CHAPTER 6
NURSING PRACTICE FOR
REGISTERED NURSES/LICENSED PRACTICAL NURSES
655—6.1(152) Definitions.
“Accountability” means being obligated to answer for one’s acts, including the act of supervision.
“Advanced registered nurse practitioner (ARNP)” means a nurse with current licensure as a registered nurse in Iowa who is registered in Iowa to practice in an advanced role. The ARNP is prepared for an advanced role by virtue of additional knowledge and skills gained through an organized postbasic program of nursing in a specialty area approved by the board. In the advanced role, the nurse practices nursing assessment, intervention, and management within the boundaries of the nurse-client relationship. Advanced nursing practice occurs in a variety of settings, within an interdisciplinary health care team, which provide for consultation, collaborative management, or referral. The ARNP may perform selected medically delegated functions when a collaborative practice agreement exists.
“Basic nursing education” means a nursing program preparing a person for initial licensure to practice nursing as a registered nurse or licensed practical nurse.
“Board” as used in this chapter means the Iowa board of nursing.
“Certified clinical nurse specialist” means an ARNP prepared at the master’s level who possesses evidence of current certification as a clinical specialist in an area of nursing practice by a national professional nursing association as approved by the board.
“Certified nurse-midwife” means an ARNP educated in the disciplines of nursing and midwifery who possesses evidence of current certification by a national professional nursing association approved by the board. The certified nurse-midwife is authorized to manage the care of normal newborns and women, antepartally, intrapartally, postpartally or gynecologically.
“Certified nurse practitioner” means an ARNP educated in the disciplines of nursing who has advanced knowledge of nursing, physical and psychosocial assessment, appropriate interventions, and management of health care, and who possesses evidence of current certification by a national professional nursing association approved by the board.
“Certified registered nurse anesthetist” means an ARNP educated in the disciplines of nursing and anesthesia who possesses evidence of current certification by a national professional nursing association approved by the board.
“Competence in nursing” means having the knowledge and the ability to perform, skillfully and proficiently, the functions within the role of the licensed nurse.
“Minimum standards” means standards of practice that interpret the legal definition of nursing as well as provide criteria against which violations of the law can be determined.
“Nursing diagnosis” means a judgment made by a registered nurse, following a nursing assessment of individuals and groups about actual or potential responses to health problems, which forms the basis for determining effective nursing interventions.
“Nursing facility” means an institution as defined in Iowa Code chapter 135C. This definition does not include acute care settings.
“Nursing process” means ongoing assessment, nursing diagnosis, planning, intervention, and evaluation.
“Proximate area” means that the registered nurse analyzes the qualifications of the licensed practical nurse in relationship to nursing needs of the client in determining the appropriate distance within the building and the time necessary to be readily available to the licensed practical nurse.
“Unlicensed assistive personnel” is an individual who is trained to function in an assistive role to the registered nurse and licensed practical nurse in the provision of nursing care activities as delegated by the registered nurse or licensed practical nurse.
655—6.2(152) Minimum standards of nursing practice for registered nurses.
	6.2(1) The registered nurse shall recognize and understand the legal implications within the scope of nursing practice. The scope of nursing practice considered to be minimum standards of nursing practice shall not be interpreted to include those practices currently ascribed to the advanced registered nurse practitioner.
	6.2(2) The registered nurse shall utilize the nursing process in the practice of nursing, consistent with accepted and prevailing practice. The nursing process is ongoing and includes:
	a. 	Nursing assessments about the health status of an individual or group.
	b. 	Formulation of a nursing diagnosis based on analysis of the data from the nursing assessment.
	c. 	Planning of nursing care which includes determining goals and priorities for actions which are based on the nursing diagnosis.
	d. 	Nursing interventions implementing the plan of care.
	e. 	Evaluation of the individual’s or group’s status in relation to established goals and the plan of care.
	6.2(3) The registered nurse shall conduct nursing practice by respecting the rights of an individual or group.
