LEVELS OF NURSING PRACTICE IN FLORIDA AND ASSOCIATED RULES

The practice of nursing is regulated by the state in order to protect members of the public who need nursing care. Safe, competent nursing practice is grounded in the law as written in the state’s Nurse Practice Act and its rules.

Practical Nursing

A licensed practical nurse (LPN) means any person licensed in Florida to practice practical nursing. Practical nursing is the performance of selected acts, including the administration of treatments and medications in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness.

Practical nursing must be performed under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. Practical nurses are responsible and accountable for making decisions that are based on their educational preparation and experience in nursing (Florida Legislature, 2019b).

IV THERAPY

[This section is taken from F.A.C. 64B9-12, Administration of intravenous therapy by licensed practical nurses.]

The administration of intravenous therapy is the therapeutic infusion and/or injection of substances through the venous peripheral system, consisting of activity which includes: observing, initiating, monitoring, discontinuing, maintaining, regulating, adjusting, documenting, planning, intervening, and evaluating.

Individuals who have completed a Board-approved prelicensure practical nursing education program, professional nursing students who qualify as graduate practical nurses, or licensed practical nurses who have not completed the specified course under Rule 64B9-12.005, F.A.C., may engage in a limited scope of intravenous therapy under the direction of a registered nurse, physician, or dentist. This scope includes:

  • Perform calculation and adjustment of flow rate
  • Observe and report subjective and objective signs of adverse reactions to IV administration
  • Inspect insertion site, change dressing, and remove intravenous needle or catheter from peripheral veins
  • Hang bags or bottles of hydrating fluid

Aspects of intravenous therapy that are outside the scope of practice of the licensed practical nurse unless under the direct supervision of the registered professional nurse or appropriate physician (as outlined above) and which shall not be performed or initiated by licensed practical nurses without direct supervision include the following:

  • Initiation of blood and blood product transfusions
  • Initiation or administration of cancer chemotherapy
  • Initiation of plasma expanders
  • Initiation or administration of investigational drugs
  • Mixing intravenous solutions
  • IV pushes, except heparin flushes and saline flushes

Although this rule limits the scope of licensed practical nurse practice, it is appropriate for licensed practical nurses, under direct supervision, to care for patients who are receiving the above IV therapy.

“UNDER THE DIRECTION” VS. “UNDER DIRECT SUPERVISION”

It is important to note that “under the direction of a registered professional nurse” means that the registered professional nurse has delegated intravenous therapy functions to a qualified licensed practical nurse. The registered professional nurse does not in all instances have to be on the premises in order for the licensed practical nurse to perform the delegated functions. This must be distinguished from “direct supervision,” which means on the premises and immediately physically available (FLDOS, 2010d).

CASE

Tanya is an LPN with five years’ experience who has recently moved from Indiana to Florida. This is her first shift on a surgical floor following orientation, and she is responsible for five patients who are 1- to 4-days post-op. A new order has been written for Mr. Hansen, who is anemic. The order is for 2 units of packed red blood cells (PRBCs).

Tanya is uncertain whether she is allowed to carry out this order in Florida, so she confers with the charge nurse. She is reminded that the task is not within her legal scope of practice in Florida unless she is under direct supervision, so Tanya requests the charge nurse, an RN, to supervise her initiation of the blood. Her charge nurse agrees, and they review the order together and prepare to initiate the transfusion.

At the end of her shift, Tanya decides to review the LPN scope of practice once more. She refreshes her knowledge by visiting the Florida Administrative Code website and reading Division 64B9, Chapter 12, which describes the role of the LPN in intravenous therapy procedures. There she confirms that initiation of blood or blood products by an LPN may be performed only under the direct supervision of an RN.

SUPERVISION IN NURSING HOME FACILITIES

[This section is taken from F.A.C. 64B9-16, LPN supervision in nursing home facilities.]

Licensed practical nurses may supervise certified nursing assistants (CNAs) and unlicensed personnel in nursing home facilities pursuant to F.A.C. 64B9-16. The LPN, however, must complete a minimum 30-hour, post-basic supervisory education course (or a supervisory course at a postgraduate level) and demonstrate a work history of no less than six months of full-time clinical nursing experience in a hospital or nursing home. A registered nurse must provide supervision to the LPN.

Unlicensed personnel (UP) are defined as persons who do not hold licensure from the Division of Medical Quality Assurance of the Department of Health but who have been assigned to function in an assistive role to registered nurses or licensed practical nurses in the provision of patient care services through regular assignments or delegated tasks or activities and under the supervision of a nurse.

