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Acting Within Autonomous Scope of Practice

Practice Standard for licensed practical nurses

​​Introduction

Standards​​

BCCNM li​mits and conditions for licensed practical nurse: 

​​​

Int​rod​​​u​ction

The Licensed Practical Nurse: Acting within Autonomous Scope of Practice standards, limits, and conditions apply to licensed practical nurses (LPNs) when they are acting within autonomous scope of practice (without an order).

Acting within autonomous scope of practice refers to licensed practical nurses:

  • Assuming accountability and responsibility for making decisions about client care, and
  • Perform​​ing activities that they are competent and allowed to perform without a client-specific order. 

Licensed practical nurses are allowed within their autonomous scope of practice to make a nursing diagnosis[1] of a client condition that can be prevented, improved, ameliorated, or resolved through nursing activities.  Autonomous scope of practice includes:

  • Restricted activities that do not require an order per the Nurses (Licensed Practical) Regulation, and
  • Care or services that are not restricted activities, unless excluded from autonomous scope of practice (without an order) by any BCCNM standard, limit, or condition.

Licensed pr​actical nurses may provide care or services to clients by acting within their autonomous scope of practice when the care or services are:

  1. Within the licensed practical nurse's autonomous scope of practice (without an order),
  2. Provided in alignment with BCCNM standards, limits, and conditions, 
  3. Allowed by organizational/employer policies, processes, and
  4. Within the licensed practical nurse's individual competence.​

Licensed practical nurses need to know when they are allowed to act within their autonomous scope of practice (without a client-specific order) and when a client-specific order is required before performing ​an activity.  Licensed practice nurses follow the Licensed Practical Nurse: Acting with Client-specific Orders standards, limits, and conditions when performing activities that are not within their autonomous scope of practice.​ ​​

​​Sta​ndards

​1.

Licensed practical nurses are accountable and responsible when they make a decision that the client's condition[2] would benefit from an activity and act within autonomous scope of practice to perform the activity.

​2.
Licensed practical nurses acting within autonomous scope of practice ensure that the activity they will perform is: 
a.​ ​With​​in the scope of practice for licensed practical nurses acting without a client-specific order as set out in the Nurses (Licensed Practical) Regulation
​b.
​Cons​istent with BCCNM's standards of practice including standards, limits, and conditions,​
​c.
​Consistent wit​h organizational/employer policies, processes, restrictions, and ​
​d.
​Wit​hin the nurse's individual competence.​
​3.
​​Licensed practical nurses acting within autonomous scope of practice ensure they have the competence to:  ​

​a.
​Make decisions about whether the client would benefit from the activity, having considered: 


​i.
​Potential risks to the clients and how to minimize those risks,

​ii.
​The benefits to the client, 


​iii.
​The predictability of outcomes of performing the activity, and


​iv.
​Other relevant factors specific to the client or situation, 

​b.
​Carry out the activity safely and ethically, and  ​

​c.
​Safely manage the intended and unintended outcomes of performing the activity.   
​4.

​​​Before performing an activity within autonomous scope of practice, licensed practical nurses consider applicable employer/organizational policies, processes, and resources, and other relevant human and system factors that may impact their ability to:

​a.
​Perform the activity competently and safely within their practice setting, and

​b.
​Manage intended and unintended outcomes of the activity.
​5.
Licensed practical nurses perform advanced activities within their autonomous scope of practice only when they have obtained the additional education, training and/or clinical experience needed to gain and maintain the competence to perform the activity safely.
​6.

​Licensed practical nurses acting within autonomous scope of practice identify the effect of their own values, beliefs, and experiences in decision-making, recognize potential conflicts, and take action for the needs of the client to be met.  
​7.
​Licensed practical nurses acting within autonomous scope of practice use current evidence to support their decision-making and the activity to be performed.  
​8.
​Licensed practical nurses acting within autonomous scope of practice follow a clinical decision-making process when they: 

​a.
​Assess the client’s health status,

b.​ ​Make a nursing diagnosis[3] of a client condition that can be prevented, improved, ameliorated, or resolved through nursing activities,

c.​ ​Determine a plan of care, 

d.​ Determine an activity to be performed,

e.​ ​Imple​ment an activity to prevent, treat, or palliate an illness or injury and/or improve, ameliorate, or resolve a condition,

f.​ ​Change or cancel a client-specific order for activities within the nurse’s autonomous scope of practice, 

g.​ ​Manage the intended and unintended consequences of carrying out the activity,