	6.2(4) The registered nurse shall conduct nursing practice by respecting the confidentiality of an individual or group, unless obligated to disclose under proper authorization or legal compulsion.
	6.2(5) The registered nurse shall recognize and understand the legal implications of accountability. Accountability includes but need not be limited to the following:
	a. 	Performing or supervising those activities and functions which require the knowledge and skill level currently ascribed to the registered nurse and seeking assistance when activities and functions are beyond the licensee’s scope of preparation.
	b. 	Assigning and supervising persons performing those activities and functions which do not require the knowledge and skill level currently ascribed to the registered nurse.
	c. 	Supervising, among other things, includes any or all of the following:
	(1)	Direct observation of a function or activity.
	(2)	Assumption of overall responsibility for assessing, planning, implementing, and evaluating nursing care.
	(3)	Delegation of nursing tasks while retaining accountability.
	(4)	Determination that nursing care being provided is adequate and delivered appropriately.
	d. 	Executing the regimen prescribed by a physician. In executing the medical regimen as prescribed by the physician, the registered nurse shall exercise professional judgment in accordance with minimum standards of nursing practice as defined in these rules. If the medical regimen prescribed by the physician is not carried out, based on the registered nurse’s professional judgment, accountability shall include but need not be limited to the following:
	(1)	Timely notification of the physician who prescribed the medical regimen that the order(s) was not executed and reason(s) for same.
	(2)	Documentation on the medical record that the physician was notified and reason(s) for not executing the order(s).
655—6.3(152) Minimum standards of practice for licensed practical nurses.
	6.3(1) The licensed practical nurse shall recognize and understand the legal implications within the scope of nursing practice. The licensed practical nurse shall perform services in the provision of supportive or restorative care under the supervision of a registered nurse or physician as defined in the Iowa Code.
	6.3(2) The licensed practical nurse shall participate in the nursing process, consistent with accepted and prevailing practice, by assisting the registered nurse or physician. A licensed practical nurse may assist the registered nurse in monitoring, observing and reporting reactions to therapy. The licensed practical nurse may add intravenous solutions without medications to established intravenous sites, regulate the rate of nonmedicated intravenous solutions and discontinue intravenous therapy. The licensed practical nurse shall not perform any procedure/treatment requiring the knowledge and skill ascribed to the registered nurse, including:
	a. 	The initiation of intravenous solutions, intravenous medications and blood components.
	b. 	The administration of medicated intravenous solutions, intravenous medications and blood components.
	c. 	The initiation or administration of medications requiring the knowledge and skill level currently ascribed to the registered nurse.
	6.3(3) The licensed practical nurse may provide nursing care in an acute care setting. When the nursing care provided by the licensed practical nurse in an acute care setting requires the knowledge and skill level currently ascribed to the registered nurse, a registered nurse or physician must be present in the proximate area. Acute care settings requiring the knowledge and skill ascribed to the registered nurse include, but are not limited to:
	a. 	Units where care of the unstable, critically ill, or critically injured individual is provided.
	b. 	General medical-surgical units.
	c. 	Emergency departments.
	d. 	Operating rooms. (A licensed practical nurse may assist with circulating duties when supervised by a registered nurse circulating in the same room.)
	e. 	Postanesthesia recovery units.
	f. 	Hemodialysis units.
	g. 	Labor and delivery/birthing units.
	h. 	Mental health units.
	6.3(4) The licensed practical nurse may provide nursing care in a non-acute care setting. When the nursing care provided by the licensed practical nurse in a non-acute care setting requires the knowledge and skill level currently ascribed to the registered nurse, the registered nurse or physician must be present in the proximate area. The non-acute care settings requiring the knowledge and skill level ascribed to the registered nurse include, but are not limited to:
	a. 	Community health. (Subrules 6.6(1) and 6.6(3) are exceptions to the “proximate area” requirement.)
	b. 	School nursing. (Subrule 6.6(2) is an exception to the “proximate area” requirement.)
	c. 	Occupational nursing.
	d. 	Correctional facilities.
	e. 	Community mental health nursing.