The tasks delegated by the LPN to the CNA or UP in a nursing home facility must be based on the following:

  • There shall be a registered nurse providing supervision of the licensed practical nurse.
  • The task/activity is within the area of responsibility of the nurse delegating the task.
  • The task/activity is within the knowledge, skills, and ability of the nurse delegating the task.
  • The task/activity is of a routine, repetitive nature and shall not require the CNA or UP to exercise nursing knowledge, judgment, or skill.
  • The CNA or UP can and will perform the task/activity with the degree of care and skill that would be expected of the nurse.

The tasks not to be delegated by the LPN include:

  • Any activity that is outside the scope of practice of the LPN, or in which the Nurse Practice Act stipulates that the LPN must have direct supervision of a registered nurse in order to perform the procedure
  • Those activities for which the licensed practical nurse, CNA, or UP has not demonstrated competence

(FLDOS, 2019b)

Professional Nursing

[This section is taken from F.S. 464.003, Definitions.]

A registered nurse (RN) means any person licensed in Florida to practice professional nursing. The practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to:

  • The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others
  • The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments
  • The supervision and teaching of other personnel in the theory and performance of any of the acts described in this subsection

A professional nurse is responsible and accountable for making decisions that are based upon the individual’s educational preparation and experience in nursing.

A nursing diagnosis is defined as the observation and evaluation of physical or mental conditions, behaviors, signs and symptoms of illness, and reactions to treatment, and the determination as to whether such conditions, signs, symptoms, and reactions represent a deviation from normal. Nursing diagnosis is in the scope of practice of registered nurses and defines their role. A nursing treatment is the establishment and implementation of a nursing regimen for the care and comfort of individuals, the prevention of illness, and the education, restoration, and maintenance of health (Florida Legislature, 2019b).

Specialty Certification

[This section is taken from F.S. 464.003, Definitions; F.S. 464.012, Certification of advanced practice registered nurse, fees; F.S. 464.0115, Certification of clinical nurse specialists; and F.S. 464.027, Registered nurse first assistant.]

ADVANCED PRACTICE REGISTERED NURSE

An advanced practice registered nurse (APRN) means any person licensed in Florida to practice professional nursing and certified in advanced or specialized nursing practice, including certified registered nurse anesthetists, certified nurse midwives, and certified nurse practitioners.

Within the context of advanced or specialized nursing practice, the advanced practice registered nurse may perform acts of nursing diagnosis and nursing treatment of alterations of health status. The advanced practice registered nurse may also perform acts of medical diagnosis and treatment, prescription, and operation defined by the Board of Nursing and their specialty.

Advanced practice registered nurse include certified registered nurse anesthetists, certified nurse midwives, clinical nurse specialists, psychiatric nurses, and certified nurse practitioners. Within the established framework, an advanced practice registered nurse may:

  • Perform acts of nursing diagnosis and nursing treatment of alterations in health status
  • Perform acts of medical diagnosis and treatment, prescription, and operation as authorized within the framework of an established supervisory protocol
  • Monitor and alter drug therapies
  • Initiate appropriate therapies for certain conditions
  • Order diagnostic tests and physical and occupational therapy
    (Florida Legislature, 2019b)
Certified Registered Nurse Anesthetist

In addition to the above, the certified registered nurse anesthetist may, to the extent authorized by established protocol approved by the medical staff of the facility in which the anesthetic service is performed, perform any or all of the following:

  • Determine the health status of the patient as it relates to the risk factors and to the anesthetic management of the patient through the performance of general bodily functions
  • Based on history, physical assessment, and supplemental laboratory results, determine, with the consent of the responsible physician, the appropriate type of anesthesia within the framework of the protocol
  • Order under the protocol preanesthetic medication
  • Perform under the protocol procedures commonly used to render the patient insensible to pain during the performance of surgical, obstetrical, therapeutic, or diagnostic clinical procedures, which include ordering and administering regional, spinal, and general anesthesia; inhalation agents and techniques; intravenous agents and techniques; and techniques of hypnosis
  • Order or perform monitoring procedures indicated as pertinent to the anesthetic healthcare management of the patient
  • Support life functions during anesthesia healthcare, including induction and intubation procedures; the use of appropriate mechanical supportive devices; and the management of fluid, electrolyte, and blood component balances
  • Recognize and take appropriate corrective action for abnormal patient responses to anesthesia, adjunctive medication, or other forms of therapy
  • Recognize and treat a cardiac arrhythmia while the patient is under anesthetic care
  • Participate in management of the patient while in the postanesthesia recovery area, including ordering the administration of fluids and drugs
  • Place special peripheral and central venous and arterial lines for blood sampling and monitoring as appropriate
    (Florida Legislature, 2019d)
Certified Nurse Midwife

