In the United States, nursing is regulated by each state, not by the federal government. Every state, the District of Columbia, and the US territories have a Nurse Practice Act (NPA) — a statute passed by the legislature — and a board of nursing (BON) that writes rules and regulations to carry out the act.

What an NPA typically contains

• Definitions of nursing and of the practice of registered nurses (RNs), licensed practical/vocational nurses (LPN/VNs), and advanced practice registered nurses (APRNs)
• Requirements for licensure (education from an approved program, passing the national licensure examination, background checks)
• Title protection — only licensed persons may use titles such as "RN"
• Standards for education programs
• Grounds for discipline and the disciplinary process
• Composition, powers, and duties of the board of nursing

Purpose of licensure — to protect the public by ensuring that nurses meet minimum competence. Licensure is a state privilege, not a right; the board's primary duty is public protection, not the advancement of the profession.

Scope of practice — the activities a licensed professional is legally allowed to perform. It is set by the NPA and board rules and narrowed further by the individual nurse's education and competence and by employer policy. An employer can restrict, but never expand, a nurse's legal scope.

Levels of nursing practice (general pattern; details vary by state)

The APRN Consensus Model (2008) promotes uniform APRN regulation through Licensure, Accreditation, Certification, and Education (LACE). States still differ on full, reduced, or restricted practice authority for nurse practitioners.

Licensure examination and the national role of NCSBN — state boards contract with the National Council of State Boards of Nursing (NCSBN), which develops the national licensure examinations for RNs and PN/VNs; since April 2023 the "Next Generation" format measures clinical judgment. NCSBN does not issue licenses; state boards do. NCSBN also maintains Nursys, the national database for verifying licenses and discipline.

Nurse Licensure Compact (NLC)

• An interstate agreement that lets a nurse hold one multistate license, issued by the primary state of residence, and practice (in person or by telehealth) in all other compact states
• The nurse must follow the NPA of the state where the client is located at the time of care
• If a nurse moves their legal residence to another compact state, they must apply for a license in the new home state
• Nurses who live in non-compact states hold single-state licenses; a nurse practicing in a non-compact state needs that state's license
• As of mid-2026, more than 40 jurisdictions had enacted the NLC, with a few awaiting implementation; always check the current NCSBN map
• The NLC covers RN and LPN/VN licenses only; APRNs need separate authorization in each state where they practice as APRNs

Delegation (NCSBN/ANA National Guidelines for Nursing Delegation, 2019)

• Assignment — distributing routine care that is within the authorized scope of the RN or LPN/VN, or within the routine functions of the assistive personnel
• Delegation — allowing a delegatee to perform a specific nursing activity that is beyond the delegatee's traditional role and not routinely performed, when the delegatee has been trained and is competent
• Five rights of delegation: right task, right circumstance, right person, right directions and communication, right supervision and evaluation
• Not delegable: nursing judgment, comprehensive assessment, care planning, evaluation, and teaching that requires nursing judgment; care of unstable clients or tasks with unpredictable outcomes
• Accountability: the delegating nurse remains accountable for the decision to delegate and for supervision; the delegatee is responsible for performing the task correctly and reporting back; the employer provides policies, training, and adequate staffing

Scope decision process (based on the NCSBN scope-of-practice decision framework)

1. Is the activity prohibited by the NPA, board rules, other laws, or accreditation and professional standards? If yes, stop.
2. Is it consistent with evidence-based nursing and health care standards?
3. Has the nurse completed the necessary education?
4. Does the nurse have documented, current competence?
5. Is it supported by organizational policies and procedures, with appropriate resources in the practice setting?
6. Would a reasonable and prudent nurse perform it in this situation?
7. Is the nurse prepared to accept accountability for the activity and its outcome?

If the answer to any question is "no," the nurse does not perform the activity.

Grounds for board discipline (common)

• Practicing beyond scope or without a valid license
• Substance use impairing practice, drug diversion
• Fraud, falsified documentation, or deception in obtaining a license
• Client abuse, neglect, abandonment, or boundary violations (including sexual misconduct)
• Certain criminal convictions
• Breach of confidentiality, including on social media
• Failure to report as required

Board actions range from a letter of concern, fine, remediation, or probation to suspension or revocation. Many boards offer alternative-to-discipline programs for nurses with substance use disorders who self-report and complete monitored treatment. Nurses are entitled to due process (notice and a hearing).

Continuing competence — license renewal periods and continuing education requirements vary by state; the nurse is responsible for knowing and meeting them.

• Know the NPA and rules of every state in which you practice, including telehealth
• Practice within your legal scope and personal competence; refuse assignments that exceed either, while not abandoning clients (notify the supervisor and help find a safe alternative)
• Delegate using the five rights; give clear directions (what, when, what to report); supervise and evaluate
• Verify licensure and competence of those you supervise per policy
• Keep your own license active; report changes (name, address, primary state of residence) to the board
• Report impaired or unsafe practice as required by state law and policy
• Supervise AP appropriately: an RN who sees an AP performing an action outside their role must stop the action, ensure client safety, and follow up

• An NPA is law; violating it can lead to discipline and, in some cases, criminal charges (e.g., practicing without a license)
• A provider's order or employer policy does not authorize a nurse to act outside the NPA
• Board discipline (administrative law) is separate from civil malpractice (Topic 5) and criminal proceedings; one event can lead to all three
• Discipline actions are public and reported to Nursys and the National Practitioner Data Bank
• Ethically, accepting an assignment beyond one's competence violates the Code's accountability provision; so does abandoning clients after accepting responsibility

Case 1. An RN plans to delegate to a nursing assistant: vital signs for a stable postoperative client on day 3, discharge teaching for a new diabetic, and ambulation of a stable client. Correct delegation: vital signs on the stable client and ambulation; not discharge teaching. Why: teaching requires nursing judgment and remains with the RN.

Case 2. A nurse assistant checks a client's glucose and prepares to draw up insulin based on the result. Correct action: the RN stops the action immediately, checks the client, administers insulin herself if due, and reports the incident to the manager. Why: medication administration and dose decisions are outside the assistant's role; the RN has a duty to supervise.

Case 3. A nurse with a multistate license issued by her home compact state gives telephone triage to a client located in another compact state. Rule: she follows the NPA of the client's state.

Case 4. A float nurse from a medical unit is asked to manage a neonatal intensive care assignment. Correct action: tell the charge nurse she lacks the competence, request an assignment matching her skills (e.g., support tasks under a NICU nurse), and not simply leave. Why: practice within competence and avoid abandonment.

• Believing the ANA or NCSBN issues licenses — only state boards license and discipline
• Thinking a hospital policy can expand scope — policies can only restrict it
• Delegating assessment, teaching, evaluation, or care of an unstable client to AP
• Assuming a multistate license lets the nurse follow the home state's NPA everywhere — follow the client's location
• Believing the delegating RN is no longer responsible after delegating — the RN keeps accountability for the delegation decision and supervision
• Confusing LPN data collection with RN assessment
• Assuming APRN prescribing authority is identical across states — it varies

• Nursing is regulated by state NPAs; boards of nursing exist to protect the public
• NCSBN develops the national licensure examination and runs Nursys and the compact; boards issue licenses
• NLC: multistate license from the primary state of residence; practice per the client's state law
• Five rights of delegation: task, circumstance, person, directions/communication, supervision/evaluation
• RNs do not delegate assessment, judgment, planning, evaluation, or teaching needing judgment, or unstable clients
• Delegator stays accountable; delegatee is responsible for performance
• APRN roles: CNP, CNS, CRNA, CNM; regulated through the LACE Consensus Model
• Employers can restrict but not expand scope