	6.3(5) The licensed practical nurse shall conduct nursing practice by respecting the rights of an individual or group.
	6.3(6) The licensed practical nurse shall conduct nursing practice by respecting the confidentiality of an individual or group, unless obligated to disclose under proper authorization or legal compulsion.
	6.3(7) The licensed practical nurse shall recognize and understand the legal implications of accountability. Accountability includes but need not be limited to the following:
	a. 	Performing those activities and functions which require the knowledge and skill level currently ascribed to the licensed practical nurse and seeking assistance when activities and functions are beyond the licensee’s scope of preparation.
	b. 	Accepting responsibility for performing assigned and delegated functions and informing the registered nurse when assigned and delegated functions are not executed.
	c. 	Executing the medical regimen prescribed by a physician. In executing the medical regimen as prescribed by the physician, the licensed practical nurse shall exercise prudent judgment in accordance with minimum standards of nursing practice as defined in these rules. If the medical regimen prescribed by the physician is not carried out based on the licensed practical nurse’s prudent judgment, accountability shall include but need not be limited to the following:
	(1)	Timely notification of the physician who prescribed the medical regimen that said order(s) was not executed and reason(s) for same.
	(2)	Documentation on the medical record that the physician was notified and reason(s) for not executing the order(s).
655—6.4(152) Additional acts which may be performed by registered nurses.
	6.4(1) A registered nurse shall be permitted to practice as a diagnostic radiographer while under the supervision of a licensed practitioner provided that appropriate training standards for use of radiation-emitting equipment are met as outlined in 641—42.1(136C).
	6.4(2) A registered nurse, licensed pursuant to Iowa Code chapter 152, may staff an authorized ambulance, rescue, or first response service provided the registered nurse can document equivalency through education and additional skills training essential in the delivery of out-of-hospital emergency care. The equivalency shall be accepted when documentation has been reviewed and approved at the local level by the medical director of the ambulance, rescue, or first response service in accordance with the form adopted by the Iowa department of public health bureau of emergency medical services. An exception to this subrule is the registered nurse who accompanies and is responsible for a transfer patient.
This rule is intended to implement Iowa Code section 147A.12 and chapters 136C and 152.
655—6.5(152) Additional acts which may be performed by licensed practical nurses.
	6.5(1) A licensed practical nurse shall be permitted to supervise unlicensed assistive personnel under the provisions of Iowa Code section 152.1(4)“b.”
	a. 	Supervision, among other things, includes any or all of the following:
	(1)	Direct observation of a function or activity.
	(2)	Delegation of nursing tasks while retaining accountability.
	(3)	Determination that nursing care being provided is adequate and delivered appropriately.
	b. 	Supervision shall be in accordance with the following:
	(1)	A licensed practical nurse working under the supervision of a registered nurse shall be permitted to supervise in an intermediate care facility for the mentally retarded or in a residential health care setting.
	(2)	A licensed practical nurse working under the supervision of a registered nurse shall be permitted to supervise in a nursing facility.
The licensed practical nurse shall be required to complete a curriculum which has been approved by the board and designed specifically for the supervision role of the licensed practical nurse in a nursing facility. The course must be presented by a board-approved nursing program or an approved provider of continuing education. Documentation of the completion of the curriculum as outlined in this subparagraph shall be maintained by the licensed practical nurse.
	(3)	A licensed practical nurse shall be entitled to supervise without the educational requirement outlined in subparagraph 6.5(1)“b”(2) if the licensed practical nurse was performing in a supervisory role on or before October 6, 1982. The licensed practical nurse being employed in a supervisory role after the enactment of these rules shall complete the curriculum outlined in subparagraph 6.5(1)“b”(2) within six months of employment.
	(4)	A licensed practical nurse working under the supervision of a registered nurse may direct the activities of other licensed practical nurses and unlicensed assistive personnel in an acute care setting in giving care to individuals assigned to the licensed practical nurse. The registered nurse must be in the proximate area.
