect the community from unsafe practices. They are continuously evaluated and monitored by the State Board of Nursing throughout the career of a nurse.

e. Defining grounds for disciplinary actions

All healthcare professionals are accountable for providing safe care to their clients. NPA provides the legal framework for disciplinary actions in violation of safe nursing practices.

2. State Boards of Nursing:

State Boards of Nursing (BONs) in the USA are regulatory bodies established under the Nurse Practice Act (NPA) of each state. The primary function of BONs is to ensure safe nursing practice and to protect public health from any injury or healthcare-related hazards (Boehning & Haddad, 2023). The following highlights the essential roles and responsibilities of State Boards of Nursing:

a. Making, enforcing, and amending the nursing regulations

Boards of Nursing have the authority to establish nursing regulations for states, make amendments according to community needs, enforce the regulations, and ensure compliance with safe nursing practices.

b. Issuance of licenses

BONs grant nursing licenses to qualified individuals who pass the nurse licensure examination and meet the educational requirements from nursing schools in United States or outside the USA.

c. Renewal of licenses

BONs manage periodic license renewals, ensuring that nurses remain competent through continuing education or professional development.

d. Interstate nurse licensure

BONs play a vital role in facilitating the Nurse Licensure Compact (NLC), which enhances the ability of nurses to provide care across multiple states with a single license. This engagement enhances the efficiency of the licensing process and facilitates the mobility and effectiveness of the nursing workforce (NCSBN, 2023). 

e. Establishing rules

Boards of Nursing develop and enforce administrative rules and regulations that clarify and implement the Nurse Practice Act (NPA).

f. Examination administration

BONs coordinate with the National Council of State Boards of Nursing (NCSBN) to conduct the NCLEX-RN and NCLEX-PN exams, which are required for nurse licensure (NCSBN, 2023). 

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g. Ensuring nursing competence

Boards of Nursing frequently require continuing education or competency assessments as prerequisites for license renewal. These requirements are designed to ensure that nursing professionals meet established minimum standards for safe and effective practice within the field.

h. Ensuring criminal backgrounds

Boards of Nursing ensure that nurses are not involved in any illegal activities by thoroughly assessing their backgrounds and investigating reports of misconduct, incompetence, or unprofessional behavior.

i. Disciplinary measures

Boards of Nursing outline the procedures for handling complaints against nurses and provide guidelines for disciplinary actions. They can impose sanctions, such as license suspension, revocation, fines, or mandatory remediation, depending on the severity of the violation.

j. Data collection and reporting

The Boards of Nursing (BONs) are instrumental in collecting comprehensive data regarding the nursing workforce, including demographic trends, practice patterns, and areas of shortage. Additionally, they make significant contributions to Nursys, a national database that serves to verify licensure and track disciplinary actions, thereby supporting the overall integrity and professionalism of the nursing field (Nursys, 2022).

3. Standards of Care:

Standards of care are essential guidelines that define the expected levels of practice and professional performance for nurses in various healthcare settings. They outline responsibilities such as patient assessment, care plan development, treatment administration, and outcome evaluation.

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These standards ensure safe, effective, patient-centered, and evidence-based nursing care. By adhering to these benchmarks, nurses can make informed decisions, navigate complex situations, and promote continuous professional growth, ultimately enhancing the quality of patient care and advancing the nursing field.

a. General standards

General standards apply to all nurses, including conducting accurate and thorough assessments for all patients, maintaining patient privacy and confidentiality, administering medications safely, and reporting patient condition changes promptly.

b. Specialty-specific standards

Besides the general standards, nurses may comply with specialty-specific standards. For instance, oncology nurses follow guidelines from the Oncology Nursing Society (ONS), while emergency nurses adhere to the Emergency Nurses Association (ENA) standards (Riwitis & Navarroli, 2024).

c. Institutional standards

Each healthcare institution develops specific protocols, such as infection control policies or documentation requirements, which align with broader regulatory standards.

