Nurse practice acts and patient abandonment

Nursing Scope of Practice and Professional Boundaries: A Comprehensive Assignment

State boards of nursing hold legal authority over nursing scope of practice through Nurse Practice Acts, and registered nurses must refuse assignments when they lack the competence to perform safely. The following brief examines five scenarios involving competence, delegation, experimental drugs, mandatory overtime, and patient abandonment, requiring students to apply regulatory frameworks from their chosen state board of nursing.

Nursing Regulation and the State Board of Nursing

The organization responsible for defining and regulating a nurse’s scope of practice in any given state is the state board of nursing (BON), which operates under the authority granted by that state’s Nurse Practice Act (NPA). The National Council of State Boards of Nursing (NCSBN) provides a unifying framework across jurisdictions, yet the final authority for interpreting scope questions rests with each individual BON. State boards of nursing regulate licensure, establish standards of practice, and hold disciplinary authority up to license revocation[reference:0]. According to the American Nurses Association, scope of practice refers to “the services that a qualified health professional is deemed competent to perform and permitted to undertake in keeping with the terms of their professional license”[reference:1]. The ANA released the fourth edition of *Nursing: Scope and Standards of Practice* in 2021, which outlines eighteen professional practice standards that all registered nurses must meet[reference:2]. Nurses bear full responsibility for knowing their state’s NPA and can face discipline even for unintentional violations[reference:3].

Select a state, then address the following five scenarios using that state’s regulatory framework and the ANA standards as your guide.

Scenario 1: Unfamiliar Patient Population or Procedure

You are asked to care for an unfamiliar patient population or to go to a unit or perform a procedure with which you feel unqualified. What do you do?

Scenario 2: New Graduate Coverage Request

The evening supervisor asks Tom, a new graduate who has just completed his orientation to an adolescent pediatric unit, to cover the patient assignment of an infant unit nurse who needs to transport a stable infant to its home hospital.

Scenario 3: Experimental Chemotherapeutic Administration

Sue is asked to administer the drug XYZ, an experimental chemotherapeutic, to one of her patients. Sue has no knowledge or experience with the drug XYZ.

Scenario 4: Mandatory Overtime and Fatigue

Nurse P is told by Nurse B, the charge nurse, that she must work another shift because of multiple sick calls for the upcoming shift. Nurse P is reluctant to work an additional shift because of her fatigue level.

Scenario 5: Patient Abandonment

Patient abandonment occurs when a nurse unilaterally severs the established nurse-patient relationship without giving reasonable notice so that arrangements can be made for continuation of care by others[reference:4]. The Washington State Board of Nursing emphasizes that the focus for disciplinary sanctions rests on the nurse’s relationship and responsibility to the patient rather than to the employer, and the primary concern is whether the nurse’s actions compromised patient safety[reference:5].

Sample Answer Guidance and Essay Excerpt

Regulatory Foundations for Scope Decisions

Nurses who face competence questions must consult their state board of nursing’s scope of practice decision-making model before accepting any assignment. The Texas Board of Nursing offers a step-by-step tool that asks nurses to determine whether an activity is prohibited by the NPA, authorized by a valid order, supported by evidence-based guidelines, and within the nurse’s demonstrated competency[reference:6]. When a nurse identifies a gap in knowledge or skill, the appropriate response involves notifying the supervisor, requesting orientation or training, and refusing the assignment if patient safety would be jeopardized. The Oregon State Board of Nursing explicitly requires licensees to refuse assignments when they lack the knowledge, skills, or abilities to provide safe care[reference:7]. For Tom, the new graduate asked to cover an infant unit, the adolescent pediatric orientation does not establish competence for infant care. Infant patients require weight-based medication calculations, different monitoring equipment, and developmental considerations that a new graduate oriented to adolescents may not possess. Sue faces a similar dilemma with the experimental chemotherapeutic drug XYZ; administering an investigational agent without protocol knowledge, safe-handling training, and adverse event recognition skills falls outside her individual scope of practice even if her license permits chemotherapy administration in general. The ANA’s fourth edition of *Nursing: Scope and Standards of Practice* includes a professional performance standard for advocacy, which obligates nurses to speak up when assignments threaten patient safety[reference:8].