​h.
​Manage and evaluate the outcomes of the activity.
9.
Licensed practical nurses acting within autonomous scope of practice communicate and collaborate with the client (or their substitute decision-maker) about nursing diagnoses, decisions, actions, and outcomes to support the client to be an active participant in making informed decisions about the care to meet the client’s needs.  
​10.
​Licensed practical nurses acting within autonomous scope of practice communicate and collaborate with the health-care team about nursing diagnoses, decisions, actions, and outcomes.
​11.
Licensed practical nurses acting within autonomous scope of practice communicate and collaborate with the health-care professional who gave the order (or their delegate), the client, and other members of the health care team when changing or cancelling a client-specific order for activities that are within the nurse’s autonomous scope of practice and individual competence.
​12.
Licensed practical nurses acting within autonomous scope of practice consult with, or refer clients to, other health-care professionals when:

​a.
​The needs of the client exceed their scope of practice or individual competence, 

​b.
Required by organizational/employer policies or processes, or 

​c.
​Client care would benefit from the expertise of other health care professionals.    


BCCNM limits and conditions for licensed practical nurse

Acting ​​​​​ within autonomous scope of practice (without an order)​


Activity BCCNM Limits and Conditions for Licensed Practical Nurse: Acting within Autonomous Scope of Practice (Without an Order)
1.​
Use of restraint

a.  LPNs apply restraints when an order from an authorized health professional is in place.

​2.
Care for clients on telemetry

a.      Licensed practical nurses work in a team nursing approach to provide care for clients on telemetry:

i.  With stable or predictable states of health

ii. After successfully completing additional education

b.      Licensed practical nurses are not responsible for monitoring or interpreting telemetry readings.

3.​ Change chest tube dressing a.  Licensed practical nurses change chest tube dressings:
i.  For clients with stable or predictable states of health
ii. After successfull​y completing additional education
iii. By following decision support tools
​4.
Measure visible central venous line

a.  Licensed practical nurses measure a visible central venous line on clients with stable or predictable states of health.

5.​

Central venous access devices (CVAD) or central venous line*:

  • Do not change dressings on central venous access devices or central venous lines

    *This may also be referred to as a central venous device (CVD) or central venous catheter (CVC).

a.  Licensed practical nurses do not change dressings on central venous access devices or central venous lines.

6.​ Perform Human Immunodeficiency Virus (HIV) Point of Care Testing (POCT) a.  Licensed practical nurses perform Human Immunodeficiency Virus (HIV) point of care testing (POCT):
i.  After successfully completing additional education
ii. By following established organizational processes and procedures for HIV POCT
iii. When an authorized health professional is available for consultation and referral.
​7.
Perform wound care 

Wounds above the dermis: 

a.  Licensed practical nurses who make a nursing diagnosis and treat reddened skin, skin tears and wounds above the dermis, without an order, follow decision support tools.

Wounds below the dermis:

b.  Licensed practical nurses provide wound care if a wound care treatment plan is in place.

c.  Licensed practical nurses probe, irrigate, pack or dress a tunneled wound:

i.  After successfully completing additional education

ii. By following decision support tools

8.​

Perform wound care:

  • Do not perform sharps debridement including conservative sharps wound debridement

a.  Licensed practical nurses do not carry out any form of sharps debridement including conservative sharps wound debridement (CSWD).

9.​

Administer by inhalation:

  • oxygen

a.  ​Licensed practical nurses administer oxygen:

i.  After s​uccessfully completing additional education

ii. ​​By following decision support tools

10.​

Administer purified protein derivative by injection for tuberculosis (TB) screening

 

a.  Licensed practical nurses administer purified protein derivative (PPD), read the results and refer the client to an appropriate health professional when they:

i.  Possess the competencies (BCCDC: TB Screening Competencies) for tuberculosis (TB) screening established by BC Centre for Disease Control (BCCDC).

ii. ​Follow BCCDC decision support tools (BCCDC Clinical Prevention Services Decision Support Tool: Non-Certified Practice - Tuberculosis Screening).

11.​ Assess integrity of the eardrum

a.  Licensed practical nurses assess the integrity of the eardrum after successfully completing additional education. 

​12.