4. Nurse licensure requirements

Each state has its own Nurse Practice Act detailing specific licensure requirements, the licensure requirements for nurses in the USA vary slightly by state. Prospective nurses should consult the website of their state’s board of nursing for detailed instructions but the general criteria are consistent across the country due to national standards established by the National Council of State Boards of Nursing (NCSBN, 2023). Below are the key requirements for nurses in the United States:

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a. Completion of an approved nursing program

To obtain licensure, nurses need to complete a state-approved and accredited nursing education program from nursing schools in United States. To pursue a career as a Registered Nurse (RN), individuals can choose different educational paths to advance in their nursing careers. They can earn an Associate Degree in Nursing, complete a nursing diploma, or get a Bachelor of Science in Nursing (BSN). This educational background is crucial for developing the competencies necessary for providing high-quality patient care in various healthcare settings.

For Licensed Practical Nurse (LPN) it requires the completion of a practical or vocational nursing program typically consisting of 1-2 years. Advanced Practical Registered Nurses (APRNs) require advanced education in the nursing field which consists of completion of a graduate program (Master’s or Doctorate in Nursing) in a specific advanced practice role (e.g., Nurse Practitioner, Nurse Anesthetist) (ANA (2020).

b. Passing the NCLEX Examination

The NCLEX (National Council Licensure Examination) is a crucial assessment that evaluates a candidate’s readiness to provide safe and effective entry-level nursing care, administered by the NCSBN. The exam plays a vital role in ensuring that nursing professionals meet the necessary standards. Registered Nurses take the NCLEX-RN Exam, while Licensed Practical Nurses (LPNs) complete the NCLEX-PN exam to qualify for practice in the United States.

c. Applications and fees

Candidates must apply for nurse licensure to the state board of nursing where they intend to practice. Licensure fees vary from state to state. The State Board of Nursing reviews the application thoroughly and grants permission to appear in the nurse licensure examination.

d. Verification of education and credentials

Education credentials require the submission of official transcripts from the nursing schools in United States to the state board of nursing for graduation proof. Foreign-educated nurses must have credentials evaluated by an organization such as the Commission on Graduates of Foreign Nursing Schools (CGFNS) to be eligible for the licensure exam.

e. English language proficiency (if applicable)

For international applicants whose primary language is not English, states may require proof of English language proficiency through tests like TOEFL or IELTS.

f. Nurse Licensure Compact (NLC) participation

Nurses in NLC states can apply for a multistate license, allowing them to practice in other compact states without obtaining separate licenses. To qualify for multistate licensure privilege, the nurse must have permanent residence status in an NLC state and comply with the licensure requirements of the home state. Currently, 43 states passed the joining legislation to address the nursing shortage, especially in rural and underserved areas, and to promote workforce mobility (NCSBN, 2023). 

The Nurse Practice Act (NPA) establishes the essential laws and regulations that guide the Nurse Licensure Compact, ensuring a standardized approach to nursing in USA and supporting continued professionalism and accountability within the field. When a nurse practices within a compact state, it’s important to adhere to the established rules. If a violation occurs, disciplinary measures may be taken, which can impact the nurse’s multistate licensure privileges. This serves as a reminder of the importance of compliance to maintain professional standing across states.

5. Oversight by Professional Organizations:

Nursing regulation requires collaboration among agencies such as hospitals, health clinics, and nursing schools in United States to ensure patient safety and effective nursing education. This partnership is vital in developing and implementing best practices, enhancing the quality of care, and safeguarding public protection by ensuring that patients receive care from highly qualified nursing professionals (ANA, 2020). 

nursing in usa

Organizations like the American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN) establish and promote national nursing standards. The ANA’s Standards of Nursing Practice outline two critical components:

a. Standards of practice

This framework outlines the essential components of nursing care, encompassing assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. It serves as a comprehensive guide for delivering high-quality patient care.

b. Standards of professional performance

Expectations for ethics, education, communication, and leadership in the nursing role.

6. Continuing Education and Competency Requirements:

Licensure confirms that nurses have met the minimum competency standards required to provide care. To maintain their license, nurses must complete Continuing Education Units (CEUs), which ensure they remain updated on advancements in healthcare and maintain compliance with standards of care.

Nurses must complete a specified number of CEUs to renew their licenses, the number varies by state. For example, California requires RNs to complete 30 hours of CEUs every two years for license renewal. Some states require periodic competency assessments or certifications in specialized areas such as infection control, opioid prescribing, or cultural competency depending on state requirements.

