Ambulatory Scope of Practice: The Nursing Process Applied to the Development of Non-Nursing Scope of Practice

Nursing is a leader in setting national standards that are the basis for establishing scope of practice for other ambulatory care healthcare disciplines. A multidisciplinary team, focused on developing and defining scope of practice pertaining to non-nursing disciplines, should include unlicensed clinical staff, providers, and nurses. Evaluating the roles, specifically the unlicensed clinical staff (e.g., medical assistants), requires an understanding of initial development of the role. Beginning with an assessment of the state and/or national laws that affect the roles is foundational. Next is to evaluate the roles’ skills and knowledge validated during their education and training, inclusive of the programs national accreditation status and curriculum. Utilizing the role’s professional organization and credentialing exams supports the development of an occupational analysis and creates a list of job/ tasks that are within their scope.

A large, integrated health system focused in the Midwest started with defining the MA scope with a multidisciplinary team and review of resources listed in the previous steps. The organization then turned to internal job descriptions for the specific roles and a fresh review of any policies/procedures/protocols applicable to the role. A crosswalk of assigned work and definition of what tasks could be delegated, identifies any issues that will be critical to the scope development and are significant determining factors. An excel spreadsheet of all tasks and delegated skills was developed for each unlicensed clinical role, e.g., paramedic. In addition, skills or tasks that were specific to a provider-based practice were looked at, and it was determined if there was a need for validation of these skills.

As scope was developed for the roles, the proposed guidelines were presented and approved by the system quality and safety committee, which was comprised of the presidents, chief medical officers, chief nursing officers, and chief operating officers. Presentations of the scope of practice, applicable state laws, and policies were made to provider-based practice leaders, and offers to present at their team meetings were extended. An intranet web page was developed posting the defined scope of practice, frequently asked questions, and a toolkit including a decision tree with available resources and references used in the development of this new scope.

Changes in outcomes were not evident until the data around e-prescribing by unlicensed clinical staff was shown and supported by the Institute for Safe Medication Practices and The Joint Commission. The data and the development of a toolkit to support the implementation of MA scope of practice, including a report to track prescriptions in the electronic health record which was communicated by the system’s chief medical officer, supported the ongoing changes in the practice level standard work for an over 83% improvement.