Put a finger beyond the anal verge:

  • digital stimulation
  • rectal disimpaction

    a.  Licensed practical nurses carry out digital stimulation or rectal disimpaction:

i.  After successfully completing additional education

ii. By following decision support tools

​13.

Apply electricity:

  • use an automated external defibrillator (AED)

a.  Licensed practical nurses use automated external defibrillators (AEDs) after successfully completing a cardiopulmonary resuscitation (CPR) course for health professionals that includes the use of AEDs.

14.​

Apply electricity:

  • Do not apply electricity to destroy tissue or affect the heart or nervous system (except AED)

a.  Licensed practical nurses do not apply electricity to destroy tissue or affect the heart or nervous system (exception: automated external defibrillators).

​15.

Apply electricity:

  • transcutaneous electrical nerve stimulation (TENS)

a.  LPNs apply transcutaneous electrical nerve stimulation (TENS) after successfully completing additional education.

​16.
Treat anaphylaxis

a.  Licensed practical nurses diagnose and treat anaphylaxis:

i.  After successfully completing additional education

ii. By following decision support tools

iii. Licensed practical nurses only administer epinephrine to treat anaphylaxis.

​17.
Treat respiratory distress (clients with known asthma)

a.  Licensed practical nurses treat respiratory distress in a known asthmatic:

i.  In a team approach

ii. With an order from an authorized health professional

​18.
Treat hypoglycemia

a.  Licensed practical nurses who make a nursing diagnosis and treat hypoglycemia follow decision support tools.

b.  Licensed practical nurses only administer glucagon to treat hypoglycemia.

​19.
Compound, dispense or administer immunoprophylactic agents

a.  ​Licensed practical nurses who autonomously compound or administer immunoprophylactic agents, in a team approach, for the purpose of preventing disease:

i.  Administer immunoprophylactic agents to clients four years of age and older who have stable or predictable states of health

ii. Successfully complete the additional education established by the BC Centre for Disease Control. (BCCDC: Immunization Courses)

iii. Follow the decision support tools established by the BC Centre for Disease Control (BCCDC: Immunization Manual)

​20.
Do not autonomously compound, dispense or administer immunoprophylactic agents for preventing disease in travellers

a.  Licensed practical nurses do notautonomously compound, dispense or administer immunoprophylactic agents for the purpose of preventing disease in travellers.

​21.
Compound, dispense, and administer naloxone to treat an opioid overdose emergency a.  Licensed practical nurses compound, dispense and administer naloxone without an order, when used to treat an opioid overdo​se emergency.
​22.
Compound, dispense, or administer Schedule II drugs (Drug Schedules Regulation)

a.  Licensed practical nurses compound, dispense or administer Schedule II drugs to treat a disease or disorder with a client-specific order from an authorized health professional.

​23.
Medical aesthetics[4]

a.  Licensed practical nurses successfully complete additional education before providing medical aesthetic procedures.

b.  Licensed practical nurses administering injectable drugs or substances or implantable devices for medical aesthetic purposes only do so:

i.  With a client-specific order from an authorized health professional, and

ii. When the ordering health professional, or another health professional who has assumed responsibility for the care of the client, is present within the facility when the procedure is being performed and immediately available for consultation.



​​

Spec​​ific practice settings

​​Practice Setting BCCNM Limits and Conditions for Licensed Practical  Nurses: Specific Practice Settings
1.

Ambulatory Care

LPNs working in ambulatory care settings need to know when they are allowed to act within their autonomous scope of practice (without a client-specific order) and when a client-specific order may be required before performing an activity

 

a.  Licensed practical nurses working in ambulatory care clinics or offices where surgical procedures are performed:

i. Re​quire a unit orientation that is consistent with LPN entry-level competencies

ii. ​Assist with surgical procedures:

                                                      • Afte​​​​​​​​​​​​​​​​​​​​​​​r successfully completing additional education 
  • When​​ an authorized health professional is imm​​ediately available 

​​​​​​​b.  Licensed practical nurses do not administer:

i.   IV push medications 

i.   IV medications through a central venous access device (CVAD), or a central venous line 

iii. Intrathecal medications 

 iv. Intra-osseous medications 

v.  Medications into epidural spaces 

vi. Medications into perineural spaces 

vii. Inhaled substances or medications for purposes of anaesthesia or procedural (​conscious) sedation

c.  ​Licens​ed practical nurses work in a team nursing approach to provide care and monitor clients under:

i.  General anesthesia 

ii.  Intrathecal anesthesia 

iii. Epidural anesthesia 

iv. Procedural sedation

d.  Licensed practical nurses work in a team nursing approach to care for clients recovering from epidural anesthesia after successfully completing additional education.
2.
Antenatal Care

LPNs working in antenatal care settings need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity

a.  Licensed practical nurses working in antenatal clinics require a unit orientation consistent with LPN entry-level competencies.

b.  Licens​ed practical nurses provide antenatal care:                  

i.  To healthy clients with an uncomplicated pregnancy                 

ii. In a team approach with medical practitioners, midwives, registered nurses and/or nurse practitioners

3.