The certified nurse midwife may, to the extent authorized by an established protocol which has been approved by the medical staff of the healthcare facility in which the midwifery services are performed, or approved by the nurse midwife’s physician backup when the delivery is performed in a patient’s home, perform any or all of the following:

  • Perform superficial minor surgical procedures
  • Manage the patient during labor and delivery, to include amniotomy, episiotomy, and repair
  • Order, initiate, and perform appropriate anesthetic procedures
  • Perform postpartum examination
  • Order appropriate medications
  • Provide family planning services and well-woman care
  • Manage the medical care of the normal obstetrical patient and the initial care of a newborn patient
    (Florida Legislature, 2019d)
Certified Nurse Practitioner

The certified nurse practitioner may perform any or all of the following acts within the framework of established protocol:

  • Manage selected medical problems
  • Order physical and occupational therapy
  • Initiate, monitor, or alter therapies for certain uncomplicated acute illnesses
  • Monitor and manage patients with stable chronic diseases
  • Establish behavioral problems and diagnosis and make treatment recommendations
    (Florida Legislature, 2019d)

CLINICAL NURSE SPECIALIST

A clinical nurse specialist (CNS) means any person licensed in Florida to practice professional nursing and certified in nurse specialist practice. Clinical nurse specialist practice is the delivery and management of advanced practice nursing care to individuals or groups, including the ability to:

  • Assess the health status of individuals and families using methods appropriate to the population and area of practice
  • Diagnose human responses to actual or potential health problems
  • Plan for health promotion, disease prevention, and therapeutic intervention in collaboration with the patient or client
  • Implement therapeutic interventions based on the nurse specialist’s area of expertise and within the scope of advanced nursing practice, including, but not limited to, direct nursing care, counseling, teaching, and collaboration with other licensed healthcare providers
  • Coordinate healthcare as necessary and appropriate and evaluate with the patient or client the effectiveness of care
    (Florida Legislature, 2019d)

PSYCHIATRIC NURSE

A psychiatric nurse who meets the requirements in F.S. 394.455(35), within the framework of an established protocol with a psychiatrist, may prescribe psychotropic controlled substances for the treatment of mental disorders (Florida Legislature, 2019d).

CERTIFIED REGISTERED NURSE FIRST ASSISTANT

Florida Statutes encourage the use of certified RN first assistants who meet the qualifications as “assistants at surgery” by physicians and hospitals to provide quality, cost-effective surgical intervention to healthcare recipients in the state.

Registered nurse first assistants meet the qualifications listed in F.S. 464.027:

  • RN licensure
  • Certification in perioperative nursing
  • Certificate from, and successful completion of, a recognized program (a recognized program addresses all content of the Association of periOperative Registered Nurses’ Core Curriculum for the Registered Nurse First Assistant, and includes one academic year, defined as 45 hours of didactic instruction and 120 hours of clinical internship or its equivalent of two college semesters)
    (Florida Legislature, 2019e)

Each healthcare institution must establish specific procedures for the appointment and reappointment of registered nurse first assistant staff members and for granting, renewing, and revising their clinical privileges.

Practice of Certified Nursing Assistants

[This section is taken from F.S. 464.201, Definitions; F.S. 464.203, Certified nursing assistants: certification requirement; and F.A.C. 64B9-15.]

A certified nursing assistant (CNA) means a person who meets the qualifications specified in the Florida Statutes and who is certified by the FBON as a certified nursing assistant. The practice of a certified nursing assistant means providing care and assisting persons with tasks relating to the activities of daily living. Such tasks are those associated with:

  • Personal care
  • Maintaining mobility
  • Nutrition and hydration
  • Toileting and elimination
  • Assistive devices
  • Safety and cleanliness
  • Data gathering
  • Reporting abnormal signs and symptoms
  • Postmortem care
  • Patient socialization and reality orientation
  • End-of-life care
  • Cardiopulmonary resuscitation and emergency care
  • Residents’ or patients’ rights
  • Documentation of nursing-assistant services
    (FLDOS, 2010c)

A comprehensive list of authorized duties for the certified nursing assistant is available in the F.A.C. 64B9-15.