7. Ethical and Legal Accountability:

Nurses are bound by ethical and legal standards, including those set forth by the American Nurses Association (ANA) in its Code of Ethics for Nurses which serves as a foundational document outlining moral principles and professional duties or set by Nurse Practice Acts (NPA) to establish the legal framework for nurses (ANA, 2015). 

the scale with right and wron

Key ethical principles include:

a. Beneficence

Nurses are committed to upholding the best interests of their patients by actively promoting their well-being and undertaking actions that contribute to their overall benefit.

b. Nonmaleficence

Nurses must not harm patients by avoiding actions that may cause unnecessary injury or suffering.

c. Autonomy

Nurses are professionally obligated to honor patients’ rights to make informed decisions regarding their care. This responsibility encompasses obtaining informed consent and supporting patients as they navigate their choices about treatment options.

d. Justice

Nurses must provide equitable care, ensuring all patients are treated fairly, regardless of race, gender, socioeconomic status, or other factors.

e. Fidelity

Nurses must remain loyal to their commitments, maintaining confidentiality, honesty, and trustworthiness in patient interactions.

f. Veracity

Nurses must tell the truth, providing patients with accurate information to support informed decision-making.

Legal accountability for nurses stems from state and federal laws, professional regulations, and institutional policies. Failure to comply can result in disciplinary actions, lawsuits, or loss of licensure.

Key aspects of legal accountability include:

  • To practice as a nurse, individuals must obtain a license from the state board of nursing, which is a regulatory body responsible for overseeing the education, training, and certification of nursing professionals. This licensure process ensures that all nurses meet the necessary standards of competence and adhere to the ethical guidelines required to provide safe and effective patient care. Each state may have its specific requirements for nurse licensure, including completing an accredited nursing program, passing a comprehensive national examination, and fulfilling any additional state-specific criteria.
  • They must adhere to their scope of practice as defined by state laws, which outline what nurses are permitted to do based on their training and qualifications.
  • Nurses are entrusted with the vital responsibility of adhering to established standards of care. When deviations from these standards occur, particularly if they result in patient harm, there may be legal implications such as malpractice lawsuits.
  • Nurses play a role in ensuring that patients understand the procedures and treatments they are consenting to. They must also advocate for patients who may not fully comprehend medical jargon.
  • Accurate and timely documentation is vital for securing legal protections and maintaining clarity in all operations. Well-maintained records not only demonstrate that care has been delivered appropriately but also serve as crucial evidence in the event of disputes.
  • Under the Health Insurance Portability and Accountability Act (HIPAA), nurses are legally required to maintain the privacy and confidentiality of patients’ medical information (U.S. Department of Health & Human Services, 2024).
  • Nurses play a vital role as mandated reporters for specific situations, including child and elder abuse, as well as communicable diseases. By reporting these conditions, they help to ensure the safety and well-being of individuals in need. It’s important to be aware that not reporting these concerns can lead to legal implications.
  • Nurses must accurately and safely administer medications to their patients. Errors in dosage or administration can result in serious legal and professional consequences.

8. Employee Guidelines:

Employee guidelines are policies and procedures established by healthcare institutions to govern the behavior, responsibilities, and expectations of nurses and other staff. These guidelines complement regulatory standards by addressing:

  • Maintaining patient confidentiality as required by HIPAA (Health Insurance Portability and Accountability Act).
  • Demonstrating cultural competence and sensitivity.
  • Following professional dress codes and maintaining proper hygiene standards.
  • Following policies on shift swaps or overtime and staff floating.
  • Penalties for repeated tardiness or absenteeism.
  • Promoting a culture of workplace safety by actively adhering to the standards established by the Occupational Safety and Health Administration (OSHA).
  • Proper handling of hazardous materials.
  • Use of personal protective equipment (PPE).
  • Reporting workplace injuries or unsafe conditions.
  • Reporting incidents of patient abuse or neglect.
  • Avoiding conflicts of interest, such as accepting inappropriate gifts from patients.
  • Ensuring accuracy in documentation and avoiding falsification of records.
  • Reporting harassment or bullying.
  • Using clear and respectful communication with colleagues and patients.

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