	6.5(2) A licensed practical nurse shall be permitted to practice as a diagnostic radiographer while under the supervision of a licensed practitioner provided that appropriate training standards for use of radiation-emitting equipment are met as outlined in 641—42.1(136C).
This rule is intended to implement Iowa Code chapters 136C and 152.
655—6.6(152) Specific nursing practice for licensed practical nurses.
	6.6(1) The licensed practical nurse shall be permitted to provide supportive and restorative care in the home setting under the supervision of a registered nurse, as defined in subrule 6.2(5), or a physician. When the licensed practical nurse provides care under the supervision of the registered nurse, the initial assessment and ongoing application of the nursing process shall be provided by the registered nurse.
	6.6(2) The licensed practical nurse shall be permitted to provide supportive and restorative care in a Head Start program under the supervision of a registered nurse, as defined in subrule 6.2(5), or a physician if the licensed practical nurse were in this position prior to July 1, 1985.
	6.6(3) The licensed practical nurse shall be permitted to provide supportive and restorative care in a camp setting under the supervision of a registered nurse, as defined in subrule 6.2(5), or a physician. When the licensed practical nurse provides care under the supervision of the registered nurse, the initial assessment and ongoing application of the nursing process are performed by the registered nurse. The licensed practical nurse is responsible for requesting registered nurse consultation as needed.
This rule is intended to implement Iowa Code sections 17A.3 and 152.1.
655—6.7(152) Specific nursing practice for registered nurses. A registered nurse, while circulating in the operating room, shall provide supervision only to persons in the same operating room.
This rule is intended to implement Iowa Code section 152.1.
[Filed 3/11/81, Notice 12/10/80—published 4/1/81, effective 5/6/81]1
[Filed emergency 12/2/81—published 12/23/81, effective 12/2/81]
[Filed 2/17/82, Notice 12/23/81—published 3/17/82, effective 4/21/82]2
[Filed 6/17/82, Notice 5/12/82—published 7/7/82, effective 8/11/82]
[Filed 8/13/82, Notices 3/17/82, 6/9/82—published 9/1/82, effective 10/6/82]
[Filed emergency 7/29/83—published 8/17/83, effective 7/29/83]
[Filed 10/21/83, Notice 8/17/83—published 11/9/83, effective 12/14/83]
[Filed 7/26/84, Notice 5/23/84—published 8/15/84, effective 7/1/85]3
[Filed 1/22/85, Notice 12/5/84—published 2/13/85, effective 3/20/85]
[Filed without Notice 7/19/85—published 8/14/85, effective 9/18/85]
[Filed 11/27/85, Notice 10/9/85—published 12/18/85, effective 1/22/86]
[Filed 1/30/87, Notice 12/3/86—published 2/25/87, effective 4/1/87]
[Filed emergency 7/29/87—published 8/26/87, effective 7/29/87]
[Filed 4/1/88, Notice 2/24/88—published 4/20/88, effective 5/25/88]
[Filed 9/18/91, Notice 7/24/91—published 10/16/91, effective 11/20/91]
[Filed 12/9/92, Notice 10/14/92—published 1/6/93, effective 2/10/93]4
[Filed 3/20/97, Notice 1/1/97—published 4/9/97, effective 5/14/97]
1	Effective date of 5/6/81 delayed 70 days by the Administrative Rules Review Committee [Published IAB 4/29/81].
2	Effective date of 4/21/82 delayed 70 days by the Administrative Rules Review Committee [Published IAB 4/28/82]. Delay lifted by committee on June 9, 1982.
3	Amendments to 6.3(3), paragraphs “g” and “h,” and 6.6 effective 7/1/85, IAB 8/15/84.
4	Effective date delayed until adjournment of the 1993 General Assembly by the Administrative Rules Review Committee at its meeting held February 8, 1993; subrule 6.4(2) nullified by 1993 Iowa Acts, HJR 17, effective April 23, 1993.