Emergency Room

LPNs working in emergency rooms need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity

a.  License​d practical nurses working in emergency rooms require a unit orientation that is consistent with LPN entry-level competencies. 

d.  Licensed practical nurses do not triage clients in emergency rooms (ERs). 

c.  Licensed practical nurses work in a team nursing approach to provide care for clients with stable or predictable states of health.
4.

Hemodialysis

LPNs working in hemodialysis settings need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity.

a.  Licensed practical nurses working in hemodialysis settings carry out hemodialysis:

i.   For clients with stable or predictable states of health

ii.  After successfully completing post-basic education through an in-house program offered by a health authority affiliated with BC Renal

iii. By following decision support tools established by a health authority affiliated with BC Renal

iv. When a registered nurse is immediately available

v.  Using an arteriovenous (AV) fistula or AV graft

b.  Licensed practical nurses working in hemodialysis settings manage, access and maintain central venous lines and central venous access devices (CVAD) used specifically for hemodialysis by:

i.  Changing dressings on central venous access lines specific to dialysis access only 

ii. Measuring visible central venous access lines specific to dialysis access only 

iii. Carrying out dialysis through a central venous access line specific to dialysis access only

c.  Licensed practical nurses working in hemodialysis settings administer solutions, substances and Schedule I, IA, II and III drugs (Drug Schedules Regulation) by any route, including intravenous and IV push, as part of routine hemodialysis procedures.

d.  Licensed practical nurses working in hemodialysis settings do not administer:

i.   Intrathecal medications 

ii.  Intra-osseous medications 

iii.  Medications into epidural spaces 

iv. Medications into perineural spaces 

v.  Inhaled substances or medications for purposes of anaesthesia or procedural (conscious) sedation

e.      Licensed practical nurses working in hemodialysis settings monitor clients receiving blood or blood products in a team nursing approach.

f.       Licensed practical nurses working in hemodialysis settings do not start transfusions of blood or blood products.
5.

Medical Aesthetics[5]

LPNs working in medical aesthetic settings need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity​.

a.  Lic​ensed practical nurses successfully complete additional education before providing medical aesthetic procedures. 

b.  Licensed practical nurses administering injectable drugs or substances or implantable devices for medical aesthetic purposes only do so: 

i.  With a client-specific order from an authorized health professional, and 

ii. When the ordering health professional, or another health professional who has assumed responsibility for the care of the client, is present within the facility when the procedure is being performed and immediately available for consultation.

6.

Mental Health and Substance Use

LPNs working in settings where mental health disorder is the primary diagnosis need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity.

a.  ​Licensed practical nurses working in settings where substance use or a mental health disorder is the primary diagnosis require an orientation that is consistent with LPN entry-level competencies.

b.  Licensed practical nurses work in a team nursing approach to provide care for clients whose primary diagnosis is substance use or a mental health disorder after successfully completing additional education.
7.

Perioperative

LPNs working in perioperative settings need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity.

a.  Licensed practical nurses work in a scrub or circulating role in the operating room (OR):

i.  After successfully completing formal post-basic education 

ii. When a registered nurse is immediately available

b.  Licensed practical nurses do not administer:

​​i.   IV push medications

​​ii.  IV medications through a central venous access device (CVAD), or a central venous line

​​iii. Intrathecal medications

​​iv. Intra-osseous medications

​v.  Medications into epidural spaces

​vi. Medications into perineural spaces

vii. Inhaled substances or medications for purposes of anaesthesia or procedural (conscious) sedation

c.  Licensed practical nurses working in a perioperative setting work in a team nursing approach to provide care and monitor clients under:

i.   General a​nesthesia

ii.  Intratheca​​l anesthesia

iii. Epidural anesth​esia

iv. Procedural sedation
8.