Competence, Fatigue, and Abandonment Boundaries

Nurse P’s reluctance to work an additional shift because of fatigue reflects a legitimate patient safety concern, not merely a personal preference. Research published in the *Journal of Advanced Nursing* demonstrates that overtime on rotating-shift patterns impairs nurses’ alertness and increases risks for patients[reference:9]. The American Nurses Association and the National Institute for Occupational Safety and Health have both linked extended work hours to elevated error rates, compromised decision-making, and diminished patient outcomes[reference:10]. When Nurse B mandates additional coverage, Nurse P should communicate her fatigue level and its potential impact on patient safety, then collaboratively explore alternatives such as splitting the shift, contacting per diem staff, or having the charge nurse assume direct care responsibilities. Patient abandonment allegations arise only when a nurse has accepted an assignment, established a nurse-patient relationship, and then left without reasonable notice or transfer of care[reference:11]. A nurse who refuses an assignment before accepting it does not commit abandonment; a nurse who accepts an assignment and then leaves mid-shift without ensuring continuity of care does. The Kentucky Board of Nursing clarifies that nurses have a professional and ethical obligation to avoid patient abandonment and to withdraw only when assured that nursing care is available to the patient[reference:12]. For all five scenarios, documentation of the refusal, communication with supervisors, and invocation of safe harbor processes where available provide legal protection while prioritizing patient welfare.

Practical Applications and Professional Standards

These scenarios reflect real workplace tensions that nurses encounter throughout their careers. The ANA Code of Ethics for Nurses with Interpretive Statements, particularly Provision 4, asserts that nurses bear responsibility and accountability for individual nursing practice and determine the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care. The National Council of State Boards of Nursing maintains a uniform scope of practice decision-tree that four major nursing organizations developed collaboratively, providing a standardized framework for licensed nurses across all settings[reference:13]. Healthcare institutions that implement nurse residency programs and competency validation systems reduce the likelihood that new graduates face unsafe assignments. When nurses understand the distinction between employer expectations and professional obligations, they can advocate effectively for themselves and their patients without fear of retaliation.

Why This Matters in Practice

Scope of practice violations can result in license suspension or revocation, malpractice liability, and patient harm. The ANA’s Standards of Professional Nursing Practice explicitly require nurses to accept only those assignments they are competent to carry out safely[reference:14]. Nurses who understand the regulatory landscape can invoke safe harbor protections, request competency validation, and document their concerns through appropriate channels. These actions protect patients, preserve professional integrity, and maintain the public trust that licensure represents.

Research, Writing, Citation and Referencing Guide

When composing this assignment, integrate citations from the ANA’s *Nursing: Scope and Standards of Practice* (4th ed.) and your state board of nursing’s position statements on patient abandonment and scope determination. Use APA 7th edition formatting unless your program specifies otherwise. Include a title page, reference list, and in-text citations that correspond to each scenario analysis. Prioritize sources published within the last five years to demonstrate currency in nursing regulation and evidence-based practice.

Commonly Asked Question

What happens if a nurse refuses an assignment and the employer threatens termination?

State nurse practice acts and board rules generally protect nurses who refuse assignments that would violate their scope of practice or jeopardize patient safety. The Texas Board of Nursing’s Position Statement 15.6 distinguishes between leaving an employment setting, which may be an employment issue, and leaving a patient care assignment without reasonable notice, which constitutes patient abandonment[reference:15]. Nurses who refuse before accepting an assignment do not establish a nurse-patient relationship and therefore cannot commit abandonment. Documenting the refusal, notifying appropriate supervisors, and invoking safe harbor or peer review processes where available create a defensible record. Some states, including Texas, permit a nurse to refuse conduct that may jeopardize patient safety under Section 301.352 of the Nursing Practice Act[reference:16]. Employers may still terminate at-will employees, but board disciplinary action typically hinges on whether patient safety was compromised and whether proper notice was given.

References

• American Nurses Association. (2021). Nursing: Scope and Standards of Practice (4th ed.). American Nurses Association. https://www.nursingworld.org/practice-policy/scope-of-practice/
• National Council of State Boards of Nursing. (2023). Nurse Practice Act toolkit. https://www.ncsbn.org/npa-toolkit.htm
• Texas Board of Nursing. (2020). Nursing practice standards and scope of practice decision-making model. Texas Board of Nursing Bulletin. https://bon.texas.gov/pdfs/newsletter_pdfs/2020/April%202020%20Bulletin%20Web.pdf
• Washington State Board of Nursing. (2022). What does the Washington State Board of Nursing consider as patient abandonment? https://nursing.wa.gov/faq/what-does-washington-state-board-nursing-wabon-consider-patient-abandonment
• Oregon State Board of Nursing. (2023). Interpretive statement: Duty to provide care and patient abandonment. https://www.oregon.gov/OSBN/

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