21 ncac 36 .0224             COMPONENTS OF NURSING PRACTICE FOR THE REGISTERED NURSE

(a)  The responsibilities that a registered nurse can safely accept shall be determined by such practice setting variables as:

(1)           the nurse's qualifications, including:

(A)          basic educational preparation; and

(B)          knowledge and skills subsequently acquired through continuing education and practice;

(2)           the complexity and frequency of nursing care needed by the client population;

(3)           the proximity of clients to personnel in the practice setting in which the nurse practices;

(4)           the qualifications and number of personnel in the practice setting in which the nurse practices;

(5)           the accessible resources in the practice setting in which the nurse practices; and

(6)           established policies, procedures, practices, and channels of communication that lend support to the types of nursing services offered in the practice setting in which the nurse practices.

(b)  Assessment is an on-going process and shall consist of a determination of nursing care needs based upon collection and interpretation of data relevant to the health status of a client, group, or community.

(1)           Collection of data shall include:

(A)          obtaining data from relevant sources regarding the biophysical, psychological, social, and cultural factors of the client's life and the influence these factors have on health status, including:

(i)            subjective reporting;

(ii)           observations of appearance and behavior;

(iii)          measurements of physical structure and physiological functions; and

(iv)          information regarding resources available to the client; and

(B)          verifying the data collected.

(2)           Interpretation of data shall include:

(A)          analyzing the nature and inter‑relationships of collected data; and

(B)          determining the significance of data to client's health status, ability to care for self, and treatment regimen.

(3)           Formulation of a nursing diagnosis shall include:

(A)          describing actual or potential responses to health conditions. Such responses are those for which nursing care is indicated or for which referral to medical or community resources is appropriate; and

(B)          developing a statement of a client problem identified through interpretation of collected data.

(c)  Planning nursing care activities includes identifying the client's needs and selecting or modifying nursing interventions related to the findings of the nursing assessment. Components of planning shall include:

(1)           prioritizing nursing diagnoses and needs;

(2)           setting realistic, measurable goals and outcome criteria;

(3)           initiating or participating in multidisciplinary planning;

(4)           developing a plan of care that includes determining and prioritizing nursing interventions; and

(5)           identifying resources based on necessity and availability.

(d)  Implementation of nursing activities shall be the initiating and delivering of nursing care according to an established plan, which includes:

(1)           procuring resources;

(2)           implementing nursing interventions and medical orders consistent with 21 NCAC 36 .0221(c) and within an environment conducive to client safety;

(3)           prioritizing and performing nursing interventions;

(4)           analyzing responses to nursing interventions;

(5)           modifying nursing interventions; and

(6)           assigning, delegating, and supervising the nursing activities of other licensed and unlicensed personnel consistent with Paragraphs (a) and (i) of this Rule, G.S. 90-171.20(7)(d) and (7)i, and 21 NCAC 36 .0401.

(e)  Evaluation shall consist of determining the extent to which desired outcomes of nursing care are met and planning for subsequent care, including:

(1)           collecting evaluative data from relevant sources;

(2)           analyzing the effectiveness of nursing interventions; and

(3)           modifying the plan of care based upon newly collected data, new problem identification, a change in the client's status, and expected outcomes.

(f)  Reporting and Recording by the registered nurse shall be those communications required in relation to all aspects of nursing care.

(1)           Reporting means the communication of information to other individuals responsible for, or involved in, the care of the client. The registered nurse shall:

(A)          direct the communication to the appropriate individuals;

(B)          assure that these communications are consistent with established policies, procedures, practices, and channels of communication which lend support to types of nursing services offered;

(C)          communicate within a time period that is consistent with the client's need for care;

(D)          evaluate the responses to information reported; and

(E)           determine whether further communication is indicated.

(2)           Recording means the documentation of information on the appropriate client record, nursing care plan or other documents. This documentation shall:

(A)          be pertinent to the client's health care;

(B)          accurately describe all aspects of nursing care, including assessment, planning, implementation, and evaluation;

(C)          be completed within a time period consistent with the client's need for care;

(D)          reflect the communication of information to other individuals; and

(E)           verify the proper administration and disposal of controlled substances.

(g)  Collaborating involves communicating and working cooperatively with individuals whose services may have a direct or indirect effect upon the client's health care and shall include:

(1)           initiating, coordinating, planning, and implementing nursing or multidisciplinary approaches for the client's care;

(2)           participating in decision‑making and in cooperative goal‑directed efforts;

(3)           seeking and utilizing appropriate resources in the referral process; and

(4)           safeguarding confidentiality.

(h)  Teaching and counseling clients shall be the responsibility of the registered nurse, consistent with 90‑171.20(7)g.

(1)           Teaching and counseling shall consist of providing accurate and consistent information, demonstrations, and guidance to clients, their families, or significant others for the purpose of:

(A)          increasing knowledge regarding the client's health status and health care;

(B)          assisting the client to reach an optimum level of health functioning and participation in self-care; and

(C)          promoting the client's ability to make informed decisions.

(2)           Teaching and counseling shall include:

(A)          assessing the client's needs, abilities, and knowledge level;

(B)          adapting teaching content and methods to the identified needs, abilities of the clients, and knowledge level;

(C)          evaluating effectiveness of teaching and counseling; and

(D)          making referrals to appropriate resources.

(i)  Managing the delivery of nursing care through the on‑going supervision, teaching, and evaluation of nursing personnel shall be the responsibility of the registered nurse, as specified in the legal definition of the practice of nursing, and includes:

(1)           continuous availability for direct participation in nursing care, onsite when necessary, as indicated by client's status and by the variables cited in Paragraph (a) of this Rule;

(2)           assessing capabilities of personnel in relation to client status and the plan of nursing care;

(3)           delegating responsibility or assigning nursing care functions to personnel qualified to assume such responsibility and to perform such functions;

(4)           accountability for nursing care given by all personnel to whom that care is assigned and delegated; and

(5)           direct observation of clients and evaluation of nursing care given.

(j)  Administering nursing services is the responsibility of the registered nurse, as specified in the legal definition of the practice of nursing in G.S. 90‑171.20(7)i, and includes:

(1)           identification, development, and updating of standards, policies, and procedures related to the delivery of nursing care;

(2)           implementation of the identified standards, policies, and procedures to promote safe and effective nursing care for clients;

(3)           planning for and evaluation of the nursing care delivery system; and

(4)           management of licensed and unlicensed personnel who provide nursing care consistent with Paragraphs (a) and (i) of this Rule including:

(A)          appropriate allocation of human resources to promote safe and effective nursing care;

(B)          defined levels of accountability and responsibility within the nursing organization;

(C)          a mechanism to validate qualifications, knowledge, and skills of nursing personnel;

(D)          provision of educational opportunities related to expected nursing performance; and

(E)           implementation of a system for periodic performance evaluation.

(k)  Accepting responsibility for self for individual nursing actions, competence, and behavior shall be the responsibility of the registered nurse, including:

(1)           having knowledge and understanding of the statutes and rules governing nursing;

(2)           functioning within the legal boundaries of registered nurse practice; and

(3)           respecting client rights and property and the rights and property of others.

History Note:        Authority G.S. 90‑171.20(7); 90‑171.23(b); 90‑171.43(4);

Eff. January 1, 1991;

Temporary Amendment Eff. October 24, 2001;

Amended Eff. August 1, 2002;

Readopted Eff. January 1, 2019.