Postpartum Care

LPNs working in postpartum care need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity.

a.  Licensed practical nurses working in postpartum settings require a unit orientation consistent with LPN entry-level competencies that includes:

i.  Infant resuscitation as part of a cardiopulmonary resuscitation (CPR) course for health professionals

ii. The Neonatal Resuscitation Program (NRP) modules 1-4 and 9

iii. Newborn and maternal assessment, including breastfeeding, consistent with the Perinatal Services British Columbia (PSBC) Newborn Clinical Pathway (PSBC Newborn Guideline 13: Newborn Nursing Care Pathway) and the Postpartum Clinical Pathway (Perinatal Services BC: Perinatal Services BC Obstetrics Guideline 20 Postpartum Nursing Care Pathway)

b.      Licensed practical nurses provide care for mothers and newborns:

i.  With stable or predictable states of health                  

ii. When a registered nurse, nurse practitioner, midwife and/or medical practitioner is immediately available

c.       Licensed practical nurses take heel pricks after successfully completing additional education.​

​​Glossary​

Additional education: Additional education is structured education (e.g., workshop, course, program of study) designed for the nurse to attain the competencies required to carry out a specific activity. Additional education:

  • Builds on entry-level competencies,
  • Identifies the competencies expected of learners on completion of the education,
  • Includes both theory and application to practice, and
  • Includes an objective evaluation of learners' competencies on completion of the education.

Advanced activities: Activities that are within a nurse's scope of practice but require additional education, training, and/or clinical experience that build on the foundational knowledge, skills, and judgement attained during entry-level nursing education.

Competence: The integration and application of current knowledge, skills, attitudes, and judgment required to perform safely, ethically, and appropriately within an individual's practice.

Competencies: The knowledge, skills, attitudes, and judgment required to provide safe, competent, and ethical care within an individual's practice or in a designated role or setting.

Decision support tools (DSTs): Evidence-based documents used by nurses to support clinical judgment and decision-making by guiding the assessment, diagnosis, and treatment of client-specific clinical problems. DSTs come in various forms and are created by organizations or specialists in a specific area of health care.

Formal post-basic education: Structured education that builds on the entry-level LPN competencies. Formal post-basic education is delivered:

  • By an educational institution that teaches a BCCNM-recognized practical nursing education program or equivalent, or
  • Through a collaborative arrangement between an employer that employs LPNs in post-basic areas and a school that teaches a BCCNM-recognized practical nursing education program or equivalent.

Team approach: When the care needs of a client include activities that are outside LPN scope of practice or the individual competencies of the LPN, the LPN seeks out other members of the health care team to jointly review the client's care needs and determine how the care needs will be met between them. Where relevant, the registered nurse or registered psychiatric nurse may be the most appropriate team member for the LPN to seek consultation and collaboration with regarding client care needs.

Team nursing approach: When the nursing care needs of a client include activities that are outside LPN scope of practice or the individual competencies of the LPN, the LPN seeks out the registered nurse or registered psychiatric nurse to jointly review the client's care needs and determine how the care needs will be met between them.

​​Foot​​​notes​

[1]  Nursing diagnosis: a clinical judgment of an individual's mental or physical condition to deter​mine whether the condition can be ameliorated or resolved by appropriate interventions of the nurse to achieve outcomes for which the nurse is accountable: Nurses (Licensed Practical) Regulation.​​

[2​​]  Based on their assessment of the client, licensed practical nurses make a clinical judgement (a nursing diagnosis) of a condition as the cause of the client's signs and symptoms.

[3]  Nursing diagnosis: a clinical judgment of an individual's mental or physical condition to determine whether the condition can be ameliorated or resolved by appropriate interventions of the nurse to achieve outcomes for which​ the nurse is accountable: Nurses (Licensed Practical) Regulation. ​

[4]  “Medical aesthetics" refers to elective non-surgical outpatient clinical procedures that include the performance of a restricted activity (activities listed in sections 6 and 7 of the Nurses (Licensed Practical) Regulation) and are primarily intended to alter or restore a person's appearance.​

[5]  “Medical aesthetics” refers to elective non-surgical outpatient clinical procedures that include the performance of a restricted activity (activities listed in sections 6 and 7 of the Nurses (Licensed Practical) Regulation) and are primarily intended to alter or restore a person’s appearance​​.​


​​​Need help